An introductory educational module for cardiothoracic trainees
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《血管的通路杂志》
Department of Cardiothoracic Surgery, Yorkshire Heart Centre, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
Abstract
In an attempt to enhance training we have developed an innovative introductory educational module for cardiothoracic trainees. Newly appointed cardiothoracic trainees at the Yorkshire Heart Centre in Leeds have piloted a 6-month programme, comprising 3 months attachment to the Cardiothoracic Intensive Care Unit, and 3 months seconded to allied departments. This report describes this programme, and considers its advantages and disadvantages.
Key Words: Education; Training
1. Introduction
The training of junior doctors has never been a more contentious issue. Whilst a number of issues have impacted on the quantity and quality of training [1], the problems facing trainees seem to be particularly pronounced in cardiothoracic surgery [2] (Table 1).
One of the consequences of recent changes to cardiothoracic training has been the appointment of trainees with relatively little previous experience in cardiothoracic surgery. In addition to limited operative experience, there is an important lack of clinical knowledge and of experience in critical care. Furthermore, the introduction of seamless training (Fig. 1), in 2005, will mean that trainees will be accepted onto a cardiothoracic programme during their 3rd postgraduate year, without having undergone any basic surgical training. In an attempt to correct some of these potential shortcomings, we have introduced an innovative educational programme aimed specifically at trainees during their first year of cardiothoracic training, which provides the opportunity to develop relevant essential knowledge and clinical experience in preparation for conventional surgical training. In the current system, first year trainees have already completed 1 year of internship after medical school and up to 3 years basic surgical training, including a period in cardiothoracic surgery, before gaining competitive entry onto a cardiothoracic training pro-gramme.
This introductory education module lasts for 6 months. Three months are spent on the Cardiothoracic Intensive Care Unit (CICU), and 3 months are spent gaining clinical experience in departments allied to cardiothoracic surgery: Extracorporeal perfusion, Cardiothoracic anaesthesia, Cardiology, Respiratory medicine.
2. Cardiothoracic intensive care unit
For patients undergoing cardiothoracic surgery, the CICU functions both as a postoperative surgical recovery unit and as a true critical care facility. Three months covering the 14 bed adult and eight bed paediatric intensive care units provides extensive experience in the management of both straightforward and complicated cases. Embodied within this experiential learning is an explicit series of learning. These outcomes are defined in the new competence based cardiothoracic curriculum. Under the supervision of intensivists, a number of practical skills are developed or refined, for example central venous cannulation, floatation of pulmonary artery catheters, intubation and percutaneous tracheostomy. The opportunity to develop these practical skills under close supervision on the paediatric CICU was particularly valuable.
The trainee liaises closely with intensive care and anaesthetic colleagues. Time dedicated to CICU allows trainees to follow the diagnostic and management process from initial stages to conclusion, an opportunity often lost in the usual schedule of a cardiothoracic trainee.
The trainee routinely holds the emergency pager, and handles all acute referrals during the day, being available for advice or direct involvement in A&E, for example. This experience was valuable to both the trainee and to other departments requiring a defined point of contact. Throughout the attachment the trainee continues to participate in the nighttime on-call rota.
Teaching duties and opportunities run concurrently, with continued involvement in the unit's educational programme, and regular sessions teaching nurses, physiotherapists and medical students.
3. Extracorporeal perfusion
The majority of cardiac surgery is performed using cardiopulmonary bypass and cardiac surgeons, thus require a working knowledge of extracorporeal perfusion technology and procedure. During this module a senior perfusionist guides the trainee through the theoretical basis of cardiopulmonary bypass (CPB), the CPB circuit and its components, the setting up and priming of the circuit, and the conduct of CPB in the operating theatre. A defined series of learning outcomes directs the attachment. The trainee is given the opportunity to run bypass during routine cases under supervision. The insights gained into the conduct of CPB, together with an understanding of complications and trouble-shooting were of considerable benefit to the trainee when he finds himself as the operating surgeon communicating with the perfusionist.
The perfusionists are also responsible for other equipment used in invasive haemodynamic and extracorporeal support, and instruction and experience was obtained in the use of the intra-aortic balloon pump, cell-saver technology, and left ventricular assist devices.
