Draft National Curriculum for Trainees in Respiratory Medicine:
what every SpR needs to know.

January 2001

Background

Introduction
Respiratory Medicine is an attractive specialty which appeals to a broad range of practitioners. The range of pathologies found in Respiratory Medicine is considerable and challenging, and opportunities for the development of a subspecialty interest abound. Research into the molecular pathology of lung diseases is advancing rapidly, holding out the promise of novel therapies for the future.

Anyone now considering a career in Respiratory Medicine is likely to be rewarded by an intellectually satisfying career, with abundant opportunities for improving the health of others

Entry requirements
Applicants for Higher Medical Training (HMT) should have completed a minimum of two years General Professional Training (GPT) in approved posts and obtained the MRCP(UK) or (I). A period of experience in Respiratory Medicine at SHO grade is considered desirable, although not essential, before entry to HMT. A certificate confirming satisfactory performance at an Advanced Life Support course should be obtained before entry.

The applicant should have:

1. a minimum of 2 years in approved posts with direct involvement in patient care and offering a wide range of experience in a variety of specialties

2. 18 months of the 2 years must be spent in posts providing experience in the admission and early follow-up of acute emergencies

3. at least 6 of these 18 months must be spent on a service or services on which the emergency take is "unselected"

4. "unselected take" is defined as acute medical intake encompassing the broad generality of medicine i.e. not restricted to any single or small group of specialties. If any major component of acute medicine (e.g. patients with stroke or myocardial infarction) is excluded from the take, this experience must be obtained in other posts. During the period on "unselected take" trainees should have an on-call commitment which averages no less than 4 takes per month.

Non-UK graduates without the MRCP who compete for HMT posts must provide evidence of appropriate knowledge, training and experience, particularly in the care of acute medical conditions.


Duration and organisation of training
The duration of HMT in Respiratory Medicine is four years. Those who wish to obtain dual certification, to include General (Internal) Medicine (G(I)M), will require at least a fifth year in training. HMT will provide experience in both teaching hospital(s), or other major centres with academic activity, and in DGH(s). The programme to which the trainee is appointed will have named consultant trainers (Educational Supervisors) for each slot in the programme. In addition, one consultant within the same region will act as Programme Director to the trainee.

Training record
A training record will be maintained by the trainee. It will be counter-signed as appropriate by the Educational Supervisors to confirm the satisfactory fulfilment of the required training experience and the acquisition of the competencies that are set out in the Specialty and Generic curriculum. it will remain the property of the trainee, and must be produced at the annual assessments. A CCST cannot be awarded unless this is properly completed.

Flexible training
Trainees who are unable to work full-time are entitled to opt for flexible training programmes. EC Directive 93/16/EEC requires that:
1 Part-time training shall meet the same requirements as full-time training, from which it will differ only in the possibility of limiting participation in medical activities to a period of at least half of that pro vided for full-time trainees;
ii. The competent authorities shall ensure that the total duration and quality of part-time training of specialists are not less than those of full-time trainees

The above provisions must be adhered to. Flexible trainees should undertake a pro rata share of the out of hours duties (including on-call and other out of hours commitments) required of their full-time colleagues in the same programme and at the equivalent stage.

For details of appointment and funding arrangements for flexible trainees, please see the revised "Guide to Specialist Registrar Training" (February 1998).

Career opportunities
Career prospects in Respiratory Medicine are excellent. Job availability forecasts depend critically on the rate of expansion in consultant posts, and this in turn depends on political and economic factors that are not only outside the control of the medical profession but also inherently difficult to predict. The Manpower and Training Committee of the British Thoracic Society has developed a deserved reputation for realistically assessing Manpower issues and generating accurate medium-term forecasts. A report is published annually in The Directory of Training Posts and Services in Respiratory Medicine, available for a nominal sum from the British Thoracic Society, New Garden House, 78 Hatton Garden, London ECIN 8JR. The directory contains details of the training available in each deanery, and much else besides, and is essential reading for anyone interested in a career in Respiratory Medicine. Further information is available on the BTS website at http://www.brit-thoracic.org.uk and is updated twice yearly.

Training Programme

Clinical placements

The overall plan for the full training programme for each trainee may be set out at the onset of training but must be flexible enough to allow trainees to follow a special interest without jeopardising core training. Special attention will be paid to the sequence of training to ensure an appropriate progression of experience and responsibility through the programme. This applies in particular to rotations between district and university teaching hospitals and later perhaps between specialist respiratory units, which will be a feature of many training programmes. These will be planned to provide general respiratory training and experience before exposure to more specialised aspects of respiratory medicine. This will usually be achieved by the first year or more of HMT being based in a DGH.

