Training ANAESTHETISTS in Training ANAESTHETISTS in Europe (UK) Europe (UK)

Monty G MythenMonty G Mythen

Portex Professor of Anaesthesia and Critical Care.Portex Professor of Anaesthesia and Critical Care.

Director, Centre for Anaesthesia, Critical Care and Director, Centre for Anaesthesia, Critical Care and Pain Management. Pain Management.

University College London, UKUniversity College London, UK

UCLCentre for Anaesthesia

USA and UKUSA and UK“ Two Great Countries Separated by a Common Language”

Oscar Wilde

Anaesthesia in Europe (UK)

• How convince Anesthesiologists to go outside the O.R?

• Is it all economics?

• Challenges in training and future plans?

• Non-physician Anesthetists?

Marathon des Sables

•Extreme endurance event- several hours/ day

•Thermal challenge

•Fluid loss

•Electrolyte imbalance

•Acute inflammatory response

Marathon des Tables

•Extreme endurance event- several hours / days

•Thermal challenge

•Fluid loss

•Electrolyte imbalance

•Acute inflammatory response

Anaesthesia in Europe (UK)

• How convince Anesthesiologists to go outside the O.R?

• Is it all economics?

YES – BUT!

Anesthesia Outside the OR?

• Critical Care – 90% Anesthetists

• Pain – Acute and Chronic – 95% Anesthetists

• Pre-op evaluation

• Critical Care Outreach

• Management

Funding in UK?

• National Health Service– National Pay Scale– No Billing!– ALL Doctors paid

same– Term pension

• Private Practice– Inflated hourly

rates– Direct Patient

Billing– Symbiotic

relationship

Anesthesia Outside the OR?

• Critical Care* – 90% Anesthetists

• Pain – Acute and Chronic* – 95% Anesthetists

• Pre-op evaluation* (replacing cardiology) – “Fit for Surgery”

• Critical Care Outreach* (PACU + post-op care)

• Management*Doctors: Doctor

*Nurses: Nurse

Anaesthesia in Europe (UK)

• How convince Anesthesiologists to go outside the O.R?

• Is it all economics?

• Challenges in training and future plans?

• Non-physician Anesthetists?

Training changes in last Training changes in last decade – 10 yrs agodecade – 10 yrs ago

• Med Student 5-6 yr

• PRHO (no debts) 1 yr

• SHO (non-anesthesia) 1-4yr

• Reg. (3 exams FRCA) 4 yr

• Research (MD/PhD) 1-3 yr

• Senior Registrar 4 yrConsultant

96 hrs pre week – “undertime”

Funding in UK?

• National Health Service– Service delivery

by senior trainees (post-fellowship)

– Consultant led

• Private Practice– Consultant

delivered

Training changes in last Training changes in last decade –10 years agodecade –10 years ago

• PRHO 1 yr

• SHO (non-anesthesia) 1-4yr

• SHO (Anesthesia) 2 yr

• Reg. (3 exams FRCA) 4 yr

• Research (MD/PhD) 1-3 yr

• Senior Registrar 4 yrConsultant

96 hrs pre week – “undertime”

Training changes in last Training changes in last decade - nowdecade - now

• PRHO (Modest Debt!) 1 yr

• SHO 1-4yr

• SpR 5 yrConsultant

48 hrs pre week – “OVERTIME!”

European Working Time Directive

EU – equivalence in training

Funding in UK?

• National Health Service– Trainees– Consultant

delivered (48 h working week)

• Private Practice– Consultant

delivered

?R.O.W

N.P.A

Anaesthesia in Europe (UK)

• How convince Anesthesiologists to go outside the O.R?

• Is it all economics?

• Challenges in training and future plans?

• Non-physician Anesthetists?

Non-Physician Anaestheitists in UK

• Can only work under Physicians• Same as SHO (competent – not “post-

fellowship” – NOT “specialists”)• Training controlled by Royal College of

Anaesthetists (27 months)• NOT just Nurses• Can not practice independently• 1 Consultant : 2 Assistants. Max 2 rooms

(Private practice?)

Non-Physician vs Physician

• Pre-op evaluation– SHO, pre-fellowship SpR, NPA:

• PMH, drugs, allergies, airway etc.

– Post fellowship SpR, Consultant:• Is the patient fit for surgery?• MY CLINIC• Special investigations (CPX)• Risk evaluation• Per-op technique• Post –op care

Training?

• Whats new in Europe (UK)?

• DR Judith Hulf – Vice President R.C.A.

