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Over the last couple of years, there have been major changes in postgraduate medical education and training, as you are no doubt all aware.

The Geriatric Medicine Specialty Advisory Committee (SAC), as a committee of the Joint Royal Colleges of Physicians Training Board (JRCPTB) (formerly JCHMT), has been closely involved in the shaping, preparation and delivery of several key aspects of those reforms, particularly with respect to higher training during what are now known as specialist training years 3-7 (ST3-ST7). Happily, there has not been quite the chaos and lack of clarity in higher training that caused such consternation in Foundation and Core Medical Training, so we have been able to concentrate as a committee on the more creative issues, most of which are highly positive for aspiring geriatricians. The SAC works very closely with the BGS Education and Training Committee (ETC), which is chaired by Dr Rhian Morse. There are several joint members and the ETC meetings are held after the SAC, usually on the same day, to enable prompt briefing on development and policy.

The new curriculum
A sub-group of the SAC wrote the new curriculum in the light of requirements laid down by the Postgraduate Medical Education and Training Board (PMETB). This drew substantially on the previous curriculum (revised 2003), though there are a few additions and the format had to be standardised. Dr Chris Turnbull, the SAC Secretary, did most of the drafting and he and I presented the curriculum to PMETB late last year. We were well received and the curriculum was accepted and approved with very little further amendment. Indeed, positive comments were made about the clarity of the document and the use of grids to summarise topics. However, PMETB clearly had no idea, at that time, of the huge range of career patterns for geriatricians, or of the size of the specialty. Nevertheless, they cottoned on very quickly and soon understood the content and structure of our training and the need for specialist training to be preceded by broad experience in medical specialties and acute care. The new curriculum can now be viewed on the JRCPTB website.

Assessment methods in ST3-ST7
Shortly after submitting the curriculum to PMETB we were required to submit detailed proposed methods for assessing the competence of higher trainees in the curricular topics of Geriatric Medicine. Again, adherence to PMETB formats, language and approved methods was mandatory. Members of the SAC agreed the methods, timing and frequency for each topic against a standard blueprint. Most of the methods are familiar, such as CEX, MSF etc, though some, such as the acute care assessment tool (ACAT) are relatively new, and some, such as patient surveys, are still in the development stage. The assessment methods have now been presented to and provisionally approved by PMETB and will be put into action by programme directors at deanery level, with the majority of the burden falling on clinical supervisors. In future, these assessment activities will be much more formal than hitherto, and there will be a need for clinical supervisors to be properly trained in their application. The SAC has concerns about the time-consuming nature of the new assessment requirements, both for trainees and trainers. We have urged the JRCPTB to continue to press for proper recognition of this time in consultant job plans.

The SAC has also been closely involved with the development of the knowledge-based assessment (KBA) for higher trainees. But as Oliver Corrado has given an eloquent account of KBA in the August issue of this newsletter, I will not enlarge on it here except to thank him, on behalf of the SAC, for taking the project forward with such enthusiasm.

The length and content of training
Two or three years ago there was a substantial amount of pressure, largely emanating from the Department of Health, to shorten the length of postgraduate training. This was never realistic for most specialties, and certainly not for Geriatric Medicine, particularly when account was taken of shorter working hours. We took the opportunity to explain this to PMETB when we presented the curriculum and, to our surprise, met with no resistance. There was parallel work being done by other Royal College committees to the same effect, which I am sure was a major factor. Therefore, for a budding geriatrician the minimum length of postgraduate training will be 9 years (2 years Foundation, 2 years Core Medical Training [ST1-ST2], or Basic Neurosciences Training or Acute Care Core Stem, and 5 years of higher specialty training [ST3-ST7]). This will lead to a CCT in Geriatric Medicine with Competence in General Acute Medicine level 2 (previously known as General Internal Medicine). We have made it clear to the College that trainees expect documentary evidence of their level 2 Acute Medical skills, and precisely how that will be done is currently under discussion.