Attachment to other departments in the same or different hospitals or attendance at special training courses may be necessary to deliver some aspects of training and should be planned and integrated at appropriate stages into the overall training programme. The particular contribution of each attachment to the training curriculum should be defined to avoid unnecessary duplication of training and unrewarding repetition of clinical or other activities. Traditionally, training and experience in in-patient work, out patient clinics, investigations and sometimes research have been concurrent, but programme directors should examine the possibility of modular training. Throughout training practical experience must be complemented by a clear programme of educational activities in which the theoretical and scientific bases of practice are taught and discussed. (The structured training programme).

Structured training programme
It is recommended that each HMT trainee has the equivalent of 46 days per annum to be used exclusively for educational purposes. The equivalent of one half day a week should be for a structured training programme. The Chairman of the Regional Training Committee is responsible for providing training covering the theoretical and scientific background by seminars, discussions, lectures, demonstrations, literature reviews, etc. The remaining allocation should be for research, audit, attendance at medical meetings and modular training in subjects not provided at the base hospitals. The JCHMT training record should contain a certified record of all training days attended and signed by the appropriate programme director. The Regional training director shall in addition make sure that days and times of the regional training programme are notified to the hospitals well in advance so that where necessary alteration in the on-call commitments or clinics can be made appropriately.

Research, teaching, audit or other appropriates non-service training
A period of supervised research or other appropriate non-service training (e.g. audit, undertaking systematic reviews, education or management) is considered a highly desirable part of HMT in Respiratory Medicine. Such a period, relevant to the individuals training, may contribute up to 12 months towards the total duration of HMT, the balance to be comprised of clinical training. (To a total of four years for one specialty and five years from dual accreditation). Some trainees may wish to spend two or three years in research leading to a MSc, MD or PhD, either before entering HMT or by stepping aside from the training programme for a designated period of time which must receive prior agreement from the Chairman of the Training Committee, the Postgraduate Dean and JCHMT. Only one full year will count towards the programme. Research undertaken before medical qualification will not be counted. For those undertaking research after entering the training programme and obtaining their NTN, a limited amount of additional educational credit may be granted at the discretion of the SAC for clinical work relevant to the programme undertaken in the course of research beyond the initial year This concession does not apply to those undertaking research prior to entry to a higher training programme. Gaining overseas experience is encouraged but trainees must obtain prior agreement from the Royal College and their Postgraduate Dean if they want this to count towards their training.

Trainees are required to perform audit during their training period and to provide evidence of recommendations and closure of the audit loop. These will be documented in the JCHMT training record.

It is an objective of the training programme that consultants of the future will be competent teachers of undergraduate, postgraduate and paramedical staff. Evidence will be required at the penultimate year assessment (PYA) that the trainee has experience of teaching in these three group;. Trainees should be able to demonstrate that they have received training in teaching and that they have been observed whilst teaching and received appropriate feedback. This may be done by attending short courses or in some cases trainees may complete formal courses leading to certificate, diploma or MSc in medical education. These can be done by distant learning or by a period out of programme in a similar manner to research training.

Generic Curriculum
Trainees must comply with the generic curriculum as set out by JCHMT.

Specialty Curriculum

Aims
The trainees will be given the opportunity to become competent in:

1. Establishing a differential diagnosis for patients presenting with clinical .features of.respiratory disease by appropriate use of history, clinical examination and investigations.

2. Applying knowledge derived from the appropriate basic sciences, which are relevant to respiratory medicine.

3. Applying appropriate and sufficient knowledge and skills in the diagnosis and management of a patient with respiratory disease to ensure safe independent practice.

4. Developing a management plan for the "whole patient" and have sound knowledge of the appropriate treatment including health promotion, disease prevention, long-term management plans and palliative medicine where appropriate.

Objectives
At the end of the training the trainee will have achieved the following:

• Knowledge - to have acquired the knowledge necessary for the safe practice of respiratory medicine (as outlined in the contents section of this curriculum). The trainee will obtain this knowledge during clinical placements, structured educational activities and independent learning.

