Acute care common stem pathway
Authors: Muhummad Sohaib Nazir, Charlie Sharp, Jamie Fryer, Mark Edwards
Publication date: 02 Dec 2011
Muhummad Sohaib Nazir and colleagues describe what the ACCS pathway entails and what it can lead to and discuss some of its pros and cons
What is ACCS?
The acute care common stem (ACCS) pathway is a relatively new core training pathway that will be of interest to trainees who enjoy the acute aspects of medicine. The programme is spread over two years with four rotations, usually six months each (fig 1). Trainees enter the pathway with a parent specialty (acute medicine, anaesthesia, or emergency medicine), which is pursued after core training (CT).
The unselected medical take enables trainees to gain confidence in managing common acute medical conditions. Presenting at post-take ward rounds is an important part of learning. Working in a busy acute medical unit for a six month period provides a wealth of clinical exposure to a wide range of conditions. The rapid turnover of patients in a busy acute medical unit provides access to a range of unwell patients and is a great learning opportunity, as dedicated input from senior doctors is close at hand. The exact configuration of this post varies, depending on how the local acute medical unit is run, but it is important to obtain maximal exposure on the acute medical take.
ACCS trainees are given a greater level of responsibility than are foundation doctors in emergency medicine, with the aim of maximising experience. Trainees become well acquainted with initial management and referral of a range of conditions, from common medical and surgical presentations to specialty problems in orthopaedics, gynaecology, ear, nose, and throat surgery, and psychiatry. Furthermore, participation in adult resuscitation, paediatric resuscitation, and trauma calls consolidates skills acquired from courses in advanced life support, advanced paediatric life support, and advanced trauma life support.
Novice trainees spend the first three months working towards the “initial assessment of competency.” This establishes basic principles of anaesthesia and, once achieved, allows participation in the on-call rota. Initially there is daily one to one training with consultants to gain the theoretical knowledge and practical skills needed for preoperative assessment, induction and maintenance of general anaesthesia, perioperative care, and management of cardiac arrest. This is a valuable opportunity to develop skills in airway management, including bag mask ventilation, airway adjuncts, laryngeal mask airway insertion, intubation, and rapid sequence induction, which cannot be gained in any other specialty.
Intensive care medicine
Intensive care medicine provides a blend of knowledge and hands-on experience in managing acutely unwell patients. Trainees gain exposure to organ support with non-invasive and invasive ventilation, inotropes and vasopressors, renal replacement therapy, and fluid management. During outreach work trainees are often the first point of call, recognising acutely unwell patients and instigating initial management. There is the opportunity for active involvement in resuscitation, sedation, hospital transfers, and procedures such as invasive and arterial line insertion, which are valuable skills whatever final specialty is chosen.
What happens next?
ACCS anaesthesia trainees enter another year of training in anaesthesia (CT2b) to train further in obstetric and paediatric anaesthesia (fig 2 ). Successful completion of CT2b and a pass in the primary fellowship examination of the Royal College of Anaesthetists (FRCA) is required before competitive entry to specialty training year 3 (ST3) in anaesthesia.
ACCS emergency medicine trainees enter a CT3 year in emergency medicine, during which they spend six months focusing on trauma and orthopaedics and six months in paediatric emergency medicine, before applying for an ST4 post. Although ACCS emergency medicine is not the only route to ST4, it is increasingly difficult to get an ST4 post by any other method. Exams for membership of the College of Emergency Medicine (MCEM) must be completed before trainees can enter ST4.
ACCS acute medicine trainees either do another year in core medicine (CT2b) or apply directly for a medical ST3 post after two years of ACCS. Whichever route is taken, full membership of the Royal College of Physicians (MRCP) and core medical training competencies are required for progression to higher specialty training. If trainees are applying with 24 months’ experience, the rotation must be a six month placement in each module. As of 2011, ACCS trainees can apply to any of the medical specialties.
Experience in ACCS provides the basic training in intensive care medicine required for progression to intermediate and advanced training. This makes the pathway especially suitable for trainees wanting to obtain accreditation in intensive care medicine. The training pathway for intensive care is currently under review and will be changing in 2013. Further details are available on the Faculty of Intensive Care Medicine’s website.