4. Cardiothoracic anaesthesia
This 1-month attachment is divided between thoracic, cardiac and paediatric operating theatres. The consultant anaesthetists supervise the cardiothoracic trainee through practical skills including airway management (including the use of double-lumen tubes), peripheral, arterial and central venous cannulation prior to induction of anaesthesia, and intra-operative data interpretation. Discussions included the principles of anaesthesia, preoperative assessment of patients, pharmacology, physiological monitoring and principles of ventilation.
5. Cardiology
The first week of this attachment is spent in the Cardiac Catheter Suite where there is an extremely active programme of percutaneous coronary intervention, as well as sessions in catheter ablation for dysrhythmia and cardiac pacemakers. The second week is designated an echocardiography week and each afternoon is spent with the echo technicians — undoubtedly the best people to teach the basics of transthoracic echocardiography. Ample hands-on opportunity is available. During this attachment, each morning commenced with a ward round on the Coronary Care Unit. The trainee also attends the weekly combined cardiology/cardiac surgery meeting attended by all the cardiology and cardiothoracic consultants. Participation in clinical decision-making and discussion of techniques, and indications for non-surgical management of heart disease are particularly valuable.
6. Respiratory medicine
Two weeks are spent with the respiratory physicians and their teams, involving outpatient clinics and ward rounds. All cancer cases are discussed at a weekly multi-disciplinary team (MDT) meeting, and there is opportunity to visit the regional cancer hospital where patients are assessed for radiotherapy. Of particular relevance are the fibreoptic bronchoscopy sessions, where there is opportunity to perform the procedure under supervision. Two days are spent in the pulmonary function laboratory, offering an insight into the practical difficulties present in assessing elderly patients with crippling respiratory disease. There are dedicated tutorials on thoracic imaging with consultant radiologists, again, an opportunity rarely available to the trainee with surgical commitments.
7. Educational assignment
As well as the clinical attachments, the trainee undertakes an educational assignment. The first author (RM) prepared a report on the use of Integrated Care Pathways in Cardiac Surgery, attending a course on Integrated Care Pathways at the Royal College of Surgeons of England. Other assignments included designing a teaching programme for critical care nurses, and an audit of percutaneous tracheostomy. The assignments were designed to be of educational benefit to the trainee, but also of wider use to the department in general. The assignments were assessed by the training programme director (CM) and formed part of the formal trainee assessment process.
8. Assessment and appraisal of trainee and trainer
As this was a pilot programme, the first author (RM) also prepared a report on each of the attachments outlining his personal experience, and included key learning points. Being the first trainee to undergo the module, this included defining the aims and objectives of the module for future trainees. Furthermore, as this module accounted for 6 months of the training programme, the relevant assessment forms were completed, and submitted as part of the trainee's annual appraisal. The module also provided opportunity, where appropriate, for appraisal by other colleagues (360° appraisal).
All consultant trainers have completed a course in training (‘Training the Trainers’), and are themselves subjected to annual appraisal by the university.
9. Discussion
The emphasis of this module is on education rather than service or experiential learning. Importantly, throughout the module the trainee is not available for routine ward work, outpatient clinics and theatre sessions. This reduces distractions, allowing the trainee to concentrate full-time on the components of the module. Nonetheless, a 3-month commitment to the CICU has the advantage of ensuring a high level of continuity of care for the patient, at the same time providing a constant point of contact for all the cardiothoracic consultants. This period was under the mentorship of a consultant cardiothoracic anaesthetist, who provided senior cover on the CICU on a weekly basis while also being free of other commitments.
Three months shared between the Departments of Perfusion, Anaesthetics, Cardiology and Respiratory medicine provided valuable educational opportunity, and also afforded the opportunity of meeting and working alongside colleagues from related specialities. The relationships and rapport developed during these spells benefit both the trainee and the department. In particular, it was extremely beneficial to gain an understanding of what is involved in patients undergoing cardiac catheterisation, often associated with an interventional procedure, prior to their referral for consideration of surgery. The practical skills gained or honed depend both on the attachment and the trainee. These include management of the ventilated patient, percutaneous tracheostomy, vascular access, flexible bronchoscopy and trans-thoracic echocardiography.