• Skills - demonstrate ability and training in the following areas:

a) advanced life support

b) pleural procedures including pleural intubation and pleural biopsy

c) bronchosocopy. The bulk of training of bronchoscopy will be in units performing more than 200 examinations per year. Bronchoscopy will be taught as part of the overall respiratory service with co-operation between physidans, surgeons, radiologist and pathologist. Initially the trainee will be an observer and then perform 30-40 bronchoscopy under direct supervision. During the training period sufficient supervised bronchoscopies to demonstrate competence in the procedure should be performed. Additional supervised training will be provided so that trainees become confident in transbronchial biopsies and bronchoalveolar lavage.

d) respiratory function testing. Trainees should know how to perform routine lung function tests, plethysmography, assessment of airways hyper-responsiveness, hypoxic challenge and exercise testing. The trainee should also be competent in reporting the results.

e) sleep studies. Trainees should have experience in screening studies, polysomnography and initiation of CPAP.

f) non-invasive ventilation. Trainees should have experience in selecting patients who will benefit from this treatment in the acute and chronic situation and have experience of setting up the machinery.

The trainee will obtain these skills during clinical placements, structured educational activities and practice under supervision.

• Attitude - the trainee will demonstrate a high standard of ethical and professional behaviour in his/her work. S/he will have the ability to work as part of a multi-disciplinary team and to show the appropriate tact, empathy and communication skills in dealing with patients and colleagues. The following behaviour characteristics will be demonstrated:
a) Interpersonal skills
b) Self confidence together with recognition of own limitations
c) Flexibility
d) Resilience
e) Decisiveness
f) Accountability
g) Non-judgemental approach
h) Thoroughness
i) Enthusiasm and drive
j) Probity

These attitudes will be developed during clinical placements and by the formal training programme.

• Ability to manage a respiratory service - the trainee will be required to demonstrate appropriate management and negotiating skills, participating in multidisciplinary staff organisation and effective supervision of junior staff.

Content

Section I: Clinical Experience

In-Patient training and experience
This is best obtained particularly in the early stages of HMT in a unit dealing with the full range of the commoner acute and chronic respiratory conditions. If training takes place in more specialised units appropriate attachments either to other specialised units or to a more general unit will be required to provide a sufficient and balanced range of training and experience.


Out-patient training and experience
The trainee should undertake at least two respiratory out-patients clinics per week during the years of clinical training and should see new as well as follow-up patients. In the early years outpatient experience is best obtained in general respiratory clinics (unselected respiratory referrals) although additional valuable training and experience can be obtained in specialised clinics dealing with selected conditions. Educational supervisors will specifically aid trainees to obtain skills in effectively organising outpatient services and in communication with referring physicians.


Intensive care
Practical training and experience in intensive care are essential for training in respiratory medicine. All trainees must spend a minimum of 60 whole days training in ICU. Ideally this should be a full time three months allocation but if this is not possible then it can be done in segments of 15 consecutive working days.


Palliative medicine
Trainees should gain experience in palliative care particularly in relation to patients with carcinoma of the bronchus. The trainees should have knowledge of palliative care services and understand the role of the MacMillan nurses.

Pulmonary rehabilitation
Trainees should understand the importance of pulmonary rehabilitation and seek opportunities to gain first hand experience in this area. A knowledge of methods of administration of supplemental oxygen and the appropriate selection of patients is essential.

Respiratory physiology
Dedicated time within the training programme should be allocated for practical training and laboratory experience in measurement and interpretation of lung function tests. Trainees should be involved, with appropriate supervision, in issuing reports on physiological investigations. A period of attachment to a unit regularly performing more detailed assessments of pulmonary physiology is highly desirable. Experience should be gained in plethysmography, assessment of airway hyper-responsiveness, hypoxic challenge and exercise testing.

Radiological and imaging techniques
Training in imaging techniques, whether by formal teaching or by discussion 3f imaging in relation to individual patients, should involve radiologists as well as respiratory physicians. A short period of formal attachment to a nuclear medicine department and to a CT or MR unit should be considered if there are not very close day-to-day links between these activities and respiratory practices in the training unit. Trainees should be aware of the indications for high resolution computerised tomography and ventilation/perfusion lung scans.

Essential areas of training i.e. where care of patients with these conditions should occur during clinical placements
• asthma including patient education and self management
• chronic obstructive pulmonary disease (including pulmonary rehabilitation)
• lung cancer including surgical management, chemotherapy, radiotherapy and palliative care
• pulmonary infections including the pneumonia
• tuberculosis - respiratory and non-respiratory, contact tracing and DOTT
• pulmonary disorders in the immuno-compromised host
• bronchiectasis
• diffuse interstitial lung disease
• sleep related breathing disorders
• pulmonary vascular disease including pulmonary embolism and infarction, secondary
pulmonary hypertension, pulmonary haemorrhage and pulmonary vasculitides
• allergic lung disorders and anaphylaxis
• intensive care medicine (60 days)
• respiratory failure due to obstructive lung disease, adult respiratory distress syndrome and neuromuscular disorders and the use of invasive and non-invasive ventilation (acute and chronic) in the management of these conditions
• disorders of the pleura and mediastinum
• cardiopulmonary resuscitation and obtain ALS(UK)
• pulmonary manifestations of systemic diseases including collagen vascular diseases
• smoking cessation methods
• palliative care medicine

