Core Medical Training at North Bristol NHS Trust
North Bristol NHS Trust is the largest Trust in the South West region, and one of the largest trusts in the country. Last year the Trust treated over 100,000 inpatients, over 350,000 outpatients, 90,000 emergency department patients and helped deliver over 6,000 babies. It employs more than 9,500 staff, has approximately 1,050 inpatient beds and income in excess of £540 million.
The Trust provides medical surgical, neonatal and maternity care for its local population of approximately a million people in Bristol, South Gloucestershire and North Somerset. The Trust also provides regional, regional services in neurosciences, orthopaedics, pathology, plastic surgery and burns, renal medicine and transplant and urology and is the major trauma centre for the West Country.
The health service in Bristol, North Somerset and South Gloucestershire is being remodelled to concentrate acute facilities and where appropriate to provide more care close to patient homes through a network of community hospitals and facilities. The Trust recently moved the majority of its acute services to the Brunel building, regarded as one the most the best hospital facilities in Europe, on the Southmead Hospital site. At Southmead Hospital, we also have our excellent maternity and women’s health services, the Bristol Breast Care Centre and the Trust’s Severn Pathology service.
As well as Southmead Hospital, the Trust also has Cossham Hospital, in Kingswood, that recently underwent a £19m refurbishment, the Bristol Centre for Enablement, at Cribbs Causeway (Bristol) and the Trust also runs children’s community health services across Bristol and South Gloucestershire.
The Trust has University Teaching status and is associated with both the University of Bristol and the University of the West of England.
There is a 5-6 week block on Acute Medical Unit (AMU) and nights during each medical specialty, except in renal and neurosciences who have their own specialty take.
The Acute Medical Unit (AMU) includes:
o 2 x four-bedded bays (trolley spaces) for Primary Assessment / Triage
o 24 single side rooms (beds) for Secondary Assessment
• AMU-Short Stay (16 single side rooms)
• AMU-Enhanced Care (ECU) (2 x four-bedded monitored bays)
• AMU-Ambulatory Emergency Care
The ‘medical take’ consists of 55-65 patients in each 24 hours.
There is a Consultant present on AMU from 0800 – 2200hrs daily. Post-take Consultant reviews occur during these hours. You will present your post-take patients to the consultant, which provides you with a good learning opportunity.
There is AMU Teaching every week.
You will have the opportunity to complete SLEs including ACATs during your 6 week Acute Block.
Your prime duty when on a clerking shift during your 6 week Acute Block is to see and assess acute medical admissions under the direction of the on-call medical registrar.
Learning outcomes can include but are not limited to:
- Recognition of acute illness and sudden deterioration including appropriate assessment and immediate care.
- Work with the wide range of differential diagnoses with the acutely ill patients they care for
- Work effectively in teams and to co-ordinate care
- Skills in liaison with other team members and across the secondary / primary care interface to ensure effective handover/ transfers of care
- Prioritise problems and establish a differential diagnosis in patients often with multiple problems
- Consider the appropriateness of interventions according to the patient’s wishes, the severity of their illness and the co morbid diseases they have
- Take responsibility for management of complex patients whilst also using available senior support.
- Remain person centred whilst managing acute illness
- Demonstrate that you have an awareness of the emotional and stress related aspects of caring for acutely ill patients and demonstrate appropriate self care
- Demonstrate particular skills in interpretation of ECGs, ABGs, CXR, AXR, etc.
- Work with colleagues in health and social care to support older people with their particular needs
- Organised approach to the management of chronic conditions and co-morbidities
- Skills in the management of acutely ill people as well as their chronic illnesses (in particular Ischaemic heart disease, Diabetes and COPD)
Cardiology training for core medical trainees at North Bristol NHS Trust is provided at the Southmead Hospital site, Brunel Building. There are 6 Consultant Cardiologists with various specialist interests spanning coronary intervention, electrophysiology and pacing, echocardiography, valvular heart disease and heart failure.
There is a single dedicated cardiac catheterisation laboratory and a hybrid lab shared with the vascular unit. Coronary intervention including urgent and elective PCI and device implantation happen throughout the working week. Procedures included diagnostic coronary angiography, percutaneous coronary intervention, optical coherence tomography, fractional flow reserve, pacemaker and ICD implantation.