Disadvantages with the module are dependent on the individual trainee's perspective. Whilst on the module, the trainee is out of the conventional surgical training programme for 6 months, yet the clock is ticking and this time counts towards their date of completion of training. Naturally, all surgical trainees want to operate and cardiothoracic trainees will often have entered a cardiothoracic programme with limited clinical exposure. A further 6 months delay before gaining the expected operative experience can feel frustrating. Realistically, however, this hiatus should not make any long-term difference to their surgical aptitude, while the educational and practical benefits gained during the module should be more than ample compensation.
We recognise that this introductory module may not be considered suitable for all trainees. Those trainees who are already several years into their training programme may understandably not wish to have a break in their surgical training. This view may also be shared by newly appointed trainees who have already spent one or more years at registrar level in locum or non-training posts. The ideal time to participate in this module would be during the first year of a training programme. With the forthcoming introduction of seamless medical training in 2005, as part of Modernising Medical Careers, this would probably be towards the end of basic cardiothoracic training (Fig. 1). However, we believe that the formal educational programme with defined learning outcomes would be of benefit to all trainees irrespective of seniority or previous experience. The implementation of the European Working Time Directive will restrict time on CICU, as trainees attempt to maximise time spent in the operating room. Trainees will be less likely to acquire skills in critical care management simply by exposure and experience and there will be a definite need for formal instruction and education in this area of the speciality for all trainees.
The module may also be suitable for trainees to gain an insight into the speciality before progressing into higher surgical training. This strategy may be particularly relevant to the changes suggested in Modernising Medical Careers [3,4]. With robust assessment trainers may also find this period useful in identifying at an early stage trainees’ suitability for the speciality. Many of the skills obtained during the programme are relevant to other specialities, and trainees may use them as transferable credits if they decide to move into a different speciality.
10. A word of caution
This module took a great deal of time and effort to organise by the programme director, and would not have succeeded without commitment from the lead clinicians within the other departments involved. With regards to the CICU component, this meant a complete reorganisation of the anaesthetic schedule, with consultant anaesthetists being removed from their routine practice for 1 week at a time to enable them to provide senior cover on the CICU. Before adopting a programme such as this, individual training programmes and cardiothoracic units should evaluate the resources locally and modify the programme accordingly.
In conclusion this 6-month module, introduced at the Yorkshire Heart Centre, was found to be enjoyable and beneficial, and is certainly different in style and content from other 6-month appointments on the training programme. We would recommend that a similar module be considered in all cardiothoracic surgical units.
Appendix A. ICVTS On-line discussion
Author: Sion Barnard (Freeman Hospital, UK)
eComment: A good descriptive paper of a new module for cardiothoracic trainees. James Cook Hospital in Middlesbrough have a similar program but shorter - 3 months on CICU may be too much for some. Also for most programs, only one suitable trainee may be needed per year so it would have to be set up with CICU, perfusion etc. each time a new trainee starts. Many at present have spent some time in the specialty including up to two years as a LAT and would have picked up a lot of the CICU skills in that time but agree it would be very suitable for the new seamless training program.
Author: Brian Nyawo (James Cook University Hospital, UK)
eComment: The module described has already been in place at James Cook University Hospital for at least 3 years. The trainee spends 3 months on a programme of attachments on fixed days of the week to Echocardiography, Cardiology, Perfusion and pursuing a research project. As a beneficiary of such a module, I suggest it should be pursued as it helps understanding of important areas of training which would otherwise be ignored. My only reservation is that in the described module attachment to respiratory medicine for 2 weeks is inadequate.
References
Kelty C, Duffy J, Cooper G. Out-of-hours work in cardiothoracic surgery: implications of the New Deal and Calman for training. Postgrad Med J 1999;75:351–2.
Chikwe J, de Souza AC, Pepper JR. No time to train the surgeons. Br Med J 2004;328:418–9.
Donaldson L. Unfinished business: proposals for reform of the senior house officer grade. London: Department of Health, 2002.
