Getting Training where you want : An insight into upgrades and facilitated placement

¬ By Dr. Asadullah Anees Khan

        I wanted to write this post in order to help others who might be in a similar situation and are aiming to stay in a particular region while applying for Core Medical Training with a view to specialist training. My wife and I both wanted to apply for training in the same round, she was applying for GP training and I was applying for Core Medical training.


       Now I must mention, I really like my trust and it was the goal to stay here for further training if possible, but being on a Tier 2 visa and being subject to the Resident Labour Market Test (RLMT), I wasn’t hopeful of getting a post in this area. I applied for CMT in March, 2018. I had my interview on 26th April, 2018 and ranked my preferences. I was very disappointed when they released the offers and I was informed that even though I was deemed appoint-able to the post, I was on the reserve list due to the RLMT. I had ranked very few places and I would not suggest that but I had a few reasons for wanting to stay where I was:


  • We wanted to stay close to London and only ranked places within an hour from London
  • Wanted proximity to an airport
  • Wanted to stay close to where ever my wife got her GP training post (she found out a day before I found out about my preferences)


I had given up on getting a place after having ranked very few places but still held out for upgrades on Oriel.  Following were my preferences:



After two days, I received an email and a text message saying I had been offered a post in East Kent at Kent and Canterbury hospitals, which I was happy with. The thing I did not like were the rotations in that post as I didn’t have ITU, Gastroenterology or Respiratory rotations which are quite important in your training pathway. While ranking my preferences, I kept programmes which had Oncology at the top of my preference list while also preferring Palliative care (because it contributes to a career in Oncology). I also ranked places which were near my current place of work and preferred Surrey as my location as my wife and I like this place a lot.

Now the way the upgrade system works is if you are offered a post, you can rearrange your preferences on oriel if you have accepted with upgrades or held a post with upgrades. If you accept a post without upgrades or decline that offer, that decision is final.


asad (2)The picture  shows my ranking for CMT applications and the first one was at Royal Surrey which included Oncology as a rotation. I accepted my offer with upgrades and was hoping for a better offer before the offers closed.


On the day the offers were supposed to close, I was offered the post labelled 2 on the above picture whereas my previous post was 1. This gave me Gastroenterology and Respiratory rotations which I was very happy about. Now as the situation stood, I was upgraded to Margate hospital with both years of my CMT in the same hospital and my wife would have had to refuse her GP training post (which was in Wessex and a non-commutable distance).


However, we had recently read about something called a facilitated placement which is a way for them to allocate training to people who want to remain close to each other after getting training spots in different deaneries. Please go through the following guideline to help with information about enhanced preferences and ranking offers:

Please refer to the following link as well for and read about what is says under facilitated placement:


My wife filled out the form for a facilitated placement and she emailed it to GPNRO and CMT recruitment along with our marriage certificate on Priority 2 under the guidance for facilitated placements. While trying to accommodate people via facilitated placements, they try to match either of the two candidates rather than keeping one of them as a focal point and matching the other one. Both people can apply for a transfer based on this scheme. They gave my wife a list of places where she could potentially apply for a transfer but none of those places suited us. They emailed my wife thrice within a span of 5 days regarding new CMT posts and sent a list of places where a transfer was possible. The third and last list had a post at my current hospital. There were a couple of other places as well which would have been suitable and I emailed them with my preferences in numerical order. In a couple of days they offered me the post at my current hospital.


I immediately accepted because it was the first choice for me with 2 year rotations in Geriatrics (my current job), Palliative care (my first choice speciality – oncology would benefit from this post), ITU (very important to learn procedures and to manage critically ill patients), Respiratory (very important post and something I wanted), Rheumatology (my second choice speciality) and AMU as my last rotation.


Now my wife will be able to take her GP placement as well and we will live midway and commute to our workplaces.

If don’t know about the application process in general, please read Omar Alam’s guideline on applying for CMT and the application process:


some email addresses for point of contact:


GP :




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.


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.


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


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.