There is a 33-bedded cardiology ward including 8 CCU beds located on ward 27a. We also have a busy CT coronary angiography service with 3 lists per week and nuclear myocardial perfusion imaging. The cardiac investigation unit also provides trans-thoracic and trans-oesophageal echocardiography including 3D echo, ECG monitoring, treadmill exercise testing and tilt tests.
There is a weekly cardiology educational meeting and SHOs regularly attend general cardiology outpatient clinics. They have opportunities to supervise exercise tolerance tests, DC cardioversion lists and to observe the range of cardiac procedures, which take place on site. There are many opportunities to perform audit projects relevant to cardiology.
There are 7 Gastroenterology consultants who lead teams of specialist doctors, nurses and professionals allied to medicine. The inpatient work includes caring for patients with GI bleeding, inflammatory bowel disease, nutritional problems and acute and chronic liver disease. The team works closely with the GI surgical unit and there are regular multidisciplinary histopathology, radiology and journal club meetings.
The weekly outpatient clinic provides experience of the less acute aspects of Gastroenterology including chronic liver disease, functional bowel disease and less acute IBD.
There is also a Medical day case unit where procedures such as ascitic drains and infliximab infusions are regularly carried out.
There are 5 consultant Haematologists across the Trust with an active Day unit and 2 Specialist Nurses, based at the Brunel building, Southmead Hospital. There are plentiful opportunities for learning about general haematology and haematological malignancies through out-patients, day care patient management and in the in- patient setting.
There are 2 Specialist Registrars, 3 specialty doctors, 1 Haematology SHO. There is a weekly journal club meeting and haematology MDT.
There are also 8 haematology in-patient beds which the CMT doctor is responsible for (with senior support). You will be able to attend clinic weekly.
The ID team has 16 dedicated beds in 2 wards (6 beds on 27b isolation suite and 10 beds on 8a), within which are up to 5 HIV beds. There is a 6-bedded isolation suite area with ventilated lobbied isolation cubicles where airborne infections such as TB, measles, Chicken pox, Corona viruses, influenza, etc., can be safely isolated.
There are 4 consultants, 2 Consultants ID physicians, Dr Heys (ID & acute medicine) Dr Bovill (ID & HIV) and 2 consultant immunologists (Drs Gompels and Johnston, HIV). There is one ST3-7 in ID/ GIM and at times, trainees in GUM and ID/Microbiology also rotate through the department. There are 2 CMTs and 1 clinical fellow at CMT level who rotate through the department (2 present on the team for 2/3 of the time, and 1 for 1/3 of the time depending on allocation to acute block. There is one FY1.
The trainee will gain experience in the care of HIV, TB, fever in the returning traveller, PUO as well as cosmopolitan infections such as pneumonia, meningitis, gastroenteritis, skin & soft tissue infections, etc. Approximately half of cases of TB in Bristol are seen and managed at NBT. Most inpatient TB is managed in the isolation ward. There will also be opportunities for trainees to attend TB, HIV, general and hot infectious disease clinics.
NBT is one of the few hospitals where TB & HIV co-infection is managed under one specialist team. The trainee will gain experience in the management of complex extra-pulmonary TB including, but not limited to spinal, bone and joint, CNS, and disseminated disease, as well as TB in patients with renal disease. NBT receives out of area referrals for complex TB as well as imported & community acquired infection. We have established excellent links with the Hospital for Tropical Diseases in London for the shared care of highly specialised tropical diseases such as leprosy.
The trainees will have the opportunity to participate in the following regular weekly multidisciplinary teaching ward round/ meetings
- Weekly radiology meeting lead by Consultant radiologist where-in all complex infections from both inpatient as well as outpatients are discussed in length to formulate appropriate further diagnostic and intervention strategy
- Weekly Multidisciplinary ward rounds with participation of the ID Physician, HIV physician, GUM trainees, dedicated clinical psychologist, dietician, and ID/HIV specialist pharmacist.
- Weekly Grand rounds where all complex/academically challenging cases will be presented from a variety of specialties.
- Weekly HIV meeting where all complex HIV cases are discussed on regular basis.
