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How to get on a SpR rotation in emergency medicine (and make the most of it)
  1. G Lloyd1,
  2. I O’Sullivan2,
  3. N Rawlinson2,
  4. C Mann3,
  5. A Harris1
  1. 1Emergency Department, Royal Devon and Exeter Hospital, Exeter, UK
  2. 2Emergency Department, Bristol Royal Infirmary, Bristol, UK
  3. 3Accident and Emergency Department, Musgrove Park Hospital, Taunton, UK
  1. Correspondence to
 Dr G Lloyd, Emergency Department, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK; 
 gavin.lloyd{at}rdehc-tr.swest.nhs.uk

Abstract

Emergency medicine is now proving a popular specialty in the United Kingdom. A recent report ranks emergency medicine second in specialties attracting the most applications for specialist registrar (SpR) interview. Numbered posts are becoming increasingly competitive as a result. This paper offers advice to aspiring emergency department SpRs. It identifies areas in which a curriculum vitae may be improved. It should also enable emergency department trainees to set objectives for their early SpR years.

  • SpR rotation
  • education
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This paper covers:

  • Mentorship

  • Pre-SpR experience

  • The SpR appointment

  • Teaching: a teaching portfolio

  • Audit

  • Research

  • Management skills

  • Information technology skills

  • Generic skills

  • Progress through the SpR years

MENTORSHIP

Finding a mentor who knows you well is important. They can offer valuable advice on your career plan and progress; your curriculam vitae (CV); the suitability of posts leading to the SpR grade; interview technique, and format. It is worth discussing and setting emergency medicine orientated goals for each post leading to SpR appointment.

PRE-SpR EXPERIENCE

The Faculty of Accident and Emergency Medicine have issued a Career in emergency medicine—a guide for students and doctors. This is available on the Faculty web site (www.faem.org.uk/career.html). It covers not only essential but optional experience. Our current regional person specification is illustrated in table 1 as an example. It sets out further requirements necessary for a competitive application. Person specifications vary slightly from region to region and it is clearly worthwhile seeking early advice from the area you wish to apply for.

Table 1

Do note that the potential need for 12 months rather than six months experience in anaesthesia/ITU before SpR application is a subject of much debate at present. It is worth keeping up to date on this issue by following the Faculty meeting minutes and consulting your mentor and regional training programme director.

THE SpR APPOINTMENT

Do remember it is the CV that gets you shortlisted. Ensure that it is well presented and up to date. Take advice on its content and design. Have a careful look at the person specification and adjust your CV accordingly. Having it professionally prepared may well be worth the money. Ask for the application form on disk and type your application. Beware that additional CVs are not always accepted so be fastidious about what you put on the template application form and always get someone to check it for you.

If you are successfully shortlisted, make every effort to see all members of the appointment committee before interview. In addition, visit each of the departments through which the post rotates. The job description supplied by the personnel department should contain details of the rotation and a contact person within each department. Note that asking to visit departments before the shortlisting has occurred is not universally welcomed. When you do visit, speak to the current trainee and some of the SHOs as well as the consultants. Some of the seniors may not wish to see you because they are on the interview panel. Do not get upset by that. Dress as you would for interview and arrive on time. Any pre-interview visit is an opportunity for you to ask questions, so make sure you have several well thought out ones prepared. Give some consideration as to whether this is the right rotation for you in terms of your future requirements. Does it provide you with the necessary experience to develop a special interest, allow you to chose between full time and flexible training, and would there be opportunity for you to go abroad during your training if you so wished.

Do prepare for the interview. Be aware of current hot topics and reports. Interview practice is clearly an advantage—seek out your mentor or educational supervisor—certainly more than one person. This will give you experience in different approaches, mirroring the interview process. Viewing yourself on video can provide you with valuable insight. Look out for dedicated SpR interview courses if you are particularly apprehensive (Firstcourse{at}barclays.net).

TEACHING: A TEACHING PORTFOLIO

It is important to develop a teaching portfolio, a summary of which is a useful adjunct to your CV. A portfolio is not only a compilation of your teaching activities, it also encourages self evaluation of teaching skills. At pre-SpR level you are already likely to be contributing to the teaching of medical students and perhaps fellow junior doctors, nursing staff, and nurse practitioners. Box 1 illustrates some examples of what a portfolio may contain and some questions that may stimulate self evaluation. While the teaching portfolio is personal, it is worth discussing your development as a teacher with a proven educator. List any suggested changes in your educational delivery within your portfolio. Just as your CV will in time list your publications, research grants, and academic honours, the portfolio is a way of listing comparable achievements in teaching.

Box 1 Suggestions for a teaching portfolio

Content

  • Topics taught

  • Your experience of facilitating small group teaching, teaching one to one, delivering a lecture, dealing with multidisciplinary groups, and teaching psychomotor skills

  • Your experience of coordinating an education programme

  • Your experience of assessment

Self evaluation

  • Have you sought feedback on your teaching skills:

    • – from the target group?

    • – from an experienced educator?

    • – self or facilitated analysis with video recording?

  • What changes have you made to your teaching skills:

    • – teaching style?

