Playing the OSCE GAME

Hello. Beginning to post a bit more now I’m emerging from the FRCEM OSCE bunker. Over the next few weeks I’ll streamline and put up some of the revision materials I’ve made. It’s important to note I am just an ED trainee, I have nothing to do with the exam.

I’ve been thinking about what I did to prepare, maybe what I could have done better. Here are some of my thoughts:

I didn’t think the FRCEM OSCE wasn’t that clinically challenging in terms of knowledge. I knew most of what they were asking me, and the scenarios sort of made sense. I also felt that the exam was fair.

How is it structured?

The FRCEM OSCE is a 16 station OSCE exam, two stations are double stations, and 1 station is a rest station. That means there are 13 stations. The double stations are always ATLS/APLS/ALS. The exam itself takes place over about 7-8 days. The exam is different on different days, but the college do complicated statistical things to make it fair. So for example on one day you might be asked to teach a GI exam to a medical student, on the next day you might be asked to teach RS exam. They may be examining different content, but the skills/attributes/behaviours they test will be the same.

The college isn’t made of money, this means that high fidelity sim, or examination stations where you are going to have to use a lot of single use equipment probably aren’t going to be tested. It’s also impractical to re-set some complex chest drain, or cricothyroidotomy mannequins within the time you have between stations. This means they are more likely to test things that are easier to simulate eg difficult patients, complex toxicology, consent, histories, mental health. This is good, because let’s face it they are much more likely to happen in your day job than boshing in an ECMO system.

Similarly there is nothing stopping the college putting an USS machine in front of you, however given the number of different models and types many would feel that that might be unfair, so you are more likely to get interpretation/governance stuff than ‘image this aorta’ as a station, but USS in some form will feature.

OSCES are improvisation games for doctors whereby you’ve got to hit a number of key words or actions. Now I’m not going to debate their utility or efficacy here, but the best thing to do is to practice playing these games with your colleagues until you feel comfortable. All OSCES have marks for basic or obvious stuff. This is stuff like washing your hands, or asking permission of a patient before you touch them. They are easy marks to hit, and even easier to forget. If you work on creating a mental script for a number of common scenarios you will perform better.

Most of the stations conform to a number of types:

  • A Teaching Station
    • A good way of both checking you know the content of a topic and also can structure your teaching. A weakness of this station is that you don’t have to know the topic very well to collect the ancillary marks around the edges if you are good at the game.
  • A History Station
    • At FRCEM level you are going to have a relatively simple history but with a complication. Here the trick is finding the complication, as until you do many of the marks will be unavailable to you. So you need to use broad questioning techniques to start off with, and respond to the cues from the actor, it is likely there will be a ‘difficult question’ you have to ask, then the history will open up for you. These are scenarios like:
      • Saturday Night Palsy + Language Barrier
      • PR bleeding secondary to sexual assault
      • ?PE but might be pregnant
  • An Examination Station
    • At FRCEM level these are most likely going to be a teaching station, so you are going to have to teach a medical student to do an exam.
    • Again doing an OSCE style exam in 7 minutes while explaining what you are doing and why is quite challenging, but it can be practiced VERY easily with friends.
    • It is important to not forget the ‘teaching’ aspect of the exam, because there will be ancillary marks for signposting and checking understanding.
  • Explaining Station (these are the commonest type of station)
    • Complaint
    • Explain a diagnosis
    • Consent – eg Thrombolysis for stroke, procedural sedation
    • Explain a procedure/policy (eg DNACPR)
    • Break Bad News
    • Conflict
  • Resus Station
    • Lead the team
    • Maybe deal with conflict
  • Managerial Stuff
    • Triage a group of patients waiting for Assessment
    • CDU board round with F2
    • USS governance
    • Drunk/intoxicated junior

It is good OSCE technique to have a opening and a closing paragraph for each kind of station. You have a minute of reading time to collect your thoughts prior to the station. It is best to use that time to work out what ‘script’ fits best, and use it.

On reflection there was a lot more talking than doing during my exam, and there was a lot more ‘teaching’. However I can see how putting a ‘teaching’ slant on many scenarios gives the examiner a better insight into how much you know, and gives the actor licence to probe a bit more.

Have a look at the OSCE scenarios page for specific mark schemes I’ve made up,.

How do I revise?