Department of Health. Modernising medical careers. The response of the four UK Health Ministers to the consultation on unfinished business. London: Department of Health, 2003.(Richard Milton, Ralph Whi)
Abstract
In an attempt to enhance training we have developed an innovative introductory educational module for cardiothoracic trainees. Newly appointed cardiothoracic trainees at the Yorkshire Heart Centre in Leeds have piloted a 6-month programme, comprising 3 months attachment to the Cardiothoracic Intensive Care Unit, and 3 months seconded to allied departments. This report describes this programme, and considers its advantages and disadvantages.
Key Words: Education; Training
1. Introduction
The training of junior doctors has never been a more contentious issue. Whilst a number of issues have impacted on the quantity and quality of training [1], the problems facing trainees seem to be particularly pronounced in cardiothoracic surgery [2] (Table 1).
One of the consequences of recent changes to cardiothoracic training has been the appointment of trainees with relatively little previous experience in cardiothoracic surgery. In addition to limited operative experience, there is an important lack of clinical knowledge and of experience in critical care. Furthermore, the introduction of seamless training (Fig. 1), in 2005, will mean that trainees will be accepted onto a cardiothoracic programme during their 3rd postgraduate year, without having undergone any basic surgical training. In an attempt to correct some of these potential shortcomings, we have introduced an innovative educational programme aimed specifically at trainees during their first year of cardiothoracic training, which provides the opportunity to develop relevant essential knowledge and clinical experience in preparation for conventional surgical training. In the current system, first year trainees have already completed 1 year of internship after medical school and up to 3 years basic surgical training, including a period in cardiothoracic surgery, before gaining competitive entry onto a cardiothoracic training pro-gramme.
This introductory education module lasts for 6 months. Three months are spent on the Cardiothoracic Intensive Care Unit (CICU), and 3 months are spent gaining clinical experience in departments allied to cardiothoracic surgery: Extracorporeal perfusion, Cardiothoracic anaesthesia, Cardiology, Respiratory medicine.
2. Cardiothoracic intensive care unit
For patients undergoing cardiothoracic surgery, the CICU functions both as a postoperative surgical recovery unit and as a true critical care facility. Three months covering the 14 bed adult and eight bed paediatric intensive care units provides extensive experience in the management of both straightforward and complicated cases. Embodied within this experiential learning is an explicit series of learning. These outcomes are defined in the new competence based cardiothoracic curriculum. Under the supervision of intensivists, a number of practical skills are developed or refined, for example central venous cannulation, floatation of pulmonary artery catheters, intubation and percutaneous tracheostomy. The opportunity to develop these practical skills under close supervision on the paediatric CICU was particularly valuable.
The trainee liaises closely with intensive care and anaesthetic colleagues. Time dedicated to CICU allows trainees to follow the diagnostic and management process from initial stages to conclusion, an opportunity often lost in the usual schedule of a cardiothoracic trainee.
The trainee routinely holds the emergency pager, and handles all acute referrals during the day, being available for advice or direct involvement in A&E, for example. This experience was valuable to both the trainee and to other departments requiring a defined point of contact. Throughout the attachment the trainee continues to participate in the nighttime on-call rota.
Teaching duties and opportunities run concurrently, with continued involvement in the unit's educational programme, and regular sessions teaching nurses, physiotherapists and medical students.
3. Extracorporeal perfusion
The majority of cardiac surgery is performed using cardiopulmonary bypass and cardiac surgeons, thus require a working knowledge of extracorporeal perfusion technology and procedure. During this module a senior perfusionist guides the trainee through the theoretical basis of cardiopulmonary bypass (CPB), the CPB circuit and its components, the setting up and priming of the circuit, and the conduct of CPB in the operating theatre. A defined series of learning outcomes directs the attachment. The trainee is given the opportunity to run bypass during routine cases under supervision. The insights gained into the conduct of CPB, together with an understanding of complications and trouble-shooting were of considerable benefit to the trainee when he finds himself as the operating surgeon communicating with the perfusionist.
The perfusionists are also responsible for other equipment used in invasive haemodynamic and extracorporeal support, and instruction and experience was obtained in the use of the intra-aortic balloon pump, cell-saver technology, and left ventricular assist devices.
