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Did you know that accident and emergency (A&E) registrars have as many as five three month secondments to other specialties during their training? These secondments involve the specialist registrar (SpR) joining a specialty related to A&E in a supernumerary capacity. The aim of the secondments is for the trainee to learn how related specialties manage their acute problems. This article outlines the background of why A&E SpRs have secondments and some ideas on how they can be used to full advantage.
A&E has a five year registrar training programme. The minimum entry requirements are to have passed MRCP, FRCS (there is an A&E version of the fellowship), or final anaesthetic examinations and have at least six months' A&E experience. Currently A&E registrars are equally drawn from medicine and surgery. Towards the end of the programme trainees are required to sit an exit examination.
A&E is a broad specialty and its doctors need a wide variety of skills. A&E deals with a whole spectrum of acute medical, surgical, obstetric and gynaecological, psychiatric, paediatric, anaesthetic, and social problems. Trainees should be skilled in treating minor injuries and have an understanding of pre-hospital care. In order to help train doctors in this broad discipline, the Joint Committee of Higher Training in A&E have stipulated that all registrars must have experience in the following specialties:
Acute medicine (including cardiology)
Acute surgery (including, if possible, general surgery, plastics, neurosurgery, and cardiothoracic surgery)
Anaesthetics (with at least one month in intensive care)
SpRs who have not had at least six months' experience in any of these areas as a senior house officer are sent on a three month secondment to observe and work in that specialty.
During a secondment the registrar is still funded by, but does not work for, the A&E department. The trainee is expected to work their normal hours, including on-call time, in the specialty to which they are attached. The possible exception to this is that if on-call time in a particular specialty is of little training value, the registrar may be asked to work “on-calls” in the A&E department. This point is open for local negotiation.
So how can we make best use of these secondments? The following points should be considered when planning a secondment:
(1) Where will the trainee gain the best experience? This need not be in the hospital where the SpR is currently working and often the best experience can be obtained in other hospitals or the community.
(2) Who is the best person to mentor the trainee when on attachment? Ideally this will be a consultant with an interest in acute illness and who is keen to teach.
(3) What are the objectives for the attachment? This should be decided between the SpR, the A&E trainer, and the appointed specialty mentor several weeks before the start of the secondment.
(4) How can these objectives best be achieved? Decisions need to be made about:
The trainee's working pattern. From which wards, theatre sessions, and outpatient clinics the maximum will be gained.
Specific responsibilities, particularly the level of clinical responsibility the trainee should take on.
Teaching sessions that would be useful and if any extra teaching input is needed.
If it is appropriate for the trainee to take on any projects, for example drawing up clinical guidelines, research, or audit.
If it is necessary to have extra time allocated towards study and research.
(5) How is the progress of the attachment to be monitored? We suggest that a further meeting between the SpR, the A&E trainer, and the specialty mentor should take place 2–3 weeks into the attachment. This should address any problems and ensure the attachment is productive for the trainee and the specialty to which he or she is attached.
(6) What appraisal is required? At the end of the attachment a formal appraisal should take place, identifying the trainee's strengths and weaknesses. The trainee should also comment on the attachment and how it could be improved for the future.
One of the authors recently undertook an orthopaedic attachment. He undertook most of this at his base hospital, some at specialist units elsewhere. Activities were as follows:
Much of the time was spent in fracture clinics, helping to see patients and learning about the follow up of orthopaedic trauma.
Several trauma theatre sessions.
Specialty clinics such as dedicated knee or children's clinics.
Weekly orthopaedic teaching half days, which were useful.
Two weeks with a plastic surgeon (at another hospital) learning about hand injuries.
One week attending rheumatology outpatient clinics and learning about joint aspiration and injection.
One week at a regional spinal injuries unit. Because of the distance involved it was necessary for this to be residential.
It can be seen that a whole variety of activities can be organised and that a huge amount can be experienced in a relatively short time. Forward planning reaps great rewards. Particularly, choosing a centre of excellence (other than your own!) can invigorate.
One of us has recently been on a medical attachment. There is a separate medical assessment unit (MAU) at our hospital and it was decided that this, with some time on the coronary care unit, would be the most relevant place for an A&E SpR to spend his medical attachment. The consultant in charge of the MAU was chosen as mentor. He has particular experience in managing acute medical illnesses and is also an enthusiastic teacher. The trainee received a lot of individual teaching during the three month period. Due to the excellent input from the mentor the attachment was productive for the trainee and because of the clinical work put in by the trainee, and his teaching of the junior senior house officers, the unit also benefited. Word has quickly spread and A&E trainees from other hospitals in the region have sought attachments to our MAU, to the benefit of all.
There are advantages to both the trainees and the specialty to which they are seconded. Trainees have a chance to see and manage cases from the viewpoint of the specialty they are working in, which may be different from that in A&E. They also have a chance to observe the continuing care and outcome of patients, something that is not usually possible in A&E.
The unit the trainee is attached to can also benefit. As an addition to the usual compliment of staff they can help manage patients. This is primarily a learning exercise for the trainees and they should not be used to make up for staff shortages; however involvement in clinical work can be of benefit to both parties. Also trainees can contribute different skills to the management of patients, especially with their breadth of A&E experience. These attachments foster links, understanding, and respect between the A&E department and the specialties involved. With improved communications patients will only benefit.
There are potential problems of a poorly planned attachment. The A&E department that the trainee comes from can suffer from short term staffing problems due to the loss of one of its doctors for three months. On occasions locums may be needed to fill the gap. There are certain times in the year when it might be inconvenient for SpRs to go on attachment, for example when the new compliment of senior house officers join A&E in February and August or over Christmas time. It is wise for trainees to avoid secondments at these times.
This is an expensive exercise and the cost of the trainee's salary alone during a three month attachment is nearly £10 000. Hence it is worth taking great care that the trainee and all departments involved benefit from these secondments.
A&E registrar secondments are for three months and enable the trainee to experience the practices of related specialties. If properly organised they can be of great benefit to the trainee and to the unit that receives the trainee. Communication and planning are the key to a successful attachment, which provide an unparalleled opportunity for training.
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