  1. Assemble a Team.You can revise scenarios with a team of other people who are sitting the exam. I would also recommend writing scenarios and questions. This is useful because it gives you insight into what kind of things will carry marks.

2. Practice Playing the game. I would also write a script for each broad OSCE type and memorise it. This will give you some momentum when you come into a scenario and allow you to not forget the simple marks for washing your hands, offering pain relief, or checking level of understanding.

3. Enlist Allies. Trainees who are post exam will be helpful, consultants will also be happy to provide some time to help with exam preperations. Some consultants really like doing this. Find them, get them to help you.

Good LUCK!

wasting time…

I’ve had some time for a bit of deeper reflection recently as I’ve been awake a lot longer, and not really able to *do* anything (birth of second child) other than walk up and down my living room holding something that’s noisy.

I’ve been wondering why whenever a patient complains about ‘their wait’ they always over-estimate, sometimes massively.

Every single person who has worked in an emergency department has had an exchange between an exasperated family member or patient about the wait time.  We’ve also probably used our fancy computer tracking system as a rebuke – ‘ well you’ve only been here for 2 hours 12 minutes ‘ we’ll say.  Now anecdotally I’ve noticed people talking about waiting ‘all day’, or ‘6 hours’ when in reality they’ve not even got to 2 or 3 hours of ED wait time.  This is a relatively common occurrence, now we could assume that all patients have no concept of time, or they can’t tell time, or that they are maliciously somehow inflating their wait time to make us care a bit more about them.  Now I’m sure at some point one or all of these reasons are true, but I don’t think they are true in the majority of cases.

This is because generally speaking people aren’t temporally illiterate, and nearly everyone has a watch of some kind.

Now we start our clock when someone has booked the patient in.

When does the patient start their clock?

Probably when they call 111, 999, or go to their GP.  If you start thinking about things from that perspective you can see where frustration arises.

GP does home visit at 10am, calls ambulance for patient, patient is waiting 6 hours for ambulance, gets taken to hospital, 10 ambulances arrive at once, 1 hour wait to be booked in, another 1 hour wait to emerge from triage.  Wheres the day gone? Patient has to stay as no transport home.  Our wait 3 hours 39 minutes.  Patient wait: 8 hours 39 minutes, plus a pointless hospital admission.

Person cuts finger at 14:00, ANP at GP service at 16:00 assesses, might have nerve damage, can’t book into local plastics/hands clinic remotely so goes to A+E.  Gets there at 17:30.  Seen at 21:00.  Discharged home at 21:15 with follow up clinic for the next day.  ED wait 3 hours.  Patient wait 5 hours 15 minutes, and they’ve still not seen the appropriate specialist!

Father calls 111 at 11:00 about 6 month old’s breathing who has a cold, waits for 1 hour for nurse call back, nurse calls back and upgrades to GP appointment at OOH centre.  GP appointment at 15:30 suggests ED attendance for ‘further tests’.  Taken to ED at 16:00 Seen in ED quickly, and discharged at 3 hours 30 as viral URTI.  Patient wait: 10 hours 30 minutes.

Now those three examples aren’t particularly unusual, or poor examples of care, but example 1 might have gone to an ambulatory frailty unit, example 2 could have been referred to hand clinic directly by the GP, and example 3 could have been seen and observed for a few hours in a children’s assessment unit.

Now imagine if we could measure this patient centred ‘time to care’.  I’m not saying this metric should be a target, and certainly not that it should be 4 hours.  But.  Just imagine if the DoH, trust, and CCG we were able to actually  measure what was moving through our healthcare system with this level of accuracy.  I’m amazed that they don’t or can’t.

In fact the first time I’m aware of someone trying to combine all the disparate A+E, 111, and Ambulance data is work currently being undertaken in Yorkshire by the utterly brilliant Prof Sue Mason.  Expect lots of interesting research to start trickling out soon….

My Self Rostering Story.

We’ve all been slaves to a rolling rota.  Whenever my wife and I change jobs we have to spend about 2 hours simulating the compatibility of various slots to work out when we can do flippant things like pick up our child from nursery, or go on holiday together.  We are all used to stories such as having to fight for time off for your own wedding, or having to work nights during paternity leave, losing annual leave allowances because there is no ‘space’ for you to take it.  We’ve all been there.

