Intended for healthcare professionals


Acute care common stem: trainee’s perspective

BMJ 2009; 339 doi: (Published 12 August 2009) Cite this as: BMJ 2009;339:b3167
  1. Nitin Jain, year 2 core trainee in acute care common stem emergency medicine
  1. 1James Cook Hospital, Middlesbrough
  1. nitin.jain{at}


Nitin Jain describes what trainees can gain from acute care common stem placements

Acute care common stem training was started in 2007 as a common entry point for four specialties: acute medicine, anaesthesia, emergency medicine, and intensive care medicine.1 Although it is the sole entry point for training in emergency medicine, acute care common stem training is an alternative entry point for training in acute medicine and anaesthesia. Currently, intensive care medicine does not have a separate certificate of completion of specialist training, and trainees who wish to train in intensive care medicine can progress from any of the three specialties (emergency medicine, anaesthesia, and acute medicine). All three specialties have a separate third year after the acute care common stem before higher training; therefore, most deaneries are now offering a three year programme in the respective stream.2

Clinical experience

Emergency medicine is an excellent place to see a variety of major surgical and medical emergencies, apart from trauma and paediatric, psychosocial, and gynaecological and obstetric emergencies. The hours are usually long, however, and you may have no social life. You will have an opportunity to develop communication skills and work in a multidisciplinary team.

From the acute medicine point of view, a placement exclusively in an acute assessment unit is more useful than attachment to a medical firm with medical on-calls. During this time you can expect typical medical takes and should aim to cover most of the curriculum. Always try to present your case and discuss the clinical presentations and management decisions on the ward round. Some assessment units have a short stay ward, and time spent on these units helps to build confidence in managing this group of patients.

Intensive care medicine is a steep learning curve and it is useful to keep a record of interesting cases you have seen. You will learn a range of procedures such as central line placements, arterial line placements, setting up ventilators, use of infusion pumps, and transferring patients. You should take every opportunity to evaluate sick patients on the wards and discuss the further management or escalation of care decisions.

A placement in anaesthesia gives an excellent opportunity to gain skills in advanced airway management and some regional nerve blocks such as femoral and wrist blocks, which are easy to learn and useful in practice. Day case lists of ear, nose, and throat patients are an excellent way to gain airway and paediatric experience. Maxillofacial and dental lists are useful in difficult airway management, awake or asleep fibreoptic intubation, and learning various dental blocks. Orthopaedic lists provide a good opportunity to do various regional and neuroaxial blocks. Emergency and general surgery lists are useful for learning rapid sequence inductions. An anaesthesia placement before intensive care medicine will help you to consolidate your anaesthetic skills.

Acute care common stem curriculum and annual review of competence progression

The aim is to get outcome “one” after every annual review of competence progression.3 You will have to produce an evidence summary which should map the competencies with the curriculum.

Competencies to be achieved at the end of two years

  • Generic acute care common stem competencies

  • General internal medicine (acute) level one competencies

  • Specialty training year 1 emergency medicine competencies (written in normal text in emergency medicine curriculum)

  • Initial test of competencies in anaesthesia

  • Specialty training year 1-2 anaesthesia (in part)

  • Core competencies in intensive care medicine

  • Procedural and investigation competencies

The acute care common stem curriculum encompasses the curriculum from four different specialties and you should follow not only the curriculum of the specialty you are working in but also that of your parent specialty. An acute medicine trainee working in emergency medicine would, therefore, be expected to follow both the acute medicine curriculum and the emergency medicine curriculum at the same time.

Most deaneries have provided guidance regarding minimum workplace based assessments required for trainees to proceed through the annual review of competence progression.4 You should discuss your training needs with your educational supervisor as soon as possible. This will help you to map out the competencies that you need to gain in the respective placements. You should also enrol with your college at the earliest opportunity and use the respective forms for recording the assessments.

Maintain a portfolio

The emergency medicine, acute medicine, and anaesthesia portfolios are now fully online and following them from the start of your training will help you in mapping the evidence against the curriculum. You should make and agree a personal development plan with your trainer and keep all the documents in the portfolio.

Most of the competencies overlap; therefore, one piece of evidence can be used to show multiple competencies.


  • Workplace based assessments

    • Direct observation of procedural skills

    • Mini clinical evaluations

    • Acute care assessment tool

    • Case based discussion

    • Multisource feedback

  • Reflective practice

  • Learning modules

    • E-learning for anaesthesia5

    • BMJ Learning


  • In-house teaching

  • Attendance at meetings and conferences

  • Audits, presentations, and publications

  • Learning from practice

  • Life support courses

  • Postgraduate exams

    • Membership of the College of Emergency Medicine

    • Membership of the Royal College of Physicians

    • Fellowship of the Royal College of Anaesthetists (primary)


An excellent logbook in anaesthesia is available from the Royal College of Anaesthetists website. The intensive care medicine logbook is in Excel format and you should try to keep a short account of the cases entered. It is more difficult to keep a record of acute medicine and especially emergency medicine cases. Some hospitals have electronic input of patient information and it might be possible to get a list of the patients you have seen.

In emergency medicine you should try to keep a list of resuscitations, trauma scenarios, cardiac arrests, paediatric patients, and practical procedures to map with the curriculum.

After the acute care common stem

After uncoupling, trainees in acute medicine and anaesthesia will have to compete with core medical or pure anaesthesia trainees for specialty training year 3 places. You will also have to consider that the exam requirements are the same and therefore clinical experience may not be enough to do the exams. Royal colleges have given separate guidance covering the trainees in these situations.1

Whatever stream you choose, the acute care common stem provides a useful understanding of acute patient management. It gives an insight into the work of other professionals and is, therefore, excellent for teamwork and a multidisciplinary approach, which are so often required in the management of acute patients.


  • Competing interests: None declared.


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