There are important areas in respiratory medicine practice in which some trainees may receive insufficient exposure in their main training units due to local arrangements for the care of certain categories of patients. It may be necessary for them to attend an approved course (e.g. BTS course) or have a secondment to a specialised unit, local or distant to complete their training experience. These areas include:
• Tuberculosis
• cystic fibrosis
HIV/AIDS
• respiratory allergy and immunology
• occupational and environmental lung disease
pulmonary rehabilitation
• genetic and developmental lung disorders
• pre and post operative transplantation
• smoking cessation methods
• hospital at home schemes, early discharge programmes and specialist services delivered at home
• other areas which in the opinion of the SAC have not been adequately covered by the trainee. (Detailed guidance will be given to the trainee and the Chairman of the Regional Training Committee at the Penultimate Year Assessment)

The trainees will have to demonstrate before they receive a RITA G that they have appropriate experience in all these areas. In some very specialised areas this appropriate experience may comprise evidence of attending lectures or seminars, together with attending in a supernumery capacity a number of ward-rounds or out-patients dealing with the care of a particular group of patients. This evidence will be documented in the training record and countersigned by the appropriate consultant.

Other aspects of respiratory management
At least two years of HST should be undertaken in units with close working links between Respiratory Medicine and surgery. The training timetable should include joint meetings, seminars, consultations between respiratory physicians and surgeons. Similarly close working.links between respiratory medidne and clinical oncology and palliative care are also of great benefit, so that all trainees can develop expertise in the role of radiotherapy and chemotherapy in the treatment of thoracic malignancy.


Training in Respiratory Medicine and Intensive Care Medicine
Training and experience in intensive care is an essential component of a Respiratory Medicine programme. Trainees who wish to seek additional training in 1CM with a view to pursuing an appointment with sessional commitments in this area at consultant level should seek advice from their Local Education Advisor (LEA) in 1CM. Details of LEAs can be obtained from the Secretariat to the Intercollegiate Board on Intensive Care Medicine, 48-49 Russell Square,London WC1B 4JY. Briefly, individuals within Respiratory Medicine SpR programmes (i.e. who.already possess an NTN) may seek appointment to 1 (Intermediate Level Training) and 2.(Advanced Level Training)year training posts in 1CM. These are based in approved units, inspected and assessed by the Intercollegiate Board. The number of posts available for training non anaesthetists at each level varies from Deanery to Deanery. For entry to an Intermediate level training post, candidates must possess an NTN and 3 months experience in 1CM at SHO level.

For entry to an Advanced level post leading to the award of a dual CCST (with base specialty), training in anaesthesia (6 months) and 1CM (3 months) must have already been obtained at SHO level. Subject to satisfactory performance, at the end of the approved period of training, individuals will be awarded a certificate of completion, recognising their proficiency at the appropriate level. A Diploma in Intensive Care Medicine (which is not compulsory) has also been developed; the first examination for this was held in July 1998.


At the time of writing (1.1.01) the circumstances surrounding training in 1CM remain in a state of flux. Interested candidates are strongly recommended to contact the Regional Advisor in 1CM, or the Secretary of the Intercollegiate Board for Training in 1CM. Although circumstances may change, at the time of writing 1CM is not a specialty and therefore a CCST may not be awarded in the discipline. The periods of training outlined above represent a secondment from a base specialty for individuals already training at SpR level.


Training in Respiratory Medicine and Allergy
Combined training may be undertaken to obtain dual certification. A model joint programme with respiratory medicine is outlined below. It is emphasised that the full curriculum requirements in both allergy and respiratory medicine must be met in order to achieve the award of both CCSTs. The combined training programme will be a minimum of six years duration.
year one Allergy
year two Allergy
year three Respiratory medicine
year four Allergy/Respiratory medicine
year five Allergy/Respiratory medicine
year six Research

The ordering of the above components is flexible. The above model provides a five year programme in Allergy and a four year programme in Respiratory Medicine.