    • – content of any particular session?

    • – use of educational media?

Some of you may have been put forward for instructor status on an advanced life support course. The transition from successful candidate to instructor entails passing an instructor course as well as observation of your teaching performance (instructor candidacy) on at least one subsequent course. Instructor courses are geared towards developing good teaching skills. Their typical content is illustrated in box 2. Clearly instructor status in one or two disciplines is advantageous. It is worth discussing with your mentor what a faculty looks for in selecting future instructors.

Box 2 Educational content covered in a typical advanced life support instructor course

  • Specific steps and teaching strategies for planning a lecture with reminders on how to deliver the lectures appropriately

  • Methods for preparing specific plans for skills-teaching episodes

  • A review of how to utilise group discussion techniques

  • A review of the faculty’s roles and responsibilities for conducting the initial assessment skills station

Several teaching courses complement the “instructor” type and are open (Lister (jan.caspell{at}nherts-tr.nthames.nhs.uk), London (k.stephens{at}chime.ucl.ac.uk), are examples. Higher qualifications in medical education are also available. The University of Wales College of Medicine in Cardiff runs a part time modular MSc/Diploma course, as well as a postgraduate certificate course through distance learning (medicaleducation{at}cf.ac.uk). The University of Dundee (www.dundee.ac.uk/meded/) and more recently the Universities of Surrey (www.surrey.ac.uk/pgms/) and Bristol (www.tlhp.bristol.ac.uk) run similar courses. Postgraduate regional deans are generally supportive towards funding applications for these.

AUDIT

A working knowledge of audit is an essential requirement for SpR appointment. It is a key part of clinical governance. Illustration of at least one completed audit cycle is desirable on your CV. It is important to illustrate how you effected (or at least tried to effect) change.

If you have not undertaken a quality audit to date, speak to your educational supervisor or mentor. They may either be able to identify an area of clinical practice ripe for audit, or show you a list of previous departmental audits that may need revisiting. Alternatively, your clinical experience may alert you to a topic in need of audit. Examples of clinical audits published in this journal (box 3) not only show what is achievable, but may act as a further source of inspiration.

Box 3 Examples of published audits in this journal

  • Improving detection of alcohol misuse in patients presenting to an accident and emergency department

  • Consistency of retrospective triage decisions as a standardised instrument for audit

  • A risk management audit: are we complying with the national guidelines for sedation by non-anaesthetists?

  • Epilepsy in the accident and emergency department—developing a code of safe practice for adult patients

  • Brain attack! How good is the early management of subarachnoid haemorrhage in accident and emergency departments?

  • Oral contraceptives and oral antibiotics: interactions and advice in an accident and emergency setting

  • Burns and scalds in pre-school children attending accident and emergency: accident or abuse?

  • Asthma management in accident and emergency and the BTS guidelines—a study of the impact of clinical audit.

  • Audit of upper limb fracture management in an accident and emergency department

  • The use of audit to set up a thrombolysis programme in the accident and emergency department

Having identified an audit topic, prepare well before collecting data. Your educational supervisor can again help in this regard. Your Trust’s clinical audit department may also be of service and indeed may run audit workshops. Examples of clinical audit “how to . . .” booklets are available on line (www.ubht.ng.uk/clinicalaudit/clinical%20Audit/resources.htm). You may need to set or modify standards, or perform an activity analysis to establish current practice. Initiating change is likely to require good communication and education. This may include updating the ED handbook and incorporating the standards/guidelines into the departmental teaching. This may result in any improvement in care quality that you achieve having a lasting effect.

RESEARCH

(1) Critical appraisal

Formulating a clinical question, searching the literature and appraising the evidence is the basis of evidence based medicine.1 These skills are required of ED consultants and acquiring them at an early stage in your career is an advantage. Note that critical appraisal has played a sizeable part in the Faculty examination from its outset (www.faem.org.uk/exam.htm).

Where do you begin? Get hold of Evidence-based medicine by Sackett et al1 and How to read a paper by Greenhalgh.2 Concentrate on the chapters that cover posing clinical questions and searching, and those that cover therapeutic, diagnostic and meta analysis papers. The book by Sackett is accompanied by useful cards that summarise the key questions for each publication type.

Start identifying knowledge gaps in your clinical practice. Try setting three part questions for these. Select the most important to you and search the electronic databases. Compare your search strategy (and yield) with interested colleagues and your librarian. The ED of the Manchester Royal Infirmary has demonstrated evidence based medicine in practice. Their best evidence topics (BETS) are based on clinical knowledge gaps, quality literature searches, and appraisals. A tenet of evidence based medicine is to share your results—BETS are published in each edition of this journal and on a web site (www.bestbets.org.cgi-bin/browse.pl). The Manchester group invite submissions from external sources. Publication of your best evidence topic is clearly illustrative of a working knowledge of evidence based medicine.

In addition seek out local university led workshops. These are often free to Trust employees. Your educational supervisor, mentor, clinical tutor, or Faculty regional research supervisor may be able to identify other local training opportunities. Alternatively, look at generic evidence based medicine courses (http://cebm.jr2.ox.ac.uk) or emergency medicine orientated courses run at Leeds General Infirmary and the John Radcliffe Hospital, Oxford.