Trainees will be expected to take an active role in educational activities, presenting at postgraduate educational meetings, including grand round and HIV meetings. Also HIT trainees will contribute to the ID core curriculum educational programme, and the ID/GIM trainee will participate in training & coordinating teaching for PACES. They will also be expected to deliver tutorials, and bedside teaching. Active participation in research will be encouraged. The trainees are encouraged to participate and present abstracts in the national infection meetings, such as British Infection Association annual conference (BIA) and Federation of infection Society (FIS) annual conference, and international conferences such as ECCMID (European) and ICAAC (USA).
Medicine for the Elderly
Our department manages all aspects of the care of older people in hospital. Given that the needs of frail older people make up a huge proportion of the work in modern healthcare, experience in this field is useful for all hospital and community medical careers, not just those interested in specialising in medicine for the elderly.
There are currently eight (WTE) consultants, one and half (WTE) orthogeriatric physicians and five registrars.
Frail older people are assessed and managed in wards with a proactive approach to their treatment and rehabilitation. A multidisciplinary approach is fundamental on all elderly care wards based around board rounds, giving experience of the issues surrounding the inpatient rehabilitation and discharge planning in elderly patients. There is a multidisciplinary, consultant lead acute elderly care team working within the acute assessment unit and emergency department. There is also an inpatient rehabilitation facility on the Southmead site.
The department also offers several specialist services, including the investigation and management of Parkinson’s Disease, falls, bone health, elderly care surgical liaison, respiratory medicine in the elderly and dementia. Elderly care physicians are also central to the care of patients admitted under orthopaedic care with hip fractures. There are outpatient clinics on both the Southmead and Cossham sites. These principally provide a comprehensive geriatric assessment, often for rapid assessment, but also providing falls, movement disorders and breathless patient services.
There is a strong emphasis on education, with links to the university and the opportunity to teach both on the wards and in workshops. There is a lively post-graduate meeting within the department each week, at which articles, cases and clinical governance issues are discussed. There is a weekly Grand Round, and an elderly care x-ray meeting with radiologists weekly, which provide educational opportunities.
The Department of Neurology is based at Southmead Hospital NBT Bristol and is part of the Neuroscience Directorate. This is a Regional Neuroscience centre with multi-disciplinary specialist departments in Neuroscience.
TIA Clinics, Stroke prevention, treatment of acute stroke and stroke rehabilitation have become an integrated part of the Neurology department providing a comprehensive service to patients and providing excellent experience and training in stroke neurology for CMT Medical Trainees during their post in neurology at NBT.
There is an academic department of neurology at NBT with an active interest in medical research. Neurology also benefits from excellent working relationships with our colleagues in Neuroscience at NBT including the departments of neurosurgery, neurophysiology. There are also experts in neuropsychology and neuropsychiatry. There are excellent departments of neuroradiology and neuropathology at NBT which again provide great experience and training for CMT Trainee doctors in Neuroscience.
In Neurology there is an enthusiastic team of Consultants and SpRs (Neurology and Stroke Registrars) and there are also CMT Medical trainees and Foundation trainees and doctors in GPVTS training who have a placement post in neurology as part of their training programme.
All of our consultants in Neurology have a sub-specialist interest as well as expertise in General Neurology. There are regular Tutorials in Neuroscience for CMT Trainees. These educational opportunities allow medical trainees to gain knowledge and experience in both inpatient and outpatient specialist neurological practice.
At NBT we aim to provide excellent neurological experience and training for all our junior staff in Neuroscience. Training opportunities include weekly formal academic meetings, neuroscience teaching, informal bed side teaching during ward rounds and radiology meetings. There is also support for the Trainees to work on their portfolios while in post, with assessments provided where possible. Study leave for appropriate courses is encouraged. For candidates taking PACES for MRCP we are delighted to offer neurology specific PACES coaching from our enthusiastic team of registrars and consultants.
The on-call is within the neurosciences department covering neurology, stroke and neurosurgery.
There are 11 Nephrology consultants and 1 specialty doctor divided into two firms for the management of renal inpatients. Doctors working in the renal unit are well supported and the post provides excellent experience in all aspects of renal medicine. Doctors will leave with an awareness of the range of causes and presentations of acute kidney injury and experience of managing these acutely unwell patients.
They will also have exposure to the investigation and management of other renal conditions such as nephrotic syndrome and vasculitis, and also have involvement in the management of newly transplanted patients. Considerable general medical training is also provided in the inpatient care of complex long term dialysis and renal transplant patients.