Post-Graduate Medical and Education Training Board

(PMETB)

• Single unifying framework for postgraduate medical education and training

• General and Special Medical Practice (Education and Qualifications) Order

• Approved by Parliament April 2003

PMETB

“The order places a duty on PMETB to establish, maintain, and develop

standards and requirements relating to postgraduate medical education and

training in the UK.”

PMETB

The Board:• NHS appointees• Chairman, CEO• 25 members – 9 lay / 16 medical members

6 Academy of Medical Royal College nominees4 observers, 1 from each Department of Health

STASTA PMETBPMETB

* Independent * Accountable Secretary of State

* Certification & regulation body * Wider remit

* Devolved activity to Medical * Will run own activity

Royal College

* Colleges ran own visiting * Will commission own visits programme. Reported to STA to include lay members

• Does competency based training still need to be time based?• European minimum recommended training time• Does all “training” need to be completed before the award of a Certificate Completion Training?

PMETB and Length of Training

PMETB and the CCT

• CCT=CCST• Level of assessed competence in one or more areas of training• What is the minimum training time for a CCT?

“The standard for the award of a CCT should be the same as that currently required for a CCST”

Foundation YearsFoundation Years

-2 year planned programme of general training

-Series of placements - number of specialties

- number of healthcare settings-Demonstration of competence against set standards-Started in August 2005

Foundation YearsFoundation Years

• F1 and F2 are generic training• F1 normally works on 3 x 4 month posts• F2, more variety, 3 x 4/12 or 4 x 3/12, but can be individually tailored• Feeds into “general” specialty training• Level of service commitment?• Some specialities have lost their Junior Residents!

Medical school Two Year Foundation Programme

Specialist or GP training

Provisional Registration

GMC

Full Registration

GMC

F2 CurriculumF2 Curriculum

Case mix suited to be taught by;

Critical Care

A&E

Acute Medicine

Anaesthesia

Oct 2005

F2 assessments

Overall Pass or Fail – no grades

• Mini-Cex (clinical evaluation exercise – 6 observed encounters)• DOPS ( direct observed procedural skills)• Mini-PAT (peer assessment tool)• CbD (case-based discussion)

Expect to identify doctors in difficulty early

Specialist Training

• To be streamlined• Years following F1/2 are Specialist Training (ST) years 1,2 etc• Specialist training years to be “seamless”• ST1 starts in August 2007• Selection process for ST1 will start in December 2006

Specialist Training

• PMETB sets the standards• Apply direct from F2• Competency based curriculum• Defined levels of competence for service delivery• End point is a CCT “Accredited doctor”

Foundation Year 1

MMC – Possible Foundation

Foundation Year 2

Accredited Accredited Specialist (CCT) Specialist (CCT)

Accreditation

(Ref

orm

ed S

AS

Gra

des)

Competency Threshold 2

Competency Threshold 1

Level 2Level 2

Level 1Level 1

STST

Accredited SpecialistTraining

Programmes

Accredited SpecialistTraining

Programmes

Accreditation

Accredited Accredited GP (CCT) GP (CCT)

ESAESAST Non ProgrammePosts

Enhanced ServiceAppointmentsC

ompe

tenc

y B

ased

Pro

gram

mes

Accredited Accredited GeneralGeneralPracticePracticeTrainingTraining

ProgrammesProgrammes

Seamless specialty training

•Direct Path

•Broad-based Path - Common stem programme

Oct 2005

ICM,acute medicine, anaesthesia,A&E

ST1common stem programmes

FY2FY1

surgeryneuro

sciencesnon

acutemedicine

GPpaeds

communitymedicine

A&EICMAcute

medicineAnaesthesia

Oct 2005

FY2FY1

ST1and beyond

ICM,acute medicine, anaesthesia,A&E

Anaesthesia

Seamless training

• Choice of specialty needs to be correct for the trainee• Currently 50% drop-out from Anaesthesia at SHO• Choosing a doctor with correct attributes• Selection criteria as yet un-validated

Manpower planning

Managing competency-based training

Stopping continual change

Keys to Success

Article 14 and Equivalence

• Previously: judged equivalence under Article 9 of the ESMQO

• Under the new medical order and PMETB Article 14 takes over the comparison with CCT training

Oct 2005

Article 14

• Country of origin is immaterial• Considers training and experience from anywhere

–Ratio T:E is unclear

Equivalence

144: experience of the applicant measured against the CCST(CCT)

145: experience of the applicant measured against a non-UK specialty

This could equate to a “generic” consultant

or

A non-UK specialty e,g. a cardiac anaesthetist

145

Have to have done training abroad to fit into this category

( to stop UK trainees taking this route)

Nuffield Chair at Oxford University

“Any fool can give an Anaesthetic”

“Yes, that’s what worries me!”

