Acute care common stem pathway

Acute medicine

The unselected medical take enables trainees to gain confidence in managing common acute medical conditions. Presenting at post-take ward rounds is an important part of learning. Working in a busy acute medical unit for a six month period provides a wealth of clinical exposure to a wide range of conditions. The rapid turnover of patients in a busy acute medical unit provides access to a range of unwell patients and is a great learning opportunity, as dedicated input from senior doctors is close at hand. The exact configuration of this post varies, depending on how the local acute medical unit is run, but it is important to obtain maximal exposure on the acute medical take.

Emergency medicine

ACCS trainees are given a greater level of responsibility than are foundation doctors in emergency medicine, with the aim of maximising experience. Trainees become well acquainted with initial management and referral of a range of conditions, from common medical and surgical presentations to specialty problems in orthopaedics, gynaecology, ear, nose, and throat surgery, and psychiatry. Furthermore, participation in adult resuscitation, paediatric resuscitation, and trauma calls consolidates skills acquired from courses in advanced life support, advanced paediatric life support, and advanced trauma life support.

Anaesthesia

Novice trainees spend the first three months working towards the “initial assessment of competency.” This establishes basic principles of anaesthesia and, once achieved, allows participation in the on-call rota. Initially there is daily one to one training with consultants to gain the theoretical knowledge and practical skills needed for preoperative assessment, induction and maintenance of general anaesthesia, perioperative care, and management of cardiac arrest. This is a valuable opportunity to develop skills in airway management, including bag mask ventilation, airway adjuncts, laryngeal mask airway insertion, intubation, and rapid sequence induction, which cannot be gained in any other specialty.

Intensive care medicine

Intensive care medicine provides a blend of knowledge and hands-on experience in managing acutely unwell patients. Trainees gain exposure to organ support with non-invasive and invasive ventilation, inotropes and vasopressors, renal replacement therapy, and fluid management. During outreach work trainees are often the first point of call, recognising acutely unwell patients and instigating initial management. There is the opportunity for active involvement in resuscitation, sedation, hospital transfers, and procedures such as invasive and arterial line insertion, which are valuable skills whatever final specialty is chosen.

ACCS versus core medical training

Pros—ACCS guarantees exposure to acute or emergency care and intensive care medicine to give trainees confidence in managing the acute take before higher specialty training. It enables achievement of procedural competencies (invasive lines, airway skills) that may not be acquired on a core medical training pathway. Working in the accident and emergency department and the intensive treatment unit (ITU) exposes trainees to a broader range of specialties to give a working knowledge of surgical emergencies and complications, psychiatry, obstetrics and gynaecology, and ear, nose, and throat. The environment of ITU, theatres, and accident and emergency means that team working skills become highly developed. This route also enables trainees to gain the competencies required for higher training in ITU if so desired.

Cons—When going on to a medical specialty registrar post, trainees have a less diverse grounding in medical specialties (depending on the local design of the CT2b rotations). The schedule is tighter, and there is less “medical” time to acquire the knowledge and skills for MRCP exams. Furthermore, there is less academic opportunity in the ACCS route, as trainees move between diverse jobs.

ACCS versus core anaesthesia

Pros—Exposure to emergency and general medicine provides confidence and a broader understanding in managing common medical, surgical, and specialty problems encountered as an anaesthetist in theatres and ITU and when reviewing ward patients. This also has the benefit of meeting minimum requirements for complementary specialty experience to enter higher intensive care medicine training later on. The skill sets gained through ACCS are broader. A more general outlook can be maintained than in direct entry to anaesthesia from the foundation programme.

Cons—The design of the ACCS programme means that the schedule to complete the FRCA primary exam may be tighter and pressure to gain specialist anaesthetic core competencies in paediatrics and obstetrics is greater. There is also the risk that trainees emerge from ACCS with less total anaesthetic training time than in the core programme (depending on the local programme design).

ACCS versus non-training emergency medicine posts

Pros—Although an emergency medicine training programme that entails only six months of emergency medicine in the first two years might seem inadequate, the skills and experience gained in the acute specialties are of immense value. The role of the future emergency medicine specialist is to be competent in diagnosing and managing a wide range of conditions. The confidence gained in anaesthesia and intensive care medicine, which is outside most trainees’ experience before ACCS, pays dividends when treating the most unwell patients in the emergency department’s resuscitation room.

Cons—Less time is spent in the emergency department.

The box summarises the advantages and disadvantages and qualities of the ACCS pathway and the required qualities.

The ACCS programme is an exciting opportunity to acquire a diverse range of knowledge and skills in acute care that will leave you in good standing whatever your final choice of specialty.