University Hospitals Bristol NHS Foundation Trust
Introduction
University Hospitals Bristol NHS Foundation Trust (formerly United Bristol Healthcare NHS Trust) is a busy acute teaching trust that is one of the largest providers of core medical training within Severn Postgraduate Medicine Education (PGME).
Core medical training is provided at Bristol Royal Infirmary (BRI (a 550 bedded hospital situated in the heart of Bristol)) with some trainees also rotating through the Bristol Haematology and Oncology Centre which is part of UH Bristol.
Clinical Placements
Currently core medical training occurs over 2 years, each year being split into three, 4 month rotations. We endeavour to offer trainees the rotations of their choice. The following specialties are available at UH Bristol.
- Cardiology
- Care of the Elderly
- Diabetes and Endocrinology
- Gastroenterology
- Haematology
- Hepatology
- Medical Assessment Unit
- Oncology and Palliative Care Medicine
- Respiratory Medicine
- Stroke
Cardiology
BRI has a regional tertiary referral cardiology unit that is based in the cardiology and cardiothoracics specialist hospital, the Bristol Heart Institute. The service provides 24 hour angioplasty for the south west and has clinical and research interests in a wide range of cardiac disease. The cardiology department works closely with the regional cardiothoracic service and the adult congenital heart disease service. There is a full range of cardiac services including angiography, cardiac MRI and EP suite. The 8 consultant cardiologists take part in a specialty take on a daily basis. Trainees duties include covering the 2 cardiology wards and 8 bedded coronary care unit. When on call CMTs take part in the acute medical rota.
Care of the Elderly
Trainees rotate within the geriatric department to experience acute geriatrics, general medical wards and rehabilitation medicine. There are 7 geriatric consultants and 9 wards including the South Bristol Community Hospital. There is an excellent acute geriatric admissions unit which accepts patients direct from ED and the community. There is a daily consultant ward round and great experience in the initial assessment and management of complex medical patients with multiple comorbidities. Care of the Elderly provides a supportive learning and teaching environment. Trainees will then rotate to general geriatric wards with many specialist interests including; orthogeriatrics, syncope, movement disorders and diabetes. There is then a placement at the South Bristol Community Hospital to experience rehabilitation medicine. Once a week there is a morbidity and mortality meeting and journal club with lunch provided. This meeting provides an opportunity for the trainees to present cases and/or journals. There is also a weekly x-ray meeting to discuss interesting radiology with the presence of a neuroradiologist from North Bristol.
Stroke
There is a specialist stroke ward which can admit directly from A&E and from the TIA clinic. TIA clinics are held morning and afternoon Monday - Friday and trainees are welcome to attend. There are two stroke consultants on the ward and a consultant running the TIA clinic. Thrombolysis calls occur at the BRI and members of the stroke team are encouraged to attend and receive training to be able to run a thrombolysis call themselves. Whilst on this rotation there is a two week attachment at South Bristol Community Hospital to gain more experience of stroke rehabilitation.
Diabetes and Endocrinology
The D and E service includes an academic unit with an interest in neuroendocrinology. There are 2 NHS and 3 University consultants who share responsibility for inpatients. CMTs are based on MAU where they look after the endocrinology patients and have excellent opportunities to attend outpatient clinics which includes a post-clinic educational de-brief with the relevant consultant. There are specialist clinics for thyroid and diabetes related eye disease and diabetes in pregnancy. Trainees take part in the acute medical take. There is also a once weekly departmental teaching session where difficult cases are presented and discussed.
Gastroenterology
The gastroenterology department consists of 4 consultants who have expertise in the care of a wide range of luminal GI disease. There is ongoing research into nutrition and IBD and trainees have the opportunity to present at local and regional meetings. Consultants rotate responsibility for in-patient work. There are general gastroenterology clinics with an emphasis on IBD and monthly multi-disciplinary nutrition clinics. There is a large endoscopy unit which allows trainees to observe the full range of diagnostic and therapeutic GI endoscopy. There is a weekly departmental educational meeting, Biologic MDT, histopathology, radiology meeting and nutrition round. Trainees in gastroenenterology take part in the acute medical rota.
Haematology
The haematology department based at the separate Bristol Haematology and Oncology Centre (BHOC) is a regional service providing a full range of care for patients with haematological disease including, malignancy blood cell dyscrasias and disorders of coagulation. They are responsible for over 20 in-patient beds and run a bone marrow transplant service. Trainees are responsible for in-patients, and help staff the Avon haematology day units which is a 24 hour walk in service for patients. The post offers opportunities to develop practical skills such as bone marrow aspiration and the insertion of various types of central venous access. There are opportunities to attend specialist and general outpatient clinics and to gain experience in the laboratory based aspects of haematology. There is weekly departmental teaching as well as case presentation and journal club. During this attachment CMTs do not take part in the acute medical take but out of hours are responsible for inpatients and direct admissions to the BHOC (including oncology and bone marrow transplant unit).
Hepatology
There are 4 hepatology consultants at the BRI who look after the full range of liver disease, with specialist interests in viral hepatitis, metabolic and alcohol related liver disease, hepatocellular cancer, iron overload and portal hypertension. There is a 23 bedded in-patient ward that includes 4 higher dependency beds for the care of decompensated liver disease as well as patients with significant upper GI haemorrhage. There is an active research and audit interest in liver cancer, hepatitis C, alcoholic hepatitis and hepatic encephalopathy and many trainees have the opportunity to present projects at local and national meetings.
The BRI is a regional centre offering innovative technologies such as TIPS, Fibroscan, RFA and TACE. Trainees will have an opportunity to familiarise themselves with all aspects of the care of patients with severe liver disease and major GI haemorrhage and improve their practical skills in central venous access, paracentesis and the assessment and management of the acutely unwell patient. There are also opportunities to attend outpatient clinics (including a liver transplant clinic) and therapeutic endoscopy sessions.
Weekly departmental teaching takes place on a Monday in conjunction with other GI colleagues and there are supplemental monthly teaching sessions on aspects of hepatology. There is also a lecture course at induction to familiarise the trainees with the care of liver disease.
Oncology and Palliative Care Medicine
Also based at the BHOC, the oncology service provides specialist in and out patient care for the region. There is a large in-patient ward, a small specialist Teenage and Young Adult unit, and an acute admissions unit. Patients can be admitted directly to the acute admissions unit 24 hours a day. The service provides chemo and radiotherapy to for patients with a wide range of malignancy with most consultants sub-specialising in particular areas of disease. There is an active research programme with many clinical trials on-going. CMTs are responsible for inpatients in a large unit and this provides exposure to a wide range of oncological emergencies as well as close liaison with palliative care services. There is a locum registrar overseeing admission of patients Monday to Friday 9 - 5, outside of these hours the trainees clerk new patients. There are departmental teaching sessions and a journal club. There are opportunities to attend specialist MDT meetings. During this attachment CMTs do not take part in the acute medical take but out of hours are responsible for inpatients and direct admissions to the BHOC (including haematology and bone marrow transplant unit).
Respiratory Medicine
The respiratory medicine department encompasses a large number of inpatient beds, outpatient clinics and diagnostic services. There are 6 consultants with a range of specialised interests including the regional cystic fibrosis service, tuberculosis and sleep service. There are 2 inpatient wards and a specialised cystic fibrosis unit. There is also a 5 bedded high dependency unit where patients receive non invasive ventilation which give trainees an opportunity to develop their skills in managing patients with severe respiratory compromise. There is an opportunity to attend outpatient clinics and bronchoscopy lists. There are weekly educational meetings including a large MDT meeting. There is opportunity to learn and develop practical skills in chest drain insertions and thoracocenthesis.
Acute medicine at the BRI
There is a 19 bedded MAU department which admits on average 40 patients a day referred from general practice and the emergency department. Elderly patients are also directly admitted to a dedicated assessment unit. Each day Monday - Friday there is a consultant from each of; respiratory, gastroenterology/hepatology, and endocrinology. The consultants do a ward round of patients whose main presentation fits into their speciality so that patients get expert care as early as possible. General practice direct admissions to the MAU are screened first by a resident experienced GP which helps prevent unnecessary admissions. There is also a MAU clinic, DVT clinic providing services which accept direct referral from MAU and ED. There is a separate cardiology post take ward round daily run by a cardiology consultant, and is done with a cardiology specialist nurse or registrar. There is an acute stroke thrombolysis service and a 24 hour on call GI endoscopist.
Formal and Informal Teaching Opportunities
Formal teaching out with the departmental teaching mentioned before includes a weekly grand round and designated CMT teaching. The grand round includes 2 presentations chaired by a member of the academic faculty and provides a forum for the discussion of interesting cases and updates on current and future practice relevant to specialist and general physician. Speakers include representatives from a wide range of medical specialities. The meeting is preceded by a lunch sponsored by a pharmaceutical company. CMT teaching has recently been redesigned to cover the new GIM curriculum directly aimed at ST1 and ST2 CMT trainees but with one session a month also relevant to GP trainees. The timetable is enclosed for the next year. There are monthly clinical governance meetings which provide an opportunity for all consultants and trainees to meet and discuss specific governance issues and every 3 months there is a medical department mortality and morbidity meeting which includes nursing and managerial staff. As to be expected in a large teