IMGs work experience in Acute Medicine (AMU)

¬By Abeera Khan

Acute Medicine is a specialty concerned with the assessment, diagnosis and treatment of adult patients with urgent medical needs. Acute Medicine is distinct from Emergency Medicine (A&E), although specialist acute physicians often work in close collaboration with specialists in Emergency Medicine. In the NHS hospitals, both departments work side by side.

There can be different names of Acute Medical Unit in different hospitals like CDU (Clinical Decision Unit) or AAU (Acute Assessment Unit). AMU is a short stay unit where patients stay for a maximum of 72 hours. They are then transferred to respective wards (Gastro/Respiratory/Care of Elderly or else) depending upon their line of management, transferred out of Trust if needed or discharged home direct from AMU.

If you have worked in the NHS, you must be familiar with the breech time in A&E. The NHS Constitution sets out that a minimum of 95% of patients attending an A&E department should be admitted, transferred or discharged within 4 hours of their arrival. However, on the floor, it’s not practically possible many a times due to number of reasons (huge influx of patients, understaffing in A&E at various shift times, blood tests and other results, shortage of beds in the hospital especially during winters/weekends and many more). However, trusts do their best to reach this target.

When the patient comes to the A&E, he/she is stabilised and then transferred over to the Acute Medical unit (if the patient is undergoing medics). The AMU is a team led by Consultants, on call Registrar, on-call SHOs (CMTs, GPSTs, Trust grade, FY1/FY2), Advanced Nurse Practitioners and the base team of AMU. In my previous Trust, we had 3 SHOs who were AMU based. The Consultant can be an Acute Physician or from a sub-specialty.

AMU also receives urgent admissions from GPs, patients from chemotherapy unit for suspected neutropenic sepsis, from Ambulatory care and Outpatient department.

Aim/Purpose of AMU:

The basic aim of AMU is to assess the clinical condition of the patient, follow up pending blood and Radiology results, start appropriate line of treatment, request further tests if required, refer to sub-specialties for review, make a diagnosis and then transfer to ward/discharge home.

My experience:

I have worked as AMU based doctor for 06 months. Around 80-90% of admissions are from A&E (roughly my statistics). The AMU team (SHOs/Reg) will review the patient, clerk, follow the pending investigations, do further tests (depending what the patient is coming in with), make a management plan and discuss with the Registrar and patient is then reviewed by the Consultant.

AMU ward rounds start at 08:00. This is called post-take ward round (PTWR) when the consultant reviews the patients admitted overnight. As there is constant influx of patients, so Consultants try to move patients to the ward if they need to stay in the hospital for few more days or discharge them home from AMU.

Example:

If the patient is admitted overnight with a mild/moderate acute attack of Asthma, had baseline investigations, CXR, ABGs, Nebulisers, steroids, antibiotics (if needed) and is now clinically stable, maintaining saturations on air and not needing Nebs, peak flow within normal range, he can be discharged home from AMU with a prescription.

After the ward round there is a handover in which the team goes through the patients and you write up on the board what further investigations need to be requested for each patient, any referrals to be made to specific teams or subspecialties within the hospital, TTOs( discharge letters) to be done, any investigations to chase up or expedite, mostly with Radiology like CT scans/MR/Ultrasound. If any discussion need to be done with Consultant Microbiologist on call or any out of hospital referrals.

It is best to work as a team in AMU. After the ward round, we used to divide work like half of SHOs used to do the jobs mentioned above and 1-2 SHOs keep clerking new patients coming in. If at times there was a bed blockage and no movement is happening from AMU to the wards, we used to finish the jobs at AMU and 2 of us (SHOs) used to go to A&E with the on-call registrar and start clerking patients there in ED who are definite admission. This helps your night team if you are working on days as staffing at night is less as compared to full day team. The same we used to do at night shifts too.

Common cases encountered in AMU:

There is a broad spectrum of clinical work in AMU. The range of clinical problems encountered is very wide, which gives the work a great deal of variability and that’s what I like best, mixture of medicine and blended work.  AMU routine is tough on everyday basis, but I like continuity of work, so I thoroughly enjoyed my rotation. You would commonly see,

Headache (Rule out Subarachnoid haemorrhage). Would have had their CT Brain from ED and would get LP in AMU.

Asthma

Acute exacerbation of COPD

Chest infection/ Pneumonia

Acute Kidney injury

Overdose (most common- Paracetamol)

GI Bleeding

Acute flare up of Inflammatory Bowel disease (Crohns/Ulcerative Colitis)

Chronic pancreatitis

UTI in elderly causing delirium

Diabetic Ketoacidosis

Cellulitis

Suspected Pulmonary embolism

Neutropenic Sepsis

Suspected cauda equina (in my previous trust, it used to come under medics)

Anaemia requiring blood transfusion

CLD patients

Sometimes patients come in for pain management, social admissions

 

What I learnt:

  • Best place to work as a team, constant support from fellow colleagues and Consultants
  • Clerk patients every day, make your own plan of management, discuss it with your Reg/Consultant and then mark it off as a CBD (case base discussion) and mini-CEX (Clinical evaluation exercise)
  • Do ACATs (Acute Care Assessment Tools)
  • Opportunity to do various procedures (Lumbar puncture, ascitic drain, pleural taps)
  • Good mix of cases keep you up to date

Overall, it’s a good learning opportunity and make the most of it when you are working in AMU (Well, that holds true for every rotation). Hope it helps.

My A&E Experience as Starting IMG

¬ By Abeera Khan

A&E is the front door of the hospital. A lot of IMGs think about picking up A&E as their first job as ED is on shortage occupation list and there are lot of vacancies in different trusts. It is commonly heard that ED job is very hectic at SHO level, and some people might tell you not to join ED as a first job. However, I can assure you that many IMGs have started it as their first job and they settled well with time. No matter where you start from, it would be difficult at first as this would be your first NHS experience.

I had many job rotations offers but I opted for A&E and AMU rotation for a year (06 months each). I worked in one of the busiest A&E departments in the North region which covers a very large population. We had an 8 bedded Resus, 15 bedded Majors with 4 Rapid Assessment Rooms, 6 in Minors/urgent care and a separate Paediatric area, fracture/plasters room and GP consultation room.

Yes, it is very overwhelming especially during winter months, but you need to understand that if its busy in ED, its busy in the medical and surgical departments too.

Watch this video to see how winter pressures affect NHS. BBC was given free access to the A&E of Royal Blackburn Hospital while I was working there last winters (2016-2017).

The best thing I like about working in A&E is a good mix of cases you see ranging from trauma (if the ED department is a trauma centre), acute medical and surgical conditions, orthopaedic emergencies (fractures), managing paediatric conditions, gynae cases to assess and then refer and common illness seen in minor area.

As a starter, it is the best place to practise ABCDE protocol. From the moment you start taking your history, you try to rule out differentials. If you have been out of practise, you will get hands on doing cannulations, blood sampling, ABGs, urinary catheters, suturing. As ED is constantly busy with rapid influx of patients, you can’t just sit and wait for the Nurses to come over and do everything for you.

There is a lot of senior support on the floor and they would always listen to you and guide you.

In urgent care/minor area, you can see, manage and discharge patients on your own if you are confident. If you are not, always consult with the Registrar.

Be very clear in your documentation. If you are not sure about reading X-rays (especially for fractures), don’t make your assumptive diagnosis. Always ask your seniors.

You can easily get your foundation competencies signed off if you are working well.

Yes, the job is hectic because it is constant brain storming. You see one patient, plan and then move on to the next. We could have a 20-minute break after 4 hours in an 8-hour shift. And two 20-minute breaks in 10-12 hours every 04 hours.

You develop good communication and referral skills when you deal with other specialties. Remember you are the one who has seen the patient and you know if patient is stable to be discharged or not. Treat the patient, not the Numbers.

Just to quote an example, I have had 5-year-old with extradural hematoma and midline shift (prompt History, examination, knowing NICE guidelines for CT scan, speaking to radiology Registrar and referring to Manchester Royal Infirmary all done in an hour) and then followed up with that patient post-surgery, reflected upon it on my portfolio.

The only thing I found hard was my Rota as there is a constantly changing pattern of shifts. You would do Standard days, long days, then twilight shifts (18:00 to 02:00, 18:00 to 04:00, 16:00 to 04:00, 12:00 to 00:00), night shifts. Be prepared for this as the ED rotas may be a bit maniac.

You can even follow up your patients in AMU/Surgical assessment Unit/Paediatrics later, as in ED you would manage the acute condition and stabilise the patient.

Another thing IMGs worry about is the portfolio. I would say that,

  • There is a lot of experience you can reflect upon in your portfolio while working in A&E.
  • You can get MSF from colleagues working at different grades.
  • You can get your CBDs and mini-CEXs signed off.
  • You can do audits while working in A&E.
  • You can get your foundation competencies signed off (I did after 04 months)

All the above things I have mentioned, I have got them all in 06 months rotation.

Only drawback I found was there is less of teaching as due to rotas, you tend to miss the teaching sessions. But then you can ask for a teaching presentation to deliver. You can always email the undergrad/postgrad department in your trust and they are always very helpful.

IMGs worry if working in A&E would help them in future or not especially when applying for training. The UK foundation trainees do get to rotate in A&E in their training as it is very essential. I applied for my CMT and GP training while in A&E and got offer for both.

I believe every work you do helps you and gives you experience and knowledge. I have a variety of background experience of working in general medicine, neurology, radiology, A&E, acute medicine, undergrad teaching and I have never regretted anything I have done so far as I feel I have learnt a lot from everywhere I have worked.

 

Experience of Applying and obtaining a Higher Speciality Training / ST 3 post as an IMG in Medical Specilties

¬ Dr. Irfan Qamar

 

   Seven months back I moved to UK from a very well settled Job in middle east after completing my MRCP exam and the only aim to move  to this country was to enter a higher speciality training with a special interest in respiratory medicine.

    When I was moving to UK everybody around me, my colleagues and my friends thought that I am making a big mistake, it’s a perception in the mind of many people that life in UK is very tough and you will keep on struggling for a training slot but will never get it and you will not able to earn and save money. A part of this perception might be right, but one must take risks in life to progress in life.

     After my results of IELTS I directly applied on NHS jobs official website although I do get a lot of calls form many medical recruiting agencies but what I found was all the jobs which were mentioned by the recruiting agencies were also on NHS jobs website and there is no difference in applying directly as compared to medical recruiting agencies.

I got a job in acute medicine as a middle grade (registrar level) in a big DGH (district general hospital) I got my COS (certificate of sponsorship) and visa without any difficulty. The procedure is very simple and very well explained over internet.

    The beginning of a new career in altogether a different health care system was never easy, but all the people including administrative staff, consultants and colleagues were very supportive and helped me a lot to settle in the new system. My education supervisor was very helpful he was always willing to help me whenever it was needed, he also held long meetings with me just to help me to understand how things work in NHS. I was told many scary stories about NHS that you would be put alone on the duty at middle grade where you must make many bold decisions all about yourself and you would be under tremendous pressure to make such decisions, but honestly, I was never given any responsibility until and unless I was fully prepared for it. I did many mistakes as everyone is expected to do in a new system, but I was always given a feedback in a very positive way so that I can improve myself and grow professionally.

     After settling down in the new system, which took me around three months, I started to work on my application for speciality training in Respiratory medicine. First and most important thing is you need to be eligible for application for which you need Your core competencies signed off by consultant with whom you have worked in last three years and have worked continuously for three months.  As I was applying for ST3 i.e. speciality training year 3 so I need to give a proof that I have attained all the competencies that are required during year 1 and 2. Generally in UK they are attained during core medical training Hence easily called as core competencies. Their is a form which is available on ST3 recruitment website which has all the competencies mentioned on it all you need to fill it up and get it signed by the consultant. I informed my consultant well ahead of time that I need this certificate to be signed by you he agreed and started to observe my skills in managing a patient and in doing the common medical procedure. He observed all the procedures which are on that form and finally he signed it for me. I want to let you people know that any consultant with whom you have worked can sign that form it is not necessary that he should be GMC registered or he should be from UK. However, he should be a physician (medicine or allied specialties). the other requirements to be eligible are much easy to attain you should have an ALS advance life support they do not accept American heart Association ACLS.

I am writing it for middle grade doctors, so I assume that most of you have completed your membership exam MRCP that is another requirement to start ST3 training. If your are in UK core medical training, you can apply and start your training without passing PACES but cannot continue your training if you fail to pass it in first few months. They also require a proof of English if medium of education was not English in your medical college.