4. Cardiothoracic anaesthesia
This 1-month attachment is divided between thoracic, cardiac and paediatric operating theatres. The consultant anaesthetists supervise the cardiothoracic trainee through practical skills including airway management (including the use of double-lumen tubes), peripheral, arterial and central venous cannulation prior to induction of anaesthesia, and intra-operative data interpretation. Discussions included the principles of anaesthesia, preoperative assessment of patients, pharmacology, physiological monitoring and principles of ventilation.
5. Cardiology
The first week of this attachment is spent in the Cardiac Catheter Suite where there is an extremely active programme of percutaneous coronary intervention, as well as sessions in catheter ablation for dysrhythmia and cardiac pacemakers. The second week is designated an echocardiography week and each afternoon is spent with the echo technicians — undoubtedly the best people to teach the basics of transthoracic echocardiography. Ample hands-on opportunity is available. During this attachment, each morning commenced with a ward round on the Coronary Care Unit. The trainee also attends the weekly combined cardiology/cardiac surgery meeting attended by all the cardiology and cardiothoracic consultants. Participation in clinical decision-making and discussion of techniques, and indications for non-surgical management of heart disease are particularly valuable.
6. Respiratory medicine
Two weeks are spent with the respiratory physicians and their teams, involving outpatient clinics and ward rounds. All cancer cases are discussed at a weekly multi-disciplinary team (MDT) meeting, and there is opportunity to visit the regional cancer hospital where patients are assessed for radiotherapy. Of particular relevance are the fibreoptic bronchoscopy sessions, where there is opportunity to perform the procedure under supervision. Two days are spent in the pulmonary function laboratory, offering an insight into the practical difficulties present in assessing elderly patients with crippling respiratory disease. There are dedicated tutorials on thoracic imaging with consultant radiologists, again, an opportunity rarely available to the trainee with surgical commitments.
7. Educational assignment
As well as the clinical attachments, the trainee undertakes an educational assignment. The first author (RM) prepared a report on the use of Integrated Care Pathways in Cardiac Surgery, attending a course on Integrated Care Pathways at the Royal College of Surgeons of England. Other assignments included designing a teaching programme for critical care nurses, and an audit of percutaneous tracheostomy. The assignments were designed to be of educational benefit to the trainee, but also of wider use to the department in general. The assignments were assessed by the training programme director (CM) and formed part of the formal trainee assessment process.
8. Assessment and appraisal of trainee and trainer
As this was a pilot programme, the first author (RM) also prepared a report on each of the attachments outlining his personal experience, and included key learning points. Being the first trainee to undergo the module, this included defining the aims and objectives of the module for future trainees. Furthermore, as this module accounted for 6 months of the training programme, the relevant assessment forms were completed, and submitted as part of the trainee's annual appraisal. The module also provided opportunity, where appropriate, for appraisal by other colleagues (360° appraisal).
All consultant trainers have completed a course in training (‘Training the Trainers’), and are themselves subjected to annual appraisal by the university.
9. Discussion
The emphasis of this module is on education rather than service or experiential learning. Importantly, throughout the module the trainee is not available for routine ward work, outpatient clinics and theatre sessions. This reduces distractions, allowing the trainee to concentrate full-time on the components of the module. Nonetheless, a 3-month commitment to the CICU has the advantage of ensuring a high level of continuity of care for the patient, at the same time providing a constant point of contact for all the cardiothoracic consultants. This period was under the mentorship of a consultant cardiothoracic anaesthetist, who provided senior cover on the CICU on a weekly basis while also being free of other commitments.
Three months shared between the Departments of Perfusion, Anaesthetics, Cardiology and Respiratory medicine provided valuable educational opportunity, and also afforded the opportunity of meeting and working alongside colleagues from related specialities. The relationships and rapport developed during these spells benefit both the trainee and the department. In particular, it was extremely beneficial to gain an understanding of what is involved in patients undergoing cardiac catheterisation, often associated with an interventional procedure, prior to their referral for consideration of surgery. The practical skills gained or honed depend both on the attachment and the trainee. These include management of the ventilated patient, percutaneous tracheostomy, vascular access, flexible bronchoscopy and trans-thoracic echocardiography.