Time to come clean.  I found another way.  It took me 6 months, and it’s not perfect, but it works better than being a slot-slave.  I’m not entirely sure medical personnel know what we’ve done,  (they might know in a ‘don’t ask don’t tell’ kind of way).  Cats out of the bag now, toothpaste well and truly out of the tube.

I can let everyone have what leave they want, WHENEVER they want it, AND we’ve improved cover in the department AND we’ve decreased the amount of shifts that we need locums for.

I took over running the Registrar rota at the hospital that I work at in July.  We had a system whereby a genius registrar (who is now a consultant) looked at everyone’s requests and made a bespoke monthly rota that covered our nights, weekends, study leave and annual leave requests perfectly.  I have no idea how she did it (I suspect she filled in all of the gaps herself).

I was semi-forced to take over.   No one else wanted to do it,   it was during the period of new junior doctor contract imposition, and HR were not happy with us continuing the old system.  We had to have a rolling rota.

In June 2015 I met with the medical staffing person and devised two rota templates.  One was for ‘proper’ regs (people you could leave in charge of the department overnight) and one for fellows (CT3s, Medical sprs, F3s and the like).   At the meeting I raised self rostering.  I was told that it was impossible given the complexities of the new JD contract.

I thought I’d been quite canny.  I built a rota that had an 8 week cycle, had a combination of nights, 17-02, 13-23, and 8-6 shifts.  The OOH work was clustered and the day shifts occurred during a 3 week period, so if people wanted a long period off they could get it.  Now providing we were full we would have 2 doctors at least on during OOH, and up to 6 on during the day (I imagined a lot of people would take their AL then, so they’d be less).  I’d also used the two rotas to mean we didn’t have to do 3 in 8 weekends (fellows would do day weekends and 1-11’s would be done by HSTs).

I also decided that i’d let people pick a new slot on the rolling rota every 8 weeks so they could fit in with important events.  I also built in enough redundancy that people would be able to take AL on most shifts (apart from nights) as long as their ‘partner’ was covering the shift.

Fellow rota – for OOPE, Medical rotations, Non-training grades who don’t do solo nights
Week No Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1 22:00-08:30 22:00-08:30 22:00-08:30 22:00-08:30 0 0 0
2 13-23 13-23 13-23 0 0 08-18:00 08-18:00
3 0 0 17-02:00 17-02:00 17-02:00
4 17-02:00 17-02:00 0 0 22:00-08:30 22:00-08:30 22:00-08:30
5 0 0 0 13-23 13-23 0 0
6 08-18:00 08-18:00 NC 08-18:00 08-18:00 0 0
7 10-20:00 10-20:00 10-20:00 10-20:00 10-20:00 0 0
8 08-18:00 08-18:00 08-18:00 NC 08-18:00 0 0
Senior Reg Rota 3 (Modified) – HST’s only.
Week No Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1 22:00-08:30 22:00-08:30 22:00-08:30 22:00-08:30 0 0 0
2 13-23 13-23 13-23 0 0 13-23 13-23
3 0 0 17-02:00 17-02:00 17-02:00 0 0
4 17-02:00 17-02:00 NC 0 22:00-08:30 22:00-08:30 22:00-08:30
5 0 0 NC 13-23 13-23 0 0
6 10-20:00 10-20:00 10-20:00 10-20:00 10-20:00 0 0
7 08-18:00 NC 08-18:00 08-18:00 08-18:00 0 0
8 08-18:00 NC 08-18:00 08-18:00 08-18:00 0 0

The rota assumed we had 16 doctors (8 HST, 8 Fellows).  Had we had that many full time equivalent’s things would have been peachy.  However the reality was I had 7 HST FTEs, and 7 Fellows.  2 HSTs were imminently about to go on mat leave.  I had 1 fellow who was 50% clinical and was doing doctoral research, one fellow who was 70% clinical doing education who couldn’t work the rolling template because of educational commitments, and a GP currently negotiating his contract which would be 50% in PAs and not compatible with the rolling cycle.  I had two F3 fellows on an 80:20 education split who also had odd educational day requirements for their certificate in med ed that didn’t fit with the rota.  On top of that I had also been asked to see if we could dovetail ACP support into the rota so we could spread our resource more efficiently.  Again they couldn’t fit into a rolling rota based on JD contract as they were on the agenda for change contract which is based on a total of 40 hours, minus non-clinical commitments.

