Emergency Medicine Partnership
Torbay Emergency Medicine Dept and Nanyuki Hospital Kenya
By Dr Niki Burke (SAS Emergency Medicine – South Devon Healthcare NHS Foundation Trust)
The need for Emergency Medicine input at Nanyuki hospital was initially raised when the hospital was visited by consultant, Mr Chris Manlow in 2011; he was part of a team delivering a Primary Trauma Course at the time. The hospital was recently in receipt of funding for an Emergency department build and in a position to develop their practice. This was to be the first specialist department of its kind in the area. In light of these anticipated changes, senior members of staff from Nanyuki hospital visited us in the UK to explore how we work. They requested a team visit Nanyuki to assist with the start-up of their service.
A team of three led by an experienced staff grade doctor (Dr. Niki Burke), senior registrar (Dr. Matt May) and senior nurse (Miss Jennifer Simm) were selected to go to Nanyuki in June 2012. They had an open brief to observe and begin to formulate ideas for interventions and assistance. The team prepared with background research on the concepts and evolution of modern emergency medicine and department design. Up to date department of health policy, methodology of remote medicine, mass casualty, medicine in austere and limited resource situations and much more were researched. Teaching material was prepared in advance on those topics. Pre-requested material on mechanical back pain in the emergency department was created.
Feeling as well prepared as possible the ED team undertook an overnight flight to Nairobi as part of the MEAK/KOP project from Torbay hospital. We arrived at Nanyuki hospital the following afternoon. There followed a series of formal meetings with senior hospital staff to welcome the medical project, and the ED team had the opportunity to meet the clinical officers and nursing staff they would be working with. As newcomers to the hospital we were also treated to a guided tour of the hospital site. There followed that evening a strategy meeting. The team decided to directly observe clinical care with the clinical officers the following morning.
Dr Matt May and Dr Niki Burke were welcomed into the consulting rooms and shared consultations with the clinical officers working there through the morning. Jennifer Simm, team nurse, spent that morning with the outpatients nurse sharing her work experience. We all observed striking pathology. We were impressed with the clinical knowledge and pattern recognition of the staff. It was apparent to us all that there were issues with the current service offered to patients. There is a lack of resources that in some way is being addressed by the new build. The frequent use of injectable medicines is a cost and manpower problem, and has its roots in the history of health care development in Kenya. Infection control challenges are huge, hampered by resources and lack of facilities. ‘Outpatients’ is used for general practice and emergency care and needs some assessment process to pre-select unwell patients. Admission to the hospital separates patients from clinical staff and treatment for a period that put the sick at risk. There is an under used staff resource in experienced ancillary staff and security officers who are keen to improve and participate in care but lacking confidence to do so.
The team felt there were areas where targeted sharing of practice and ideas could provide alternative strategies to the Nanyuki staff. We spent the next 24 hours remodelling the material we had brought and creating bespoke sessions in order to achieve this. There grew a portfolio contents listed;
- Emergency medicine as a concept, the skill sets and expertise
- Assessment methods (triage)
- Initial assessment and treatment of the critically ill using ABCDE
- Practical scenarios on assessment and ABCDE
- Use of injectable medicines in emergency care
- Mechanical back pain sessions for the hospital medical education meeting (CME) and Kenyan medical association (KMA)
- Assessment methods for non-medical staff
Candidates for these sessions were determined prior to our arrival to secure release from clinical duties. In total we trained 40 clinical officer interns, 10 senior outpatient nurses, 50 multidisciplinary staff at CME, 20 local doctors at KMA and 10 ancillary and security staff.