Why ACCS? The pros and cons
ACCS versus core medical training
Pros—ACCS guarantees exposure to acute or emergency care and intensive care medicine to give trainees confidence in managing the acute take before higher specialty training. It enables achievement of procedural competencies (invasive lines, airway skills) that may not be acquired on a core medical training pathway. Working in the accident and emergency department and the intensive treatment unit (ITU) exposes trainees to a broader range of specialties to give a working knowledge of surgical emergencies and complications, psychiatry, obstetrics and gynaecology, and ear, nose, and throat. The environment of ITU, theatres, and accident and emergency means that team working skills become highly developed. This route also enables trainees to gain the competencies required for higher training in ITU if so desired.
Cons—When going on to a medical specialty registrar post, trainees have a less diverse grounding in medical specialties (depending on the local design of the CT2b rotations). The schedule is tighter, and there is less “medical” time to acquire the knowledge and skills for MRCP exams. Furthermore, there is less academic opportunity in the ACCS route, as trainees move between diverse jobs.
ACCS versus core anaesthesia
Pros—Exposure to emergency and general medicine provides confidence and a broader understanding in managing common medical, surgical, and specialty problems encountered as an anaesthetist in theatres and ITU and when reviewing ward patients. This also has the benefit of meeting minimum requirements for complementary specialty experience to enter higher intensive care medicine training later on. The skill sets gained through ACCS are broader. A more general outlook can be maintained than in direct entry to anaesthesia from the foundation programme.
Cons—The design of the ACCS programme means that the schedule to complete the FRCA primary exam may be tighter and pressure to gain specialist anaesthetic core competencies in paediatrics and obstetrics is greater. There is also the risk that trainees emerge from ACCS with less total anaesthetic training time than in the core programme (depending on the local programme design).
ACCS versus non-training emergency medicine posts
Pros—Although an emergency medicine training programme that entails only six months of emergency medicine in the first two years might seem inadequate, the skills and experience gained in the acute specialties are of immense value. The role of the future emergency medicine specialist is to be competent in diagnosing and managing a wide range of conditions. The confidence gained in anaesthesia and intensive care medicine, which is outside most trainees’ experience before ACCS, pays dividends when treating the most unwell patients in the emergency department’s resuscitation room.
Cons—Less time is spent in the emergency department.
The box summarises the advantages and disadvantages and qualities of the ACCS pathway and the required qualities.
Advantages and disadvantages of the acute care common stem pathway, and qualities needed
Gives wide clinical exposure to acute care through different specialties and viewpoints
Offers skills in airway management
Guarantees competencies in procedures such as central lines, arterial lines, and chest drains
Develops systematic approach to managing acutely unwell patients
Encourages team working between different specialties
Is ideal for a route to dual accreditation with intensive care medicine
Offers a more flexible career pathway than in other training programmes
Confers a broad rather than specialist knowledge
Results in locally variable experience in certain rotations, such as acute medicine
Puts pressure on trainees to complete exams early, often while they aren’t in parent specialty
Means an extra year of training overall if anaesthesia or acute medicine is pursued
Means that trainees can be out of synch with colleagues from parent specialty
Offers little opportunity for academic training
Lacks unified e-portfolio
Aptitude for practical skills; manual dexterity
Ability to function under pressure, and good situational awareness in rapidly changing environments
Initiative, flexibility, and adaptability
Willingness to teach
Enjoyment of and aptitude for working in teams
Lateral and logical problem solving
Passion for acute care
The ACCS programme is an exciting opportunity to acquire a diverse range of knowledge and skills in acute care that will leave you in good standing whatever your final choice of specialty.
Competing interests: None declared.
Muhummad Sohaib Nazir cardiology specialist trainee year 3, London, UK
Charlie Sharp respiratory specialist trainee year 3, Severn Deanery
Jamie Fryer ACCS (emergency medicine) core trainee year 3, London
Mark Edwards consultant in endocrinology and acute medicine, Middlesex, UK