I created the first rota which worked (just about) but it was terribly threadbear in places.  There were a number of night gaps where consultants had to act down and people who were paired with an empty slot couldn’t really take leave, or they could but would leave the department dangerously short staffed (which annoyed them because others could take leave).  We had only one spr on 1-11 most days, and there were day shifts when we had 3 or 4 doctors on (usually on tuesday and wednesday when we didn’t need it).

I persevered, but the second cycle was worse (Sept – Nov).  Another HST had CCTed, so our numbers dropped even further.  Our rota gaps got worse; I had 24 nights with little cover, 3 empty weekends (out of 8).  Looking ahead towards christmas I realised a few things:

a) Everyone was going to try and pick a slot that avoided Xmas.

b)The rota was going to very light over that period which would affect patient safety.

c)There was no ability to increase coverage over xmas shifts above what the rolling rota had already set up.  We could only get ‘extra’ doctors by getting locums in.

Sometime in early October I decided that the best thing to do about Christmas was to make people pick shifts, working out how I would do this gradually morphed into the self rostering system we are using at the moment.

Now most of the stuff I’d read about self-rostered rotas was based around annualising and consultant working.  Everything was in PAs, and no one had managed to set up and run a self-rostering rota with doctors on the new JD contract.  All of the places that had one were in hunt free zones, or using trust grade contracts (which are like the old JD contract).

At some point in October I had a moment of inspiration; as the new JD contract is based on the split between social and antisocial hours during a reference period if everything averaged out over that reference period the shift pattern wouldn’t matter.

Our reference period was 8 weeks.  During that time there were 7 nights, 5 late shifts (5-2), 7 mids (for HSTs, 5 for fellows) and 12 or 14 day shifts.  Including in that count was one weekend daytime shift.  As long as people kept to those shifts they could do them in any order and everything would be ok.  It mattered less what the split was for people on trust or old contract, as the ‘1A banding’ is a pretty broad church.

So in 8 weeks HST Fellow Fellow 80:20 Fellow 70:30
Nights (22-08:30) 7 7 7 7 inc 1 weekend
Days (8-18) 12 14 8 5 inc 1 weekend fellows
Mids (1-23) 7 5 5 5 inc 1 weekend HST
Lates (17-02) 5 5 5 5
NC 4 2 2 2
Education/Research 0 0 7 10
Total Clinical shifts 30 31 25 22

(You might have noticed I got rid of 10-20 shifts, no one liked them, and they were *NEVER* filled.)

I emailed all the doctors on the rota and explained the plan.  We would have a rota meeting, people would have complete freedom to pick their shifts.

I drew up the rota using google sheets and I realised something quite fundamentally important.

A rolling rota is an inefficient way of spreading resource.

Looking at the rota we wanted two people on nights, 1 on a 5-2, 2 on a 1-11 and 2 on a day shift.  Now my rolling rota plan had redundancy built in so that sometimes they’d be 2 people on a 5-2, or up to 6 on during the day to account for study and annual leave.  If we were self rostering we didn’t need that.  This meant that we could radically change the pattern of shifts on offer based on demand within the department.  We needed fewer doctors to guarantee the same level of cover.

I looked at Christmas, and added extra shifts all over.  For example I put an extra 5-2 on for New Years Eve which was a Saturday, where we normally wouldn’t have that shift, and I did similar things with boxing day and christmas week.  Increasing our numbers during 1-11 to deal with increasing demand (as the rest of the NHS was closed).

Then I looked at the rolling rota job plan for each doctor.  I turned this into a balance of different types of shifts;  Nights, Lates, Mids and Days.  We give everyone non clinical days but I didn’t count these, as I was only concerned with providing cover for the department.  I totalled up everyone’s contribution which gave me a pool of shifts.

This is what I had


I had 360 shifts in total to allocate, I was only down by 15, however there was a discrepancy as to where these shifts were.  I had more days and lates than I felt I needed, and I was down by many mids and nights.  This also allowed me to explain where I thought gaps would be before the rota had been written.

We’d had a long standing agreement to  compensate people for extra night shifts – essentially getting a lieu/training day,  instead of having to work on the shop floor.  I was allowed to continue offering this deal to cover more night gaps.

