Rotational Training in ICM

As East of England (EoE) TPDs we were struggling with our capacity for Paediatric ICM Stage 2 training This was the bottleneck preventing expansion of ICM training in the EoE. Our increasing demand for PICU was multifactorial: expansion in resident numbers; increasing numbers of residents requiring full 3-month blocks (as opposed to day release with dual anaesthesia ICM residents); and increasing numbers of LTFT and out of sync residents.

The EoE, whilst a large geographic region, has only one PICU at Cambridge University Hospital (CUH). This unit accommodates eight three-month placements per year for Stage 2 ICM residents.

In order to expand our paediatric ICM capacity we approached the CUH based Paediatric and Neonatal Decision and Retrieval Team (PaNDR). 

The perceived strengths of creating an ICM training post in paediatric retrieval included:

• Local, in region solution
• No additional travel - relatively centrally located within region
• Expected experience maps well to Stage 2 ICM curriculum competencies
• Flexibility with posts and timings could incorporate out of sync rotations if required
• PaNDR team very supportive of suggestion
• Trainees on PaNDR utilise the National Paediatric Retrieval Passport which details the competencies expected to be obtained during the placement. We have mapped this Passport against the Stage 2 ICM curriculum competencies
• Potential to expand post numbers in the future

We felt that this PaNDR placement would provide an ideal training environment for Consultants intending to work in a DGH. The PaNDR placement would provide a unique opportunity to master the initial stabilisation of the sick child and build ongoing future links with these services.

The identified weaknesses were as follows:

• Decision regarding which residents to place on PICU and which in PaNDR
  • Dual EM ICM trainees considered to be ideally suited to the PaNDR placement in view of their EM paediatric experience
  • Single ICM CCT trainee with DGH career intentions would also be ideally suited to the PaNDR placement
• Difficulty mapping to paediatric perioperative care competencies with PaNDR placement
  • Mitigated by 10-day PICU day release
• Risk of differential attainment
  • Nature of retrieval service means that each day is different
  • Experience between the ICM residents allocated to PaNDR may vary although this is also seen in PICU, especially with variations in seasonal activity
  • Experience may vary between PaNDR and PICU placements. Different training pathways leading to the achievement of required capabilities already exist however within the programme between Dual Anaesthesia and ICM residents and non-anaesthesia ICM residents.
  • Risk of PaNDR placement becoming more desirable than the PICU placements – could be mitigated by increasing PaNDR placements

We informed FICM of our intentions, but the decision to proceed was deemed a local one. We therefore allocated one of our EoE ICM expansion posts to PaNDR from August 2025. Our second LTFT dual ICM & EM IiT starts their placement in March. It is too early to assess the success of the programme, but we are closely monitoring the experience gained by the residents, both by direct communication and our regional end of placement survey. 

- Dr Natasha Lawrence (ICM Regional Advisor and TPD) & Dr Coralie Carle (TPD), East of England

• The East Midlands Intensive Care Medicine training programme assigns Educational Supervisors (ESs) for the entire duration of a resident doctor’s CCT. The ES is appointed by the TPD at onboarding, with an initial meeting encouraged within the first month of starting the ICM CCT programme.

  We believe this longitudinal approach fosters a deeper relationship between trainers and residents, supporting the diverse backgrounds and unique training needs of everyone. ESs can be based at any hospital within the region, with meetings held in person or over Teams/Zoom depending on preference. Regular three-monthly check-ins are encouraged to assess progress and set goals. Wherever possible ESs with the same partner specialties as the resident are assigned. If this is not feasible, or if ICM is not the resident’s primary specialty, then separate ESs are assigned for each specialty. This arrangement has been well received and, in some cases, has enhanced supervision by providing varied perspectives from different supervisors.

  Residents occasionally request to be reassigned for various reasons, and such requests are handled with care, with no adverse outcomes. The scheme is highly valued by our IiTs, and we take pride in the strong relationships we have between our residents and trainers.

- Dr Andrew Sharman, ICM Regional Advisor, East Midlands

• Although our region is geographically smaller than some, we historically have a split between those residents based in the ‘North’ or ‘South’ of the region, focused on the two main teaching hospital sites, Nottingham University Hospitals (NUH), and University Hospitals of Leicester NHS Trust respectively (UHL).

  From a programme planning point of view, we aim to keep residents geographically as close to their base site as possible, however the Stage 2 year is problematic, requiring placements at specialist centres that are geographically split to achieve the required capabilities. As it stands, in the East Midlands region we split this year into two 6-month rotations, completing paediatric critical care and neurocritical care at NUH, and cardiac critical care and general ICM (or partner specialty) at UHL. 

