Guidance for ICM CESR Applicants

MBBS, MD (Anaesthetics), FNB Intensive Care Medicine, EDIC. Consultant in Intensive Care Medicine, Lead for Mortality & Morbidity at Barking Havering and Redbridge University Hospital.

"I moved to the United Kingdom in pursuit of new opportunities and challenges as a critical care physician after having completed my education and training as an anaesthetist followed by a fellowship in Intensive Care Medicine from Mumbai, India. My journey started in November 2015 and it has been a wonderful journey full of ups and downs.

When I moved to the United Kingdom I was unclear about my future like most of the new IMGs are and my mind went through turmoil. While I was going through different options for my career advancement, I realised that undertaking a CESR in critical care was best suited to me in the given situation. I decided to pursue it and stuck to it without looking back. It is easy to get your mind clouded as others will influence you, but it is important to take a decision which suits you the best.

CESR in critical care is a very challenging and demanding process. Continuous dedication, commitment and self-motivation is necessary to achieve the ultimate goal. Before you embark upon this journey, please read the GMC website, Specialty Specific Guidelines for CESR, the experience required for CESR, Royal College specialty specific Curriculum/CESR related advice and guidance. Please also try and speak to candidates who have been successful in their CESR applications or who are currently in the advanced stages of their application. This will give you a fair idea of the process, will help you in saving precious time and to channel your efforts in the correct direction.

It is essential to go through all fourteen High Level Learning Outcomes (HILLOs) in the ICM curriculum and note down  the areas that you need to work on. Once you know what you are lacking, plan well and set a timeframe for each target to be completed. Please see the acceptable exams in the guidance and make sure you pass one of them by the time you are ready to submit, if you have not done so already.

The next step is to start collecting prospective evidence in the form of DOPS, Mini-CEX, CBDs and segregated as per HILLOs. Organise it into separate folders and save the evidence in respective HILLOs as and when you gather it. There are some courses that need to be done in the areas of teaching and training or leadership and management so as to make your application stronger. It is important to demonstrate your continued development as a critical care physician by attending regular conferences and courses, involvement in teaching & training, clinical audits and quality improvement projects. Annual appraisals, feedbacks from colleagues or patients and reflections form a significant part of your portfolio.

Clinical experience required to submit the application

Anaesthesia (indicative training: 1 year), Medicine (indicative training: 1 year, but can include up to 6 months Emergency Medicine), Specialty ICM placements: Neurosciences, Paediatric and Cardiothoracic (indicative training: 3 months training). It is also required to demonstrate evidence of a specialist year, (Please go through the guidance to see what can be included for the specialist year, there are multiple options that can be included). Evidence within the last five years will carry the maximum advantage. Evidence older than five years will be most effective if you show ongoing evidence that you are maintaining your skills. Please collect evidence of any teaching, presentations or meetings that you attend. Collect evidence for admin and leadership roles you take up. Please note that assessors need the evidence to satisfy them that you can perform as a successful consultant. Once you start the process of application on the GMC website it is valid for one year before it expires. It is advisable to start the application process once you have collected enough evidence and are confident of completing the application within the stipulated year. Evidence from your previous country of work can be submitted as well if that is available. Evidence could be in any format, but it needs to demonstrate your experience and skills. It is mandatory to anonymise the evidence before you submit.

You will need at least four referees for a successful application. Please identify the referees you would like to name in advance as it will help you with the application. One of the referees must be the divisional director and consultant lead of the trust you are currently working/have worked at.

Once the application is submitted to the GMC, you will be assigned a Specialist Applications Adviser, who will be your guide throughout the process until your application is finally sent to the Faculty for approval. Once the application is sent to the Faculty, it usually takes around three months for you to receive the final outcome. It took approximately thirteen months to get approval from FICM/GMC after I submitted the application.

The process seems very complicated and challenging before you begin, but it becomes more straightforward once you start. I can proudly say today that it was definitely worth the effort. Once you find your name on the specialist register it’s an amazing feeling of satisfaction and fulfilment.

I wish everyone who is currently in the process or starting the process of CESR in Intensive Care Medicine the very best."

MD, MRCP, FFICM, Consultant in Intensive Care and Acute Internal Medicine, Northern Care Alliance

"I obtained a CERS in Intensive Care Medicine (ICM) but my journey to get there was longer than I initially anticipated. I graduated from Syria and came to the UK where I joined the Foundation training followed by Core Medical Training (CMT-Now called IMT) in Northern Ireland. I then managed to secure a training number in the North West in both Intensive Care Medicine and Acute Internal Medicine.

I completed my training requirements apart from the FICM exam. I passed part 1 and the OSCE component of the part 2 exam but I needed repeated attempts at the VIVA exam. As a result, I exceeded the time allowed for completing training. I enjoyed ICU and was determined to pursue it as a career so I decided to apply for CESR. After obtaining a CCT in Acute Internal Medicine I took a clinical fellow post in ICU for two years during which I passed my FICM exam and applied for CESR in ICM.