Feedback was overwhelmingly positive, George Mochama as the senior clinical officer was delighted at the diverse teaching styles and active facilitation of learning used. He was keen to emphasise to his interns the variety of ways learning can be achieved. The senior outpatient nurse Harriet felt we delivered exactly what was needed at this stage. Formal feedback was carried out with feedback forms, with 100% uptake. 85% of responses gave top marks and the rest just less than. We were scored on usefulness, understanding, potential service improvement, importance and effectiveness of sessions. Most feedback was accompanied with personal and positive comments such as;
“It is perfect”
“This is the best workshop ever”
“The workshop was very educative, presented in a very entertaining way…making learning more enjoyable…helping us to learn more…please do come more often”
“Make this information available to as many clinicians as possible”
“Please give us more of this”
“Facilitators were lively and had good ways of communicating”
“Improve by inviting more emergency care teams from the UK for training”
“It is the best way to learn”
The ED team also felt their success was measurable in what we came home with. Huge lessons were learnt from the Kenyan staff who displayed great emotional intelligence and communication skills towards each other. They had an ability to work confidently and creatively in a situation of limited resource, adapting modern medicine to the limitations of their situation. We developed different perspectives on our own clinical practice and UK health care. Team working, mutual understanding and leadership are skills we had to use and improve on to deliver the best possible quality of material. We all evolved as facilitators and educators, stretched ourselves and became more self-aware, independent and inspired. It is only as time goes on after the project we are fully realising the benefit individually and to our ED.
The Torbay emergency department is committed to an on-going and consistent provision to this end, involving pre hospital as well as emergency department personnel and expertise. Team 2012 have produced and exhibited a poster for this year’s THET (partnerships for global health) conference. The conference was very educational, and provided inspiration on how to achieve further projects within the constraints of working in the NHS. We hope to demonstrate via the national skills framework the concrete benefits of this type of work both to individuals and the trust as a whole, as well as improve access to the project by building it securely into CPD processes. We continue to support their candidates through modern social networks and monitor progress.
Niki Burke was funded by SAS development monies, and as a result of the success of the initial Emergency medicine visit she is supporting a follow up visit by a junior registrar this November. That phase will reinforce the initial educational project and attempt a test of change with formal audit. After which she will be applying for further funding to return in February herself with a new and extended emergency medicine team to evolve and extend the programme, looking at further reinforcement of the current programme and extension into the community. There are plans to involve paramedic teams and roll out community first aid / first responder education. There will be added support in February from simulation education experts, Niki and her proposed team are qualified to deliver 3D simulated training and are looking at innovative ways of making this happen in Kenya with limited resources.
MSc in Pain Management
I have worked part time in SAS posts (Anaesthetics) for many years because of family commitments. Rather than return to a training post, I decided to study for an MSc in Pain Management at Cardiff University. This was to support a sub-specialist interest in Pain Management which I took on with a new post. Although many specialist nurses get funds from their employing Trust to study to Masters level, I was self-funding. My study leave budget was used for ongoing anaesthetic CPD but I was able to access SAS development funding towards some of my MSc costs.
I have now completed my course and am waiting to hear the results. My dissertation subject has been directly relevant to developing our pain service and I have been encouraged to take a leadership role on this basis.
I feel that I will have a qualification to demonstrate my commitment to my work and the course itself has fired my enthusiasm for research and evidence-based practice.
MSc in Healthcare, Ethics and Law
Having changed jobs from being a trainee to a specialty doctor in Anaesthesia I wanted a new challenge that was not directly related to my specialty. I have always been interested in the law and in day-to-day work I come across a plethora of ethical dilemmas. I found a distance-learning MSc in Medical Ethics and Law through Bristol University (entry point every two years) that would allow me to pursue these interests and gain a postgraduate qualification whilst still working. The MSc is divided into credits and this allows one to leave at certain points: with a postgraduate certificate, diploma or the full MSc. As with many courses it costs money as well as a dedicated amount of time and effort; the SAS development fund has supported me in pursuing this.
I hope in the future that I may be able to become more involved in the hospital ethics committee and know that the background reading will allow me to reason ethical dilemmas more clearly. It is really enjoyable to be able to apply one’s mind to studying a subject outside of medicine and whilst being a lot of hard work it is fun being a student again!
Update 2 years later….
I embarked upon a distance-learning MSc course at Bristol University in the autumn of 2010. The course covered six aspects of healthcare ethics and law plus a dissertation with a topic of our own choice to complete the masters degree.
The initial three topics: an introduction to ethics and law; patient-centred issues; professional issues in healthcare ethics and law lead to a postgraduate certificate.
The next topics were: decision-making at the beginning and end of life; children, young people and health care: ethical and legal dilemmas; research ethics, which enabled me to achieve a diploma.