  We aim to plan residents’ rotations well in advance, providing as much forward notice of the complete rotation as possible, however, this ultimately is never achieved due to a variety of reasons including residents taking on a second specialty, parental leave, exam failure requiring an extension to training, or other unforeseen circumstances (carers leave, career breaks, etc.). We also appreciate that a resident’s interests may change over the period of their training and aim to be as flexible as possible, providing rotations that fit their future career plans, along with supporting out of programme placements if this supports the resident doctor’s overall career aspirations. Ultimately, we nurture a shared understanding that we will provide flexibility where possible, on the proviso that the rotation is covered, and our patients are catered for.

- Dr Matt Charlton, ICM Training Programme Director. Glenfield Hospital, University Hospitals of Leicester NHS Trust

The ICM National Recruitment Office (ICMNRO) advises the Health Education Team of a successful ST3 appointment. A welcome letter is sent to the trainee from the Stage 1 TPD introducing themselves and the team, signposting the school website/information and asking for the FICM onboarding form to be completed and returned to the TPD as soon as possible. Any preferences regarding placements should be included in the onboarding form. The successful applicant is advised of the priority for placement preferences process. In London this is based on ranking at national recruitment. Area of residence is considered as much as possible in post allocation and commutes are kept to less than 60 minutes. If the recruit is dual/triple training, then placements are matched, as much as possible, with dual/triple training locations. Post availability and ranking in national recruitment is again considered. They are advised a mixture of their time will be spent in both district general hospital posts and major centres.

In several London regions a training plan (up to CCT) is devised after national recruitment and the IiT is informed of the placements. The IiT is advised the plan is provisional and they are made aware of any changes to placements with as much notice as possible (nationally agreed codes of practice are observed as a minimum).

- Dr Charlotte Anderson, Head of School, ICM Pan-London Programme

In Mersey, we have an Intensivist in Training (IiT) from an Acute and General Medicine background who joined the Intensive Care Medicine (ICM) training programme later than typical, at the end of ST5. This late entry resulted in a significant amount of time being spent on medical rotations before commencing the triple CCT pathway for ICM, Acute Internal Medicine (AIM), and General Internal Medicine (GIM).

The established guidance for medical triple CCT training stipulates that IiTs should spend 12 months in medicine during Stage 1, 12 to 15 months during Stage 2, and 6 months in Stage 3. However, in this specific case, the IiT had already completed 32 months of formal AIM/GIM training, achieving successful Annual Review of Competence Progression (ARCP) outcomes and passing the exit Specialty Certificate Examination (SCE) prior to embarking on the triple CCT pathway.

Upon commencing ICM training, the IiT successfully completed the capabilities required for Stage 1, as well as the placement for Stage 2, and passed the Fellowship of the Faculty of Intensive Care Medicine (FFICM) examinations at the beginning of Stage 2. Consequently, the conventional structure of Stage two, which entails 12 months of ICM training and 12 months in Medicine, could disadvantage the IiT by necessitating the repetition of a year of medical training. 

Therefore, a collaborative decision was reached between the Schools of ICM and Medicine to condense Stage 2 to one year, eliminating the requirement for additional time spent in Medicine during this phase of training.

In conclusion, if IiTs meet the requirements of the triple CCT programmes, including the capabilities and examinations, they should not be disadvantaged and needlessly repeat blocks of training considered redundant. This approach could be adopted nationally to promote greater flexibility within the medical triple CCTs programmes.

- Dr Paul Jeanrenaud, Training Programme Director, Mersey 

• As part of Stage 3 ICM training we aim to offer all IiTs a DGH placement at a location close enough to their home to permit an on-call rather than resident rota pattern.
• Single Lead Employer in place since 2021.
• At onboarding to ICM specialty training, new IiTs meet with the RA and their individual training requirements are assessed. An overview of their training pathway and how this will potentially influence their future postings is discussed.
• Recognise that Stage 2 specialty ICM placements require 3 monthly rotations, which can be difficult. In our region, these units are within the same trust/health board, and this offsets some of the challenges. We are developing closer relationships with partner specialty TPDs to smooth out transitions that fall before and after this block of training. 

- Dr Esther Davies, ICM TPD and RA, Northern Ireland

The East of Scotland (EoS) is the smallest ICM training region in the UK. Whilst Scotland functions largely as a single deanery, IiTs are appointed to one of 4 distinct regions. The numbers are small in the EoS with approximately 10 IiTs on the programme, presenting both unique challenges and benefits.  