(2) Getting research into practice

Ensuring departmental clinical guidelines are valid, feasible, and up to date is a challenge for any consultant. Guidelines form a key part of clinical governance and are tied closely to evidence based medicine, audit, and risk management. The applicability of newly published evidence or guidelines to local practice, its implementation, and compliance (audit) is a useful consultant supervised project. Examples might include the use of metered dose inhalers in asthmatic children or development of a protocol for pulmonary embolism. Such projects are capable of demonstrating initiative and appreciation of clinical governance. They are also impressive on a CV.

(3) Doing research

Having recognised the need to provide quality advice for emergency medicine research, the Faculty is in the process of setting up a regional system of research supervisors. If the key to a successful research proposal lies in its preparation then the need for discussion with these experienced researchers is obvious. Your educational supervisor will have the contact details of your region’s research lead. In addition the Faculty web site will in time provide research information and an avenue for advice on research proposals.

As for research ideas, how about those clinical knowledge gaps that remain unanswered by your literature search? Much of today’s practice in the emergency department is based on limited evidence.

MANAGEMENT SKILLS

At present much of the consultant workload within emergency medicine is managerial. Therefore if you have experience in this area then include it in your CV. This need not necessarily be medical but should demonstrate qualities such as initiative, personal drive, leadership skills, diplomacy, cross professional working, or pastoral care.

INFORMATION TECHNOLOGY SKILLS

Many departments lack sufficient secretarial support to allow you to have letters and other documents prepared. A number of skills in IT are therefore regarded desirable and will enable any SpR to work effectively and efficiently. These include a working knowledge of word processing, spreadsheet programmes (for example, Excel), and presentational software (for example, Powerpoint). Spreadsheet programmes are a great asset if you are collecting and analysing data for research and audit—it is difficult to produce high quality work without. The use of Powerpoint on the other hand, may enable you to enhance your slide presentations. The European computer driving licence encompasses these skills and more and is an internationally recognised qualification. It is likely to sit well on your CV, particularly as the Department of Health has endorsed the examination.

All of these skills may be self taught. Many hospital IT departments run introductory programmes however and most local educational authorities run inexpensive adult learning courses.

Generic skills

The South West Deanery has established a programme of workshops for doctors and dentists in training entitled Developing professional skills. It is generic and covers areas not necessarily taught in specialty specific core training. The modules on offer are found in box 4. The course is designed to ensure that future consultants meet the increasingly demanding challenges of working in the new NHS. The programme is offered by the Deanery at no cost and travel expenses incurred may be refunded. The opportunity is there for aspiring SpRs and such initiatives are likely to be offered nationally.

Box 4 Developing professional skills

  • Information management and technology

  • Management skills

  • Team working

  • Assessment and appraisal skills

  • Clinical governance awareness

  • Teaching skills

  • Presentation skills

  • Interviewing skills

  • Communication skills

  • Mentorship and counselling

  • Evidence based practice

  • Ethics and the law

  • Working and learning in the new NHS

PROGRESS THROUGH THE SpR YEARS

The five year rotation in emergency medicine is geared towards obtaining a certificate of completion in specialist training (CCST). In keeping with other specialties, satisfactory progress through the programme is assessed annually, the Record of In-Training Assessment (RITA). You can expect to negotiate a learning plan with your nominated educational supervisor each year. This learning plan will form part of the new Personal development portfolio (scheduled for introduction in late 2002) and will be shared at the RITA. The learning plan will be based on a self assessment checklist, your CV to date and your knowledge gaps. Quarterly appraisals with your education supervisor should confirm progress with the agreed plan. Box 5 outlines the four sections of the portfolio and further details are available.3 The portfolio would seem to endorse a culture of reflective practice and lifelong learning. A recent article “Getting the best out of RITA”4 usefully covers preparation, grading, and coping with an unsatisfactory RITA grade. Finally, successful completion of the examination of the FFAEM is a notable hurdle in attaining the CCST. Examination details including eligibility, format, scope, and guidance to examiners are available on the faculty web site (http://cebm.jr2.ox.ac.uk).

Box 5 Sections of the new personal development portfolio

  • Personal details and career summary

  • Personal development records

  • Record of achievement (courses, publications, presentations, audit)

  • Appendices (CV, curriculums)

CONCLUSION

Remember that you are presenting yourself (and your CV) as “different” to everyone else. You believe as a person that you have something special to offer emergency medicine. So after you have “ticked off the boxes” outlined in this paper, don’t let the “boxes mould you”! Know your own strengths and weaknesses and value your own contribution. Let that speak. Good luck!

Acknowledgments

We are grateful to Kirsten Jones and Tom Llewellyn for producing the person specification (table 1).

Contributors

Gavin Lloyd wrote the bulk of the paper. Íomhar O’Sullivan, Nigel Rawlinson, Clifford Mann and Adrian Harris contributed ideas and edited the paper. Gavin Lloyd acts as guarantor of the paper.

REFERENCES

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Footnotes

  • Funding: none.

  • Conflicts of interest: none.

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