Anaesthetic Grant Application

Dear Sirs:

Despite there never having been any meaningful investment in Anaesthetic research, Anaesthetics always work and are incredibly safe (mortality < 1:100,000). Therefore, please give us millions of Medical Research Council pounds so that we may indulge ourselves in intellectual frippery.

Yours etc.

p.s. if you ever need an operation you will be safe with us

Dear Sirs:

Despite having invested millions of Medical Research Council Pounds in Cardiology, heart disease remains the commonest killer in the UK. Little or no progress has been made despite having the most Professors and the biggest departments. However, I have just noticed that very few nematodes die from heart disease and we have just decoded the human genome. Therefore, please continue to give us millions of Medical Research Council pounds so that we may continue to indulge ourselves in intellectual frippery.

Yours etc.

p.s: you will probably die from heart disease

Cardiology Grant!

Hospital Mortality (%) following Hospital Mortality (%) following Major Surgery and Intensive Care Major Surgery and Intensive Care

in UK 7/99 TO 01/00in UK 7/99 TO 01/00

0

5

10

15

20

25

30

35

40

Overall Elective Scheduled Emergency

UK (n=22,059)UCLH (n=288)

ICNARC

Patients in Hospital with Morbidity Patients in Hospital with Morbidity Following Major Surgery at UCLHFollowing Major Surgery at UCLH

05

1015

2025

3035

4045

50

Day 5 Day 8 Day 15

Morbid (%) n = 183

Survival of The Fittest

Dr Paul Older: Western Hospital Melbourne

How is Anerobic Threshold Measured?

Cardiovascular mortality and anaerobic threshold

0

10

20

30

40

50

60

70

80

90

<8 8-10.9 11-13.9 >=14

Anaerobic threshold (ml/min/kg)

'n' survivors

non survivors

n = 184

Chest 1993 104: 701-04

Cardiovascular mortality in patients >60yrs undergoing major intrathoracic or intra-abdominal surgery

Early ischaemia - becoming positive within three minutes of onset of exercise and well before AT

‘AT’ 600 ml/min 9.7 ml/min/kgThis is moderate cardiac failure‘AT’ 600 ml/min 9.7 ml/min/kgThis is moderate cardiac failure

but note early onset of ST depressionbut note early onset of ST depression

Late ischaemia - becoming positive late in exercise and occurring around or above the AT

‘AT’ 1160 ml/min : 16.5 ml/min/kgNo cardiac failure

‘AT’ 1160 ml/min : 16.5 ml/min/kgNo cardiac failure

note onset of ST depressionnote onset of ST depression

Major surgery

(i) Age > 60 yrs. (n =476)(ii) Age < 60 yrs. known ischemic heartdisease or cardiac failure (n =72)

C.P.X.

AT <11ml/min/kgor aortic or

oesophageal surgery

AT >11 ml/min/kgwith myocardialischemia or Ve/VO2 >35 on CPX

AT > 11 ml/min/kg.no myocardialischemia and

Ve/VO2 < 35 onCPX

ICU 28% (n =153)

HDU 21% (n=115)

Ward 51% (n=280)

CVS mortality

4.6% (n=7)

CVS mortality

1.7% (n=2)

CVS mortality

0%

Definition of abbreviations: AT = anaerobic threshold, Ve/VO2 = ventilatory equivalent for oxygen,ICU = intensive care unit, HDU = high dependency unit, CVS = cardiovascular,CPX = cardiopulmonary exercise test

Chest 1999 116: 355-362

ICU bed utilisation and mortality per 100 patients over 65 for elective major abdominal surgery

- 15 years of development of preoperative assessment

1) all emergency admissions following elective surgery

2) all cases admitted to ICU electively pre-operatively

3) elective admissions according to triage

Number triaged to ICUTotal bed days

Average days in ICUNon surgical

mortality

<198540(1)

6001519

<1989100(2)

4304.36

<199245(3)

2605.77

<199445(3)

2255.04

<199536(3)

1524.22

<199629(3)

782.70

<199922(3)

663.00.5

Descending Aortic Velocimetry: Descending Aortic Velocimetry: Oesophageal Doppler?Oesophageal Doppler?

Intraoperative Fluid Loading guided by Doppler in major non-

cardiac (n=100) Control Protocol P value

Colloid (mL/kg/h)

0.9 2.5

Crystalloid (mL/kg/h)

15 13

Hospital Stay (Days)

75 53 0.03

Tolerate Food (Days)

54 32 0.01

Gan et al.,Gan et al., Anesthesiology Anesthesiology 2002 2002