We have weekly multidisciplinary teaching ward rounds, weekly X-ray meetings and renal histology meetings and weekly in-house specialty renal tutorials as well as bimonthly renal academic meetings.
Respiratory medicine is based in the North Bristol Lung Centre at Southmead Hospital. The department has a large team of specialists including 11 consultants, 10 of which are clinically active , and a research active Emeritus Professor. The 10 clinically active consultants include 8 full time NHS consultants - including a Clinical Senior Lecturer with part time research activity and a Honorary Senior Lecturer, 1 LTFT NHS Consultant, and 1 Professor with half time NHS clinical duties. The rest of the team includes 4-5 specialty registrars, 3-5 clinical research fellows (1-3 pleural, 1-2 interstitial disease), 13 specialist nurses and physiotherapists (including specialist nurses in cancer, pleural disease, interstitial disease and airways disease), a team of junior medical staff and one 32 bedded specialty ward with a respiratory HDU with out-patient facilities integrated with lung function
All aspects of respiratory medicine are dealt with and the department has specialist clinics for pleural disease, interstitial lung disease, difficult asthma, mediastinal disease (requiring EBUS), lung cancer, lung infection/NTM/TB and bronchiectasis and a leading pulmonary rehabilitation program. The department offers regional and tertiary services for pleural disease, interstitial lung disease (BILD Service) and endobronchial ultrasound (EBUS) and autofluorescence bronchoscopy with a very active international research programme in pleural disease, interstitial disease (via the Academic Respiratory Research Unit) as well as qualitative research in EBUS and other areas. We are at the forefront nationally in the management of pleural disease, interstitial lung disease and performing EBUS; having one of the best performing pleural and EBUS centres in the UK.
We have weekly departmental meetings, x-ray meetings, ILD and cancer MDTs with a new complex airways MDT in development with in-house respiratory teaching and weekly breakfast meetings. Access to our varied OP clinics is encouraged and there are strong links to the University with many opportunities for teaching and workshops.
The HOT clinic is also run on weekdays in the Seated Assessment Area for GP referrals for patients with respiratory problems threatening admission and is a consultant-delivered admission avoidance service. The consultants also provide a specialty consultation service for inpatients throughout the week supported by our registrars but also at the weekend delivered by the consultants alone.
This 4 month attachment offers experience of a wide range of rheumatological diseases. Based in the Brunel Building, you also have responsibility for the Medical Day Case Unit patients, covering a range of medical specialties.
You will be able to accompany the SpR or Consultant to see inpatient rheumatology referrals, with are a good learning opportunity, with excellent senior back up at all times. You will have the chance to see how a multidisciplinary team functions, liaising closely with specialist physiotherapy, OT, nursing and psychology colleagues. There will be regular opportunities to attend OP clinics, and have your own list once you have gained some experience. You will be able to attend a number of specialist clinics and Interface Services.
There are regular radiology and postgraduate meetings which you will be able to attend. There is 1 Rheumatology IP bed which in practice is rarely used for rheumatology. The post holder also participates in the acute medical on-call rota during a 6 week block. Previous post holders have become confident in musculoskeletal examination and common joint injections. The work load is generally regarded as being less onerous than some posts allowing the chance to work for higher exams such as MRCP.
There is a 2-hour teaching session each Wednesday lunchtime which covers topics from the CMT curriculum.
In addition most specialties have a weekly journal club or a teaching session as well as regular clinical governance meetings, which you should attend if possible.
Practical procedures and simulation teaching:
There is a regional Acute Medicine and Emergencies course facilitated by the deanery for local CMT doctors which is run several times a year.
In-house simulation and practical procedures training:
This is provided by the NBT teaching fellows several times a year.
Regional study days:
There are 4 CMT study days a year (at present held in Bristol). You are expected to attend 2 a year.
There is PACES teaching, mostly informal, before all PACES exams and we are also running full mock PACES exams annually.
In the past the 2-year rotations were fixed at the beginning of the CMT rotation and allocated according to preference and interview ranking.
In 2017 the second year will be allocated part-way through your 1st CMT year. There will be some choice but this will be limited by posts available, amount of acute vs. specialty take and preferences of your colleagues. Rotations are allocated according to interview ranking.