I was very nervous on the day of the rota meeting, I had my google spreadsheet and the giant pages of rota, with stickers representing everyone’s shifts ready.  I had a powerpoint with a brief explanation of what we were doing, and a flipchart with Jeremy Hunt’s safe rostering rules.   I had got permission from the consultant body to get EVERYONE on my rota into a room for 2-3 hours to construct the rota.  One person even took part via whatsapp (they were in New Zealand).

The meeting ran well.  We started with christmas.  I didn’t let Christmas go until we had each contributed 8 shifts to the two week period around it.

A funny thing happened…

It worked.  No big arguments.  That was it.  It took about 3 hours, but our coverage smoothed out.  There were no days with 5 people on day shifts, and no one on during the night.  Despite there being fewer doctors in this 8 week cycle than the last, the coverage got better.

Everyone got the time off they wanted and Everyone got their study leave.

We’ve done this 3 times now.  We are in self roster cycle 3.  HR kind of know.  I’ve been able to fold in a GP, and the ACPs because their contribution to the rota is worked out, and THEN they contribute to it, not trying to shoehorn them into a slot.  Things have become easier for our fellows too.  Their project work is easier to organize because they’ve not got to squeeze it into a rolling rota.  It also means I can accommodate wierdo doctors too.  We’ve just added someone who doesn’t work monday or tuesday because they are dissecting corpses (I think for educational reasons, AND they are 60% LTFT).  How would you even fit that into a slot?  LTFT trainees don’t need to slot share, they can just provide a pro-rata’d amount of shifts.

In my original rota I had 360 shifts to allocate, in this current rota I’ve got 394 as we’ve added in more 1-11 and 5-2 shifts during busy periods we need, but not when we don’t.  Each rota cycle the pattern of shifts can change to allow for special events.  We’ve still got gaps (21 shifts available from 12th of march to 6th of May) but nothing like we had before.  I’m also able to support more SL and AL requests (50 days of AL between everyone this cycle).

Now I’m not saying that this system is perfect, far from it, but doing it this way improves morale, training opportunities, and coverage while simultaneously reducing locum spend.  I’m also very thankful for the support and latitude I’ve received from my local medical staffing team, consultants and our operations management team.

So if you are a slave to a rolling rota,  break free.  If you are a rota-master –  make your life easier;  try something like this.

Good luck.

“R*silience” is a dirty word.

The world breaks everyone, and afterward, some are strong at the broken places. (Ernest Hemingway).

Now no sane person ever said that training in EM is easy.  No one ever said that you won’t see people at the extremes of suffering, and heights of pain.  These moments will affect you, and they will change you, now that’s part of life, and seeing it at it’s most extreme limits is one of the privileges and burdens of being an EM doc.

We have no control over what comes through our door (or flow out of our departments).  Sometimes there will be no end in sight, you’ll be tired, you’ll have 2 or 3 or 5 things on the go and worried you aren’t doing any of them particularly well.  You will feel like you cannot cope.

That is okay.  That happens to everyone.  It is normal.  It shows a degree of insight, and situational awareness which is good, and should be encouraged.

There will be shifts where you cry.  That is also okay.  It happens to everyone.  It shows that despite the NHS’s best efforts you are still, in fact, a human being.

Resilience in the context of your training is a word that someone who doesn’t know you uses when he or she means to say “I know it’s shit but you just need to cope”.  So when some people talk about resilience training I worry they want to teach you to suck it up.  It’s an excuse for poor workplace design and management.  It suggests that your management team have given up on making the lives of their employees easier.  In which case they need to go on the frickin’ course, not you.

Examine your own working day:-  You arrive, see patients, have lunch, see some more patients and go home.  There is no scheduled time for you to do audit, CPD, attend courses, or even usually do your bloody mandatory trust induction.  Annual leave is a fight.  Study leave is a rare privilege.

Even the most single minded surgeon is not operating for 10 hours straight day in and day out .  Their day is broken up with up with clinics, admin, ward rounds, and MDTs.  Remember you are in a training job.  Clearly the majority of your time should be on the shop floor, but it is insane to think that it should be 100%.

When people talk about resilience training,   I see a secondary agenda in which the trainee is being somehow chastised for not coping with an inhumane working environment.   It is essentially rationalising institutional bullying.  I’m not using hyperbole here,  someone is effectively telling you it’s your fault, where you are likely under-appreciated, unsupported, and over-worked, they are saying  you weren’t strong enough.  The truly resilient response to such a stimulus is to give them the finger.