Disadvantages with the module are dependent on the individual trainee's perspective. Whilst on the module, the trainee is out of the conventional surgical training programme for 6 months, yet the clock is ticking and this time counts towards their date of completion of training. Naturally, all surgical trainees want to operate and cardiothoracic trainees will often have entered a cardiothoracic programme with limited clinical exposure. A further 6 months delay before gaining the expected operative experience can feel frustrating. Realistically, however, this hiatus should not make any long-term difference to their surgical aptitude, while the educational and practical benefits gained during the module should be more than ample compensation.
We recognise that this introductory module may not be considered suitable for all trainees. Those trainees who are already several years into their training programme may understandably not wish to have a break in their surgical training. This view may also be shared by newly appointed trainees who have already spent one or more years at registrar level in locum or non-training posts. The ideal time to participate in this module would be during the first year of a training programme. With the forthcoming introduction of seamless medical training in 2005, as part of Modernising Medical Careers, this would probably be towards the end of basic cardiothoracic training (Fig. 1). However, we believe that the formal educational programme with defined learning outcomes would be of benefit to all trainees irrespective of seniority or previous experience. The implementation of the European Working Time Directive will restrict time on CICU, as trainees attempt to maximise time spent in the operating room. Trainees will be less likely to acquire skills in critical care management simply by exposure and experience and there will be a definite need for formal instruction and education in this area of the speciality for all trainees.
The module may also be suitable for trainees to gain an insight into the speciality before progressing into higher surgical training. This strategy may be particularly relevant to the changes suggested in Modernising Medical Careers [3,4]. With robust assessment trainers may also find this period useful in identifying at an early stage trainees’ suitability for the speciality. Many of the skills obtained during the programme are relevant to other specialities, and trainees may use them as transferable credits if they decide to move into a different speciality.
10. A word of caution
This module took a great deal of time and effort to organise by the programme director, and would not have succeeded without commitment from the lead clinicians within the other departments involved. With regards to the CICU component, this meant a complete reorganisation of the anaesthetic schedule, with consultant anaesthetists being removed from their routine practice for 1 week at a time to enable them to provide senior cover on the CICU. Before adopting a programme such as this, individual training programmes and cardiothoracic units should evaluate the resources locally and modify the programme accordingly.
In conclusion this 6-month module, introduced at the Yorkshire Heart Centre, was found to be enjoyable and beneficial, and is certainly different in style and content from other 6-month appointments on the training programme. We would recommend that a similar module be considered in all cardiothoracic surgical units.
Appendix A. ICVTS On-line discussion
Author: Sion Barnard (Freeman Hospital, UK)
eComment: A good descriptive paper of a new module for cardiothoracic trainees. James Cook Hospital in Middlesbrough have a similar program but shorter - 3 months on CICU may be too much for some. Also for most programs, only one suitable trainee may be needed per year so it would have to be set up with CICU, perfusion etc. each time a new trainee starts. Many at present have spent some time in the specialty including up to two years as a LAT and would have picked up a lot of the CICU skills in that time but agree it would be very suitable for the new seamless training program.
Author: Brian Nyawo (James Cook University Hospital, UK)
eComment: The module described has already been in place at James Cook University Hospital for at least 3 years. The trainee spends 3 months on a programme of attachments on fixed days of the week to Echocardiography, Cardiology, Perfusion and pursuing a research project. As a beneficiary of such a module, I suggest it should be pursued as it helps understanding of important areas of training which would otherwise be ignored. My only reservation is that in the described module attachment to respiratory medicine for 2 weeks is inadequate.
References
Kelty C, Duffy J, Cooper G. Out-of-hours work in cardiothoracic surgery: implications of the New Deal and Calman for training. Postgrad Med J 1999;75:351–2.
Chikwe J, de Souza AC, Pepper JR. No time to train the surgeons. Br Med J 2004;328:418–9.
Donaldson L. Unfinished business: proposals for reform of the senior house officer grade. London: Department of Health, 2002.
Department of Health. Modernising medical careers. The response of the four UK Health Ministers to the consultation on unfinished business. London: Department of Health, 2003.(Richard Milton, Ralph Whi)