The smaller programme size allows for highly individualised support and greater flexibility within the training programme. IiTs complete the majority of their ICM training at a single large teaching hospital, where both Stage 1 and Stage 3 are delivered on-site, with no mandatory rotations to other centres. Stage 2, however, requires two external rotations: one to Glasgow for cardiothoracic training and one to Edinburgh for Paediatric ICM (PICM), with accommodation provided during these placements.

Feedback from IiTs is generally very positive, with high satisfaction scores in both the Scottish and GMC training surveys. While we acknowledge the potential limitations of single-centre training, the IiTs value this highly and report that they feel valued, known and treated as individuals. This setup also offers stability, allowing trainees to settle and build strong support networks while navigating the demands of ICM training.

- Dr Judith Joss, East of Scotland ICM RA and TPD

In South East Scotland we aim to provide an Educational Supervisor (ES) for the duration of training, with a Clinical Supervisor (CS) for each placement. We find this gives an excellent balance between direct clinical supervision while on placement, with continuity of oversight of training. Where possible we try and ensure that any doctors on the Dual or Triple ICM CCTs are paired with an ES who can supervise both programmes, with the goal of reducing the administrative burden for both trainer and resident intensivist.

- Dr Neil Young, Lead RA for Scotland

• North Wales offers great ICM training and is a great place to live. However, any IiT who wishes to train here must travel to South Wales to undertake subspecialty blocks in Stage 2, and then again for ‘high-volume’ experience in Stage 3.

  Although a single deanery, the geographical separation of North and South Wales is considerable. As an immigrant from Scotland, I noticed that I can drive from my new home back to Glasgow in the same time than I can drive to South Wales! And yet we would never expect an IiT to rotate from Wales to Scotland as part of a standard training programme. To address this problem, we have established a partnership with the ‘deanery next door’ in Manchester. This is one hour away from North Wales and offers the full range of subspecialty training and high-volume ICM. The first IiT is due to arrive in 2025.

  I am immensely grateful to all the people that have worked together to make this happen; heads of school and educational directors in both regions; senior staff in affected healthcare organisations; and most crucially, the TPD in Manchester whose willingness to think differently was crucial to the project. I hadn’t previously appreciated how many moving parts there are to this sort of thing, from programme planning to business cases to memoranda of understanding and Service License Agreements (SLAs). We will be very interested to see how things pan out when our pathfinder IiT arrives in Manchester next year.

- Dr John Glen, Training Programme Director, Wales 

• Family life is of vital importance to me and minimising disruption to this was paramount when considering location of training. Though I began as a dual Emergency Medicine/ICM trainee, I opted to relinquish EM in favour of the opportunities Single CCT ICM training offered, namely the Special Skills Year. 
  
  I began ICM training with a young and expanding family in North Wales. Wales is a large and geographically challenging area. The notion of being deployed to South Wales and therefore separated for periods was undesirable. I therefore chose to undertake my training in Mersey to guarantee that I would not spend periods away from home and my family. Commuting was tough at times and required some local allowances for rest around night shifts. The ICM SSY gave me the opportunity to undertake an OOPT in Wales, close to home, in a clinical area of interest to me that is now part of my consultant job plan. I am confident these choices improved my work-life balance and wellbeing through minimising disruption to home life.

- Dr Gareth Emlyn Thomas, ICM Consultant, Betsi Cadwaladr University Health Board

• Although this is a large region, the TPD meets regularly with both existing IiTs and those new to the training programme and plans training placements with IiT input up to 2 years in advance.

- Dr Rosie Worrall, Lead IiT Representative, West Midlands

• Since joining ICM training in 2021 – both of my TPD’s have been supportive and helpful regarding LTFT training. Upon appointment to the programme I contacted my TPD to discuss my intention to apply for LTFT training and I was signposted to the process, the percentage options and the application forms.  My TPD asked new IiTs to the region a few questions to help them shape the training allocations:
• Which hospitals would represent a difficult commute? (> 1 hour drive each way/impossible by public transport from your area)
• Do you have any special circumstances? (e.g. disability, access, maternity leave, professional issues)

They work really hard to minimise unnecessary rotations, discussing any training preferences and the commute with us prior to any official allocations. In programme I have also been able to alter my LTFT percentage whilst taking exams and doing a longer commute to the tertiary paediatric hospital for PICU.

- Dr Gemma Talling, Intensivist in Training, Worcestershire Royal Hospital