Then there are many more things which are in the application list for which you get marks which are very important indeed because for limited number of seats you need to get marks to become a competitive candidate. The List is long and easily accessible on ST3 recruitment website few things which you can work on to get more marks are, try to do a audit in your trust rather a full quality improvement project other things would be your research or case report publications and your presentations in various conferences the more you do the more marks you get and better are your chances to be selected. For me I did a quality improvement project and I already had publications in international journals along with poster presentations and end of the day every single thing counts.

Now that I have worked up on my eligibility and various other things to secure more marks the time came to apply for the ST3 post it was Round 2 and round 2 is easy for foreign graduates as less locals will be available during this round. You complete your application on oriel website and apply on the same website the website is simple and easy to use once the application is completed and submitted its time to sit back relax and prepare for the interview.

The interview invites will be based upon your numbers which you claim during your application and they mainly are on your academic achievements like I have already mentioned. Don’t waste your time and just wait for the invite as sometimes the invites are over short period of time so start preparing for your interview as soon as possible. I studied two books for my interview one was oxford hand book of respiratory medicine and other was Medical Interviews,” comprehensive guide to CT, ST and registrar interviews it’s a very good book and most of the non-medical questions asked during interviews are almost covered in it. At least one read is a must especially for some one like me who is not trained in NHS.

 

Interview format is different for different specialities and can also keep on changing but it is given on ST3 recruitment website, till now so many times I have referred to ST3 recruitment website, it’s official website for recruitment at registrar(ST3) level and is very important with all the information you need from preparing your application to interview and all things after interview. therefore, it is very important that you know your format right from the beginning of the interview so that you prepare according to that format.

For me the most difficult thing was to prepare a research article as it was in the format of respiratory medicine interview that you should prepare a relevant research article and present it in four minutes during one of the stations in interview. I went to one of the respiratory consultant and directly asked him about the article and he gave me a very good study to present on COPD based on which the management guidelines were about to change. I would advise, do not just google and prepare any spontaneous article, choose your article very cleverly it should be some current or hot debate related or something important like based on which new guidelines are formed or old guidelines changed or some landmark trial, not just a spontaneous article or study. Because it should be used as an excellent opportunity for you to represent your interest in the speciality and to show the future potential for the development of speciality and your interest in it.

Always work on questions and prepare the individualised answers which should be true representative of your self not just the stuff available over the internet, try to support your answers from your life time examples. every answer should be indirectly showing some positive aspect of your personality and strong commitment to the field of Medicine and respiratory medicine. There wouldn’t be a lot of questions from your personality. During my interview the main focus was on three things First thing was commitment to specialty second thing was a clinical scenario along with relevant communication skills and third thing was the research article you need to present along with a ethical scenario. The Interview was very rapid three stations of 10 minute each and 5 minutes in between each station. One important thing about the interview preparation is your medical portfolio whatever marks you have claimed during the interview you should back them up with good evidence in it. The last thing any one would need is getting not appointable because of claiming wrong marks or not carrying the appropriate evidence with them to support it. I really worked on my portfolio arranging and organising the evidence so that everything looks professional. Again, there are guidelines on the ST3 recruitment website on how to arrange and organise your portfolio.

Once Interview is over, its time to relax and wait for the outcome initially they will ask you to give priority of the regions /deanery where you would like to spend next five years of your life as a registrar trainee later they will tell you your appointable or not appointable and will be given a rank number and based on your rank number and your preferences you would be matched to a region and this matching is more or less same as Match process in USA.

27th of September 2017, new offer received through oriel system. Respiratory and general internal medicine and that also in my top priority region Kent, Surrey and Sussex Deanery. Thanks to Allah Almighty for getting a training slot that will lead In Sha ALLAH to become a consultant.

In the end all praise to ALLAH ALMIGHTY who helped me to get a trainee post in less than a year in UK and all the theories of other people turn out to be wrong about my moving from middle east to UK as there is no match to be trained from a western country and there is little or no progression of career in middle east if you’re working their at junior or middle grade.

All the best for all those who want to move, or in UK and want to apply for ST3 training post.

training-pathway

 some useful links

http://www.st3recruitment.org.uk/about-st3/overview-st3-recruitment

https://specialtytraining.hee.nhs.uk/portals/1/Content/Person%20Specifications/General%20(Internal)%20Medicine/General%20(Internal)%20Medicine%20ST3.pdf

http://blog.messly.co.uk/messlys-guide-to-st3-applications-2017/