The certificate and the diploma each required seven days in Bristol for tutorials and then an estimated sixty hours of work including research and essay writing
In order to progress to the masters degree there was a day in Bristol followed by planning, researching and writing a dissertation on a subject of our own choosing. The topic I chose was: Can women in labour consent to anaesthetic interventions (regional anaesthesia)? Following the completion of this piece of work, which the university once again estimated to take sixty hours, I was awarded an MSc in Health Care Ethics and Law with merit in December 2012.
The two years has at times been difficult, especially finding the time to study outside of regular work, and I have also had to do some of the study days in Bristol in my own time since I have used up my study leave for other components towards revalidation. I have really enjoyed the process of studying for a higher degree that is related to my work yet is completely outside of the confines of the hospital. It has enabled me to learn about ethics and law but also to see them from the point of view of other healthcare professionals. I am more aware of ethical and legal issues in my day-to-day practice which I feel has made me a more considerate practitioner.
I have also been invited to join the hospital ethics committee for a six-month period and am really looking forward to putting the theories that I have learnt into practice. This was one of my aspirations and means I can use my specialist knowledge for the benefit of the patients of the Trust.
I have been extremely privileged to have had the opportunity to do this MSc with the support of the SAS development funding, I couldn’t have done it without this funding and it has helped me to develop myself as an SAS doctor.
I have been most grateful to the SAS development fund for financing three educational days this year. My hospital study allowance had been taken up with core training. Having funding to attend a training day in digital mammography, which will soon be implemented in our unit, allowed me to better appreciate and understand the anticipated transition phase from other clinicians who had been through it. Attending the Breast Clinicians annual study day and AGM in London was not only of great educational value but allowed me to meet several other SAS grade doctors and share experiences of working in my specific field of medicine, which is almost entirely staffed by SAS doctors. Without these funds I would have struggled to take part.
Diploma in Paediatric Palliative Medicine
I completed a Diploma in Paediatric Palliative Medicine (distance-learning) from Cardiff University recently and received funding from the SAS development fund for 2009/2010. It was hard going initially, trying to complete the modules/assignments on time while working full time. There was loads of material to read as well and I had to squeeze time between my other work to get it done. However it was well worth it.
There is a tendency to get carried away with day to day service provision, which most SAS doctors do and limited opportunities for teaching at the work place. Doing a diploma like this forced me to undertake teaching/learning, and at the same time was very interesting. My awareness of symptoms control, medications, research methods, communication skills and team working improved tremendously. I could apply the knowledge I was getting into my daily work, for example to provide appropriate management for a patient with very challenging symptoms related to her nerve pain. The communication skills modules were very relevant, considering my previous practice in a different sociocultural background.
The course is mostly online and you only need to attend 2 days per year at University.
GP becomes Psychiatrist
I am a consultant psychiatrist in Somerset. I was awarded a CESR approximately one year after submitting my final application to PMETB (Postgraduate Medical Education and training board, which has now merged with GMC) in early 2009.
I had no expectation that it would be a speedy process, and was not disappointed! It really took 2 years; once I made the decision to go for it, I bought a box file and started to fill it with what I thought was reasonable and valid evidence. The application form tells you what this should be and how to put it in order. It took me around a year to gradually collect these things and address the missing bits. Your line manager essentially has to stamp and sign every sheet of paper validating the application – so you need to trickle feed this to whoever agrees to do it – it’s a fairly big task!
PMETB allocated me a Certification Officer who checked my initial submission and sent the lot back a couple of months later (my heart sank), with an attached ‘Checklist’ listing all the weak points in the application with suggestions on how to address these before the final submission.
In summary, be extremely patient and don’t stop contacting your Certification Officer regularly (monthly) for updates and prompting them to chase things up.
If you are applying for CESR and want to contact the author, please email Maisie Shrubsall.
Sexual and Reproductive Health
Last year I was working as an Associate Specialist in sexual and reproductive health. This was really interesting, challenging and gave me opportunity to take part in teaching, audit and management. I am now working as an ST3 in c-SRH (community sexual and reproductive health, a new specialty) within the same department having gone back into training and am loving it.
Why did I do it?
There were many reasons. These were primarily in relation to future job opportunities and in order to undertake specific training in areas that had always interested me but that I had never had the opportunity to do before (such as gynaecological scanning and public health).
How did I go about it?
