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Response to Letter to the editor: Acute Medicine Journal

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Editor- Thank you for giving us the opportunity to respond to the letter received regarding the Joint Royal College of Physicians Training Board (JRCPTB) curriculum for Acute Internal Medicine (AIM) that has previously been circulated for comment and consideration of implementation in August 2022. Dr Williamson is correct in asserting that the proposed curriculum hopes to produce doctors with generic professional and specialty specific capabilities needed to manage patients presenting with a wide range of medical symptoms and conditions. It does aim to produce a workforce that reflects the current trends of increasing patient attendances to both primary care and emergency departments- one that has a high level of diagnostic reasoning, the ability to manage uncertainty, deal with co-morbidities and recognise when specialty input is required in a variety of settings, including ambulatory and critical care.

Contrary to the situation described in the correspondence, the new curriculum does not move away from each trainee being required to develop a specialist skill, such as medical education, management, stroke medicine or focused echocardiography. Trainees will still need to acquire competency in a specialist skill for their final 36 months of their training programme, usually after they have completed their Point of Care Ultrasound (POCUS) certification.

The thinking behind introducing mandatory POCUS in the curriculum is that:

  1. POCUS is in the proposed curricula for intensive care medicine, respiratory medicine and emergency medicine, therefore we feel that in order to recruit the best trainees it is imperative POCUS training is offered as standard
  2. As evidenced by the trainee surveys, they often do not get allocated time to develop their specialist skill, especially in the early years of Higher Specialty Training before they often have decided on a particular skill. The introduction of mandatory POCUS training should legtimise time off the ward to obtain this skill early in training.
  3. POCUS is becoming more and more standardised in 21st Century acute care alongside the reducing costs of Ultrasound probe e.g. Philips Lumify and Butterfly iQ which are compatible with smart phones
  4. POCUS has been heralded as the fifth pillar of examination (observation, palpation, percussion, auscultation, insonation)1

The proposed curriculum therefore facilitates trainees to have regular dedicated time to develop interests inside or outside acute medicine to supplement their professional experience and training. This will also enable trainees to have time away from the ‘front door’ high intensity acute care. Mandatory POCUS will continue to set AIM training apart from other physician training programmes and continue to attract high quality trainees to apply to the specialty.

Formal feedback seen at the SAC meeting in October 2019 to the draft curriculum (personal correspondence from JRCPTB) showed a positive response from nine individuals, an ambivalent one from two people, and only two against the introduction of formal POCUS training in the curriculum.

Point of Care Ultrasound will likely be a welcome addition to the curriculum and will benefit patients, trainees and front door services up and down the country. Concerns regarding supervision are being addressed by the POCUS working group, in anticipation of the lead in period of well over two years. It is anticipated that most trainees can achieve POCUS sign off (e.g. Focused Acute Medical Ultrasound) in 6 to 12 months (personal correspondence Nick Smallwood from POCUS working group).

With ongoing concerns regarding recruitment and retention in Acute Internal Medicine we agree strongly that with POCUS inclusion, we have a further selling point for AIM training.

Reference

  1. Narula J, Chandrasekhar Y, Branwald E; Time to add a fifth pillar to physical examination: inspection, palpation, percussion, auscultation and insonation. JAMA Cardiol. 2018 1:3(4) 346-350 doi 10. 1001/jamacardio.2018.0001.
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