Now, there are some very good bits and pieces out there on resilience, I think training in resilience is probably useful if you are going to a battlefield, or work for Médecins Sans Frontières, but for christ’s sake if you need to use techniques picked up from people working during a humanitarian crisis to manage a normal working day or night in a British hospital THERE IS SOMETHING FUNDAMENTALLY WRONG WITH YOUR WORKPLACE.

A few months ago I had two consecutive resus patients die.  I then needed to tell their families that their loved one had died back to back. I felt like the angel of death, and it was emotionally exhausting.   It affected my confidence, I certainly didn’t want another resus case, and it took me a little time to process what happened (after a period of alcohol fueled reflection with some colleagues).  That is okay.   That shows that this ED Registrar still has his some vestige of soul left .  I think there are probably different ways of being resilient, but that most of the ways we describe it are in terms of a masochistic ability to block out human suffering.  I dont think that that is healthy for us, or good for our patients.

Emergency medicine especially needs a variety of different types of people working in it to work.  We need the methodical, as well as the gutsy, we need the blunt as well as the touchy-feely, so to assume that they’ll all be able to cope with the same pressures in the same way is madness.

I also worry that people can be too resilient .  If you keep on being told that there is nothing you can do to change your environment and all of the changes have to be internalised to adapt to the environment you find yourself in then maybe you’ll tolerate poor conditions for too long, or fail to do things like report failures in safety or quality that really should be reported.  You might also fail to see or act to help people who don’t have the same hardened carapace that you do.  Not to mention the obvious effect on your ability to develop rapport with your team and your patients.

So if someone suggests you go on resilience training as part of your ED training;

Think hard.  Be resilient.  Tell them to get bent.

What to do when it’s all going wrong around you….

It’s winter.  Every ED in the country is getting progressively more crowded, and people are packed into corridors waiting for wards.  There’s nowhere to see new patients, there’s patients getting their second or third dose of antibiotics in cubicles.  There are no beds in the hospital.  The wait to be seen is 3 hours 52 minutes, there are lots of people in suits you don’t recognize (hint; they are managers) crowded around arguing with the ED consultant who looks like they’re deciding whether to break down and cry or haul off and punch someone.

Here are some tips and tricks to remaining sane, and getting stuff done in a department that’s a bomb site.

First off accept these three truths:

  1. This is not your fault. This is not even the fault of the ED, the ambulance service, or the people you are going to look after.
  2. It is rubbish for everyone at work, but it is worse for your patients. Crowded ED’s are more dangerous than uncrowded EDs.
  3. Breaches do not matter. Patient care matters.

Ten Tips

  1. See patients as you normally would. If they need bloods, they need bloods, if they need CT’s, Xrays, and they haven’t been done, get them ordered, get them done.
  2. Don’t try to cut corners or speed up, that way you’ll make mistakes, miss things or end up having to go back and go things again.
  3. Write your notes while with the patient.
  4. If you need to admit someone write a plan that’ll last longer than 4 hours. Make sure more fluid, more antibiotics are prescribed.  Keep a sticker or their name on a cheat sheet, and go back and check on them at 6 hours. You might even be able to discharge them if you’ve had them long enough.
  5. If your patient is well enough to be on a corridor after you’ve seen them, move them out to the corridor yourself. Explain why.
  6. It is okay to apologise for the wait. It is okay to apologise that people cannot get toileted, cleaned, rolled, and fed as they need to be.  It’s not good enough and it’s okay to acknowledge that.  Most patients and families will see everyone is working flat out.
  7. TAKE YOUR BREAK. If you don’t I’ll find you, and I’ll KILL YOU.
  8. Be kind to the receiving teams, the medical team especially will be absolutely swamped.
  9. Ask for advice early. Come up with a plan, by all means but don’t try and cope, find the Reg or consultant and get them to check it with you.  They might streamline things for you.
  10. Communicate with your nurses. Help them if you can.  Commodes, getting patients comfortable, mixing IV’s, putting up fluids.


Good luck.