Section II : Structured training programme

It will be the responsibility of the Chairman of the Regional Training Committee to make sure that there is an adequate structured training programme. The trainees will be expected to spend the equivalent of 10-15 days a year (i.e. half day per week, one day a fortnight or similar per year in the university terms) on this educational activity. An attendance record will be kept and detailed in the JCHMT training record. Details of the structured training programme for each region will be provided regulariy to the SAC in Respiratory Medicine. The programme including seminars, lectures, discussions, clinical reviews, etc. and must cover the following areas:

• Respiratory physiology - theory and practice
• Respiratory radiology
• Respiratory pharmacology
• Chronic obstructive pulmonary disease (including pulmonary rehabilitation)
• Asthma (including patient education and self management)
• Infection (including tuberculosis, opportunist infection, cystic fibrosis)
• Thoracic oncology including palliative care medicine)
• Smoking cessation
• Genetic and developmental lung disorders
Disorders of sleep, chronic respiratory failure
• Disorders of pleura and mediastinum
• Diffuse lung disease
• Pulmonary vascular disease
• Allergic respiratory disease
• Occupational and environmental respiratory disease
• Pulmonary manifestations of systemic disease
• Cardiological aspects of respiratory disease
• Critical care respiratory disease

The trainee should have the equivalent of 46 days a year for use in educational activities, audit, study leave, teaching, research or attending secondment to specialised units local or distant to cover particular areas of the curriculum which are not covered in the clinical rotation to which the trainee is placed. Approximately 10-15 days or equivalent of this time will be spent on the structured training programme. Trainees should attend an approved management course preferably in the last year of training. It is likely that during the last year of the training programme the trainee will spend most of the time allocated for education concentrating on special areas of training (including modules) rather than attending the structured training programme as in earlier years. Throughout the training course well organised inhouse educational activities focused on respiratory medicine may be counted towards the trainees time allocated to education.

Section III: Practical procedures

Teachingand learning methods

It is the responsibility of the Chairman of the Regional Training Committee to make sure that the trainees are provided with:

1. An appropriate structured training programme covering the syllabus of the JCHMT training programme in respiratory medicine.

2. The equivalent of 46 days per year for educational purposes. Ten to 15 days per annum should be for the structured training programme. The remaining can be used for inhouse medical education, attending courses, secondments to other units, research, audit or training and education.

3. Appropriate clinical placements to enable the trainee to fulfill the requirements of the curriculum. It is emphasised however that it is the responsibility of the trainee at all times to assume appropriate responsibility for self-assessment, continuing self-directed learning and the maintenance of competence. Trainees must be familiar with appropriate literature and using modern technology to acquire information from all the currently available sources and databases and be able to critically assess such data. The clinical placements will include:
• Ward-rounds under consultant supervision
• Ward-rounds conducted by the trainee
• Clinics under consultant supervision where some the cases can be discussed
• Clinics conducted independently but with senior advice available if required
• Lectures
• Tutorials
• Small group work
• Multi-disciplinary group
• Discussion group
• Independent study
• Research
• Audit
• Web-based research and use of the web for clinical information retrieval
• Journal clubs

Assessment of Competence
When awarded an NTN the trainee should immediately apply to JCHMT for training record which will be completed regularly throughout the training period. This training record will be taken to each annual assessment where a RITA C, D, E or F will be awarded. The annual assessments should be organised by the Chairman of the Training Committee. All penultimate year assessments must be attended by a member or the SAC or their nominated deputy. It is the responsibility of the Chairman of the Training Committee to arrange these penultimate assessments six months in advance so that appropriate outside assessors can be present.

The trainees progress is assessed by:

1. RITA assessments as outlined above.
2. A multiple choice and problem solving test must be passed before the trainee progresses to Y5 of training. This examination can be taken twice a year …
3. During Y5 trainees will be assessed conducting a ward round, outpatient clinic, fibreoptic bronchoscopy by an outside assessor who is not the supervising consultant. These assessments may take place up to three times. On the third occasion the SAC must be present. If the assessment is still unsatisfactory the trainee year i.e. RITA E will be issued.

4. At the end of the training period the trainee will send to the Royal College of Physicians
a) evidence that the JCHMT training manual has been completed,
b) proof of passing Y3/Y4 examination
c) proof of passing Y5 assessment
d) evidence of having passed ALS(UK)
e) evidence of having completed any gaps in training identified in the penultimate assessment
f) evidence of completing a course or training in:
i)teaching, ii) ethics, iii) legal issues, iv) appraisal, v) management, vi) c skills.
g) RITA G issued by Chairman of the STC.

The SAC will examine these documents and if any evidence of deficiency is apparent
The trainee and the Chairman of the STC will be required to rectify this before a recommendation is made to the STA that a CCST is granted.

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