I found the application process stressful and immensely onerous. Allowing plenty of time was the key – it took a month to complete the application form! I had to provide evidence of Foundation Year competencies (Alternative Certificate A) as proof of (e.g) venepuncture. This was hard to complete as I had been working outside of acute medicine for several years. I therefore had to write to my A&E and general medical consultants from 10 years ago who signed off what competencies they felt they could then my current consultant signed off the form based on their evidence. I found that using the person specification and scoring system (provided with the job advert) to guide me as to what to include on the application form was very useful.
In preparation for the interview I spoke to as many senior colleagues as possible about current hot topics and possible interview questions. I attended an interview skills course which was immensely useful. I put together a folder containing work placed based assessments, peer and patient feedback, certificates for postgraduate qualifications and courses and conferences attended (in order to document evidence of experience). I practiced interview questions in front of the mirror and rehearsed the 5 minute presentation required at interview with a stop watch to ensure that I stuck to time.
What’s it like now?
I’ve now been back in training for 4 months and am really enjoying it. I’m based both within my old department and also in the gynaecology department at a local hospital where I’d never worked before. I feel very lucky to have the time and support to learn new skills, and everyone in both my old and new work places have been welcoming and genuinely interested to hear what I’m doing. Going back to being a trainee within my old department has been particularly easy as it is very non-hierarchical with doctors and nurses of different grades working alongside each other. However entering a new department as a trainee has at times taken me outside my comfort zone. I’ve felt very much the new junior surrounded by colleagues who are younger but in some ways more experienced. As time goes by I have been able to appreciate how much we all learn from each other and that I am also bringing new skills into the department.
It wasn’t an easy process applying to go back into training, but all the hurdles have been definitely worth it.
Educational Supervisor - Staff Grade in Paediatrics
I was delighted to be approached by the Deanery to ask me if I wanted to become an Educational Supervisor to three Foundation Year One doctors. I do a lot of clinical supervision for our juniors that come through the department, and was interested in the educational aspect, so took myself off on a study day where I met GPs and Consultants who were supervisors already.
I have three F1s that I see regularly. It is really pleasing to see them through this first year as doctors. The enthusiasm that I witnessed the first time we met was infectious.
These early training years are very different now, and it is encouraging to see the doctors keen to participate. I have to talk to their clinical tutors and consultants if they are not being released for teaching, and we discuss how we can ensure enough cover for them, negotiating if necessary, to ensure that they hit their target of at least 75% attendance.
Equally, if there are concerns about their ability I talk to those supervising and we look for where problems might be arising. I then talk to the doctor, and see what they feel. Sometimes the consultants’’ expectations are too high, and this balance needs to be redressed.
I found one doctor had issues with a more senior colleague, which he had been trying to manage, and all he needed was encouragement that we are supporting him. This enabled him to tackle the issue directly with positive results. The next time we met he was enjoying the job much more. I do a lot of listening, ask a few questions, and maybe probe a little deeper. It is very much facilitation, helping the doctor solve their own problems.
I am shortly seeing them all again as they move onto their second jobs. I shall see how their career plans change as they gain new experiences; I shall watch their knowledge and confidence as doctors grow, able to think, rationalise and diagnose, which is a rewarding part of the job.
For the educational supervision, I get an hour per week in my job plan; my consultants know and allow me the time. The time I actually spend is about 10 hours per 4 month placement as a minimum, which might become more as issues arise. The hardest thing, on a part time contract, is trying to find time to meet all three early in their placements. But we manage it.
My route to CESR
When I joined SAS grade back in 2006, I almost accepted it as a destiny (after a few unsuccessful interviews for registrar post and then came MMC) until I came across a newly appointed consultant via CESR route.
Then I started collecting the evidences as mentioned on GMC website, which almost all of us practice in our day to day professional life but do not collect/or see as an evidence i.e. formal/informal teaching of FT/CT/ST trainees. It took me almost a year to gather all the evidences and get them verified according to GMC’s specifications.
After going through the required criteria, I applied to GMC to obtain CESR. But unfortunately, I did not meet the standard required when matched with newly qualified CCT trainees, as the curriculum was changed in August 2010. The GMC asked me to get the new evidences of my experience in some of the subspecialties and my involvement in Leadership and Management activity.