Having been through both the training and CESR routes, I found CESR more demanding both in time and effort. It requires a lot of organisation and you have to go through a long application process at the end compared to annual ARCPs during training but the more effort you put into something the more rewarding it is when you achieve it, so don’t let the challenging application put you off. Trust me it feels great when your application is approved and you start working independently as a consultant.

Before you start

Before you start you need to find out exactly where you stand and what you need both in terms of the supportive evidence and the required clinical experience [Anaesthesia (one year), Internal Medicine (one year, can include up to six months in Emergency Medicine), Specialty ICM placements (three months placements in each of Neuro, Paediatric, and Cardiothoracic ICU) and Special Skills year].

Spend some time reviewing the CESR application guide and the High Level Learning Outcomes (HiLLOs ) for ICM on the GMC website, the Specialty Specific Guidance for CESR application in ICM, the ICM curriculum, and the Special Skills Year handbook on the FICM website. After you get a good understanding of the requirements you should reflect on your own experience so far; consider what you can use as evidence in the application and, also, the gaps that you need to complete before you apply. It is useful to involve your clinical supervisor or department CESR lead in the planning phase.

 More weight is given for evidence within 5 years from the date of the submission of the application. You can still use older evidence, but you’ll need to show that you have maintained that skill or knowledge since you obtained it. (I had completed my Initial Airway Assessment more than 8 years before submitting my CESR application, so I completed a few DOPS for intubation and used my logbook to prove that I maintained my airway management skills).

Some HiLLOs cover generic skills like teaching, management, and quality improvement. You can link evidence from different placements to these HiLLOs. The evidence must be consistent from your different placements. Other HiLLOs cover more specific areas like Paediatric and Cardiothoracic ICM. Make sure you gain sufficient evidence during your specialty ICM placements as you are unlikely to manage to have other evidence to link here from your general ICM placements.

Collecting evidence

Once you’ve identified what you need, you can then start collecting your supportive evidence as you rotate in different placements. The list of evidence is endless. You’ll need to complete sufficient work-based assessments (DOPS, Mini-CEX, CbDs, ACATs, MSFs-the latter two are particularly useful as they can be crosslinked between various HiLLOs). Attend your department’s formal teaching, governance, M&M, and other meetings and present over there when possible; get feedback for the teaching sessions you deliver; complete audits and quality improvement projects. Attending conferences and courses can provide further supportive evidence for your application. A valid ALS certificate is important to support your application.

Your logbook is an important piece of primary evidence for your CESR application that can be used across multiple HiLLOs. It provides consistent evidence of the transfers and the procedures you performed, and the cases you have been involved with. The FICM website has good examples of Logbooks that you can use (but these are not inclusive). Whatever logbook you choose to use, the challenge is to complete it in a timely manner. I suggest you dedicate 5 minutes at the end of every shift to update your logbook.

You also need to have evidence of management and leadership experience. There are many courses available to support this HiLLO. Alternatively, you can complete the whole or the leadership module of the PGCERT-Other modules in PGCERT will allow you to become an educational or academic supervisor for other trainees.

Getting evidence for the Research HiLLO can be tricky at times as you rotate between different placements. Discuss this with the research team early in your rotations, complete the Good Clinical Practice training and try to complete a PI associate scheme. Writing a review article is also a good way to support this HiLLO.

Verifying your evidence

The majority of the evidence you upload needs to be verified. The GMC website provides a clear guide of what needs and what does not need verification. You will need to group your evidence into bundles. The evidence will need verification using a proforma found on the GMC website. You need one verifier per proforma per hospital/institution. It is easier if you can complete the proforma by the end of each placement (it can be done at your end placement meeting) rather than having to ask for this a few years later.

Exam

You also need to have completed an appropriate exam before you can apply. There is a list of accepted exams in the guidance. EDIC seems to be more popular among IMGs applying for CESR but different applicants might find different exams more suitable. Whichever exam you decide to take, don’t leave it too late. Delaying your application because you need more time to pass the exam can affect the strength of the evidence you are providing (remember, evidence older than 5 years carries less weight).

Referees

You’ll need a minimum of four referees in support of your application. The GMC provides good guidance on choosing your referees. Your primary referee has to be your current clinical or medical director. Carefully consider who you are approaching to be your referees. The structured report they will provide is reviewed and referred to by your application’s assessors, so your referees need to have known you well enough to comment on your skills and knowledge.

Submitting your application

While you need to plan for CESR in advance, don’t start the application itself too early. You have 12 months to submit the application from the time you open it. After you submit your application, you will be assigned an application advisor. The GMC is very specific about the evidence you submit and its format. They also provide a guide on what evidence needs anonymisation. The advisor will review your application, accept some of your evidence, recommend changes to the others and they may suggest ways to strengthen a specific area of your application. The more effort you put into ensuring your application meets the GMC recommendation before you submit it, the easier it is for the advisor to accept your evidence and the shorter this process will take (It took 8 months in my case). Eventually, your application will be submitted to the Royal College of Anaesthesia for evaluation. Once your application is submitted you usually receive an outcome in less than three months.

I hope my experience with CESR application will help you prepare your own, and I wish you all success in obtaining a CESR in ICM."