We also agreed with PMETB that our higher (ST3-ST7) trainees could use 1 year of their 5 to opt for the sub-CCT in Stroke without extending their CCT date providing all other curricular targets can be met to the satisfaction of the SAC and the trainee’s deanery. Similarly, trainees in Geriatric Medicine can opt to go to level 3 in General Acute Medicine and receive a CCT in Acute Medicine, with the same proviso. Trainees will alternatively be able to apply to their deanery and PMETB (via the SAC) for permission to take out-of-programme (OOP) time to pursue Stroke or level 3 Acute Medicine, though that would require agreed additional funding. Most trainees will do neither of these but will develop one or two special interests (such as Falls, Parkinson’s etc) within the specialty, as is currently the case, on an informal basis. PMETB are highly supportive of this approach, and there is an expectation that this will not extend the length of training. The SAC is now in the early stages of refining training grids, curricular content and assessments levels for special interests. We are lobbying for these to be properly accredited in the future, not only for trainees but possibly also for established consultants. We will keep you informed.

Trainees will also receive strong SAC support for OOP time for research, for example for an MD or PhD, or for other legitimate training consistent with the specialty.

So, the future trainee in Geriatric Medicine will, from ST3 onwards, work to the Geriatric Medicine Curriculum, usually including 1 or 2 special interest options, the General Acute Medicine Curriculum level 2 (all trainees) or level 3 (an option), and the Generic Curriculum. Those doing the Stroke sub-CCT will also work to that curriculum. Trainees on the Academic track will also work to an Academic Curriculum that has not yet been finalised. This all adds up to what is probably the most varied and flexible higher training programme for registrars in the UK and will equip young geriatricians for a wide choice of jobs from community through to the acute admissions unit. There has never been a better time to go into Geriatric Medicine.

An eportfolio for ST3-ST7
Many of you will be aware of the eportfolio developed for trainees in foundation training, and now for ST1-ST2. The next stage is to extend the design to provide a suitable eportfolio for higher trainees, eventually to replace the current paper-based training record. The Geriatric Medicine and Cardiology SACs volunteered to pilot the proposed electronic record. For our SAC, Professor James Barrett, who has been involved in the Mersey pilot of the eportfolio for junior trainees, has been co-opted to take forward the project for our specialty. There is frequent review by the SAC, with trainee input, and we anticipate starting the pilot late in 2007 or early 2008 in a limited number of deaneries. The vision is that trainees will have a single electronic record covering the whole of their postgraduate training.

Quality assurance of training schemes
PMETB have overarching responsibility for the quality assurance (QA) of postgraduate medical education and training in the UK. PMETB stopped the long established cycle of external scrutiny of specialty training conducted by SAC members on behalf of the JCHMT. The proposed replacement is still being debated and refined, with a few glimmers of common sense now showing, taking account of the responses to a consultation document published in May 2007. The SAC is of the view that some form of external specialty inspection will need to be a part of the finally agreed approach, alongside quality management by deaneries and quality control by education providers, such as Trusts. We have lobbied hard for this, as have most other specialties. Meanwhile there is a bit of a hiatus, though we are using questionnaires and PYA feedback to try to keep an eye on things. Deans still have the option of asking the SAC to make an ad hoc visit to give advice, rather than triggering a full PMETB inspection, and our SAC is involved in such a visit this year.

The constitution of the SAC
The JRCPTB now requires all SACs to be constituted according to a standard pattern approved by PMETB. Fortunately, the makeup and operational approach of our SAC was already close to the new requirements, so we have been able to morph into the modern vision of an SAC with little disruption. Our close working arrangement with the BGS Education and Training Committee is seen by the JRCPTB as a model for other SACs. One substantial change is in the process for appointing the Chairman and Secretary of the SAC. Until now this was done by election by the SAC members. In future there will be national advertisement and open competition for those posts, and specimen job descriptions have been generated.


Steve Allen
Chairman SAC Geriatric Medicine

BGS Newsletter, October 2007
Issue 13 ISSN 1748-6343 13