It was clear I would have to arrange some “top-up” training for myself. I spent 4 months, contacting training programme directors in my specialty and Consultants in various deaneries in the UK, either directly or with help of Consultants in my department, who have all been helpful in encouraging me to complete the requirements. Eventually, I got my first breakthrough – a 3 months paid post in a neighbouring trust. The human resources (HR) department in my trust raised issues regarding gaps in service delivery which my absence would leave. But with the support of the Clinical Director of my department and my willingness to help the rota as possible, I was able to take unpaid leave as this was the convenient way.
Once a door was opened, it led to others. It is hard work to leave my base hospital and work in different departments in unfamiliar surroundings, and also it requires lots of commuting. I have had to compete with local trainees in knowledge and skills, but all the Consultants I came across were very helpful and encouraging. Now after nearly 10 years long professional journey in the UK (and that is after already holding overseas post-graduate qualification, skills and experience) I have almost completed the required top-up training and can see the light at the end of the tunnel.
CESR via change of specialty
I had intended to achieve specialist registration by the standard route, having passed MRCP (UK), completed an MD in Oncology, and started a Clinical Oncology specialist registrar rotation December 2003. However, after six years of training and being unsuccessful at completing Part 2 of the Clinical Oncology exams, I came out of the training scheme and took up a Specialty Doctor post in oncology at a district general hospital. In my new role I was given a lot of responsibility and autonomy with consultant support on hand if necessary. While it became evident that I still enjoyed the specialty, I also realised that I was better suited to Medical Oncology (focus on the drug treatment of cancer) rather than Clinical Oncology (radiotherapy and drug treatment).
Colleagues in my new job gave me excellent feedback on my clinical knowledge and judgement which, while encouraging and welcomed, didn’t count for much outside the department without a specialist qualification to back it up. This led to me doing the specialist clinical examination in Medical Oncology which I passed at the first attempt in 2011- this was good to back up my daily practice and I was going to leave it there and continue in my role as a Specialty Doctor. However a work colleague encouraged me to go for CESR especially as I appeared to have covered the necessary curriculum items.
This spurred me on to look into the process in more detail. The GMC website provided guidance on eligibility, as well as indicating what I needed to include in my evidence bundle. It was pretty specific about how to select the 6 colleagues to provide structured reports. The specialty curriculum was extremely detailed and felt overwhelming, but a web-search of the annual targets (ARCP items) necessary at each year of training (had I followed the standard specialty training route) proved to be very helpful. The Divider Pack on the GMC website showed what types of evidence were needed, eg qualifications, assessments and appraisals, log books, details of previous posts, research, publications, teaching and training, audit, etc.
Then I went through my CV identifying gaps. You have to provide evidence of all previous employment posts with dates and supervisors listed, many of the documents need validation and authorisation. I set myself a target of a year to complete my application and send to the GMC. I was allocated an adjudication officer who reviewed my evidence bundle on two separate occasions and indicated any gaps or clarification needed. This was an extremely valuable service that ensured that I was happy with my final submission. The GMC sent my application and evidence bundle to the Royal College of Physicians. Within four months I was delighted to hear back from the GMC that I had been successful and was now on the specialist register for Medical Oncology. While waiting for the decision, I secured a substantive consultant post conditional on a successful CESR application.
I would say to anyone thinking about CESR: look first at what you have done and what gaps there are. You can then estimate how long it will take to fill the gaps before putting in an application. By approaching it in this way, you will give your application the best chance of success.
MSc in Breast Evaluation and Radiology
After completing essential training in breast ultrasound and mammography through the University of Kingston to enable me to work as a Breast Clinician I decided to embark upon an MSc in Breast Evaluation and Radiology with the help of the SAS development fund.
I was able to undertake a broader scope of learning by using these funds to pay for modules to complete my Masters. The dissertation module took 12 months to complete and I undertook a large project which has looked at the impact of digital mammography on our unit. This is now waiting to be published and I was awarded a distinction. Other modules funded enabled me to put together a mock-up business case for new equipment we need to purchase. This work is now being used within the formal business case and has been accepted by my peers as being completed to an exceptional standard.
Without the SAS funding I would not have been able to achieve the MSc, which was awarded with commendation. It has allowed me to push myself academically, broaden my scope of understanding within my specialist area and prove myself at a senior level within healthcare. The results of the digital mammography project have contributed to improved patient care pathways within the department and service planning for the future.