CT1: Getting the assessments.

the incredibly rare anaphylaxis CMP1 pokeman
the incredibly rare anaphylaxis CMP1 pokeman

To win ACCS CT1 you need to collect assessments.  Think of it like pokeman go, and hunt in the long grass where the things you need might be.  Sometimes this means being in resus, other times it’s about keeping one ear open to whats going on in triage.  If you have a friendly ED reg or consultant on and you let them know you are looking for ‘X’ you might be more likely to find it.

Now many deaneries will be organising a welcome event for you, often that is sometime in September, to give you guys time to bed in.  You do not have time to wait for this.

There is a lot to do, and realistically you have 9 months to do it in, as ARCPs happen in June, two months before the end of your placement, and in some deaneries your portfolio is locked in May.

Most deaneries split your requirement over AM and EM, but anecdotally I hear that most people find getting the requisite number of assessments in AM difficult and catch up in EM.  This is difficult if you do EM first (so try to get ahead).

A lot of people aimlessly gather assessments as the year progresses with no real sense of focus.  Prioritise collecting assessments you need, ‘extra’ assessments are fine, but there is no real point in having 4 DOPS for primary survey.  So to be smart about what you need you need to know what the deanery ARCP panel will want.

By the end of CT1 you will need:

  • 4 assessments for the ‘major presentations’ (2 summative ones in ED, 2 from AM).
  • 20 assessments for CAPS (5 specific ones as summative in ED).
  • 18 CAPS covered in any other way (elearning, assessments, reflection).
  • 10 DOPS (4 specific in ED, another 6 are anything you can find).

That is a minimum of 34 assessments in effectively 9 months, or just under one every week.  Does that feel manageable to you?  Well I think it’s a big ask.


How do you do this?

  • Know the curriculum
  • Know your deaneries ARCP checklist

A ‘serial killer wall’ can help match what you have with the curriculum, and allow you to see where your gaps are…

First off get to know the list of CMP and CAPS.  If you come across someone with that ‘problem’ keep a sticker or the patient’s details.  Use it for CBDs.  Make appointments in consultant’s non clinical time to do CBDs.

If a consultant offers to do a mini-cex.  Get them to fill in the eform or paper form right there and then.

Portfolio time is best spent little and often (spend 10-20 minutes a week on your eportfolio will save you lots of heartache come June).

Do a ‘elearning/reflection’ a week and you’ll be fine.  Wait till the end and you will be screwed.  Reflections do not have to be War and Peace.  Sometimes a 50-100 words is all you need.  You deanery must provide you with teaching.  If you write a short reflection on each lecture you get you can link that to a CAP.

LINK items to common competencies and core curriculum items as you go.  As soon as an assessment is done.  Link and forget.  You need to demonstrate ‘level 2 competence’ in 50% of the common competencies by the end of CT1.  This is really an exercise in wording your reflections correctly.  To do this well you need to know what ‘level 2 competent’ is for each domain.  That means you need to know the curriculum document (which is here).

EM people, here’s the list (the requirements for AM trainees and anaesthetic trainees seem to fluctuate).

2 x CMP 1 – 6  Summative mini-cex, or Cbd from a consultant.

  • CMP1 Anaphylaxis
  • CMP2 Cardio-respiratory arrest (or current ALS certification)
  • CMP3 Major Trauma
  • CMP4 Septic patient
  • CMP5 Shocked patient
  • CMP6 Unconscious patient

Summative assessments from a consultant for these (mini-cex or cbd)

  • CAP1 Abdominal Pain
  • CAP6 Breathlessness
  • CAP7 Chest Pain
  • CAP18 Head Injury
  • CAP30 Mental Health

Formative assessments, 5 covering any other CAP, these can be from a HST, and incorporate ACAT and other tools.

Covering another 10 CAP by any method you like (teaching, elearning, reflection, or other assessments).

You need 4 specific DOPs too.  Airway, Reduction of fracture, Wound management, Trauma primary survey, AND one other.

In AM you need:

2  CMPs from a consultant (some deaneries want formative, others summative so CHECK).

10 CMPs covered by Formative assessments (using mini-cex,cbd or ACAT)

9 CMPs covered by reflection, elearning, audit, assessments, teaching


So by May June in 2018 you need to have an item/assessment/certificate/reflection in each of the CMP bits of your portfolio (there are 38).  You will also need to cross reference and re-link those bits that are relevant to the general curriculum, as at least 50% of them will need to be covered.

Now many deaneries will provide their own checklists which will give you an idea of exactly what they want you to achieve by the end of the year.  Find your deaneries checklist, pin it to the wall somewhere at home.  Use it to plan.

Now there are arguments about whether this entire exercise is educationally valid, or has any kind of useful patient safety component in weeding out the bad doctors.  I’ll be talking a bit about that later in the year.  In the mean time you just need to get started.  If you start covering things as I’ve said in the above post you’ll be in a much stronger position come your ARCP, and you will feel a lot less stressed about passing.

Below you’ll find a list of ARCP checklists I’ve found for the LETBs/Deaneries in the uk.  Any mistakes, or if you find a checklist I can’t find please get in touch and I’ll add it.

Good luck!

ACCS: Induction

Right.  You are about to start CT1, either in acute medicine or EM.

You are undoubtedly going to have to fill out about 20 forms, and go to a hospital induction during which you’ll be told about diversity and fire procedures, but you won’t get access to the blood reporting system, PACs or a computer log on.  All that is going to do is p*ss you off, and it will not help you in any measurable way.  If you want to make progress do this…

Do these in week 1:

  1.  Find out the identity of your educational supervisor, and clinical supervisor.  Schedule a meeting with both of them.
  2. Gain access to eportfolio for EM.  This requires you to send £90 to Royal College of Emergency Medicine.  Yes it’s extortion.  No it’s not fair.  Just do it.
  3. Find out what heap of assessments you will need to provide at the end of the year, your deanery should publish a checklist of what they want.  If they don’t use the version from here, (I’ll be going into more detail soon).
  4. Start keeping a list/book of interesting cases.  In that book write down a list of all clinical problems you need to cover.
  5. Write a development plan, the following things should be in it, there is no reason why you can use the same development plan for your ES and CS.
    1. Courses
      1. Life support courses, do them, get instructor potential for them.
      2. USS level 1
      3. USS vascular access
    2. Vague stuff
      1. Improve management of emergencies
      2. Improve team working and communication skills
      3. Develop history taking and examination skills
      4. Develop bedside and formal teaching skills
    3. Stuff related to training in ED
      1. Sit MCEM part 1, or A, or whatever the hell its going to be called.  Aim to do the first bit.
      2. You need to do an audit.  Just because.

At the first meeting do the following.  This is your checklist.

  1.  Make sure you know what your ES/CS is expecting from you at work.
  2. Bring food/coffee to that meeting
  3. Get an assessment while you are there.  Bring a case.  Anything.
  4. Get your ES or CS to help you decide on a topic to audit
  5. Get any A/L and S/L forms signed for the next 6 months.
  6. Set the date for another meeting in 4 weeks time.
    1. This is so you can check progress, come with a tranche of further assessments AND discuss your audit.

The Rota.

You ideally need to meet your CS and ES after you’ve got a handle on the rota.  The rota will be horrible.  Every ED rota is horrible.  I am sorry.  So sorry.  It get’s better the more senior you become. I promise.

  1. Take EVERY second of annual leave you are entitled to.
    1. Yes, even odd days here and there where you have nothing planned.
  2. CHECK what you are entitled to in terms of bank holiday lieu days.  ED rotas often ignore them, but sometimes don’t give you days in lieu for working them.  So check.
  3. Book things to look forward to.  As complex as holidays, as simple as meeting someone for a coffee.  Make these a priority OVER audit, OVER portfolio, OVER revision.
  4. Your training is a marathon, it is not a sprint, it’s okay to stay late occasionally if stuff is going on that will benefit you, but make sure you leave on time, the majority of the time.  Giving the trust or the department an extra 2 or 3 hours a shift is not on.  This means being present at handover on time, and handing stuff over (my wife will roll her eyes at this point as I am very very bad at this, however I recognise it’s important).
  5. Giving handovers mean you have to have happy to receive handovers as well, so accept them with a (sometimes fake) smile.


What is ACCS:Survivor?


ACCS Survivor is a site that will grow over the coming months to include learning resources to help with progressing through ACCS,  be it candid ARCP advice, or useful physiology tips, revision resources we’ve found (or made), all free, all #FOAMed.

Survive:ED is my blog, which will populate over time.  Further static content will be added as it is made!

VAULT– The vault contains questions aimed at FRCA and MCEM A, they are free to use, but require you to contribute to them.

The site is not affiliated with any institution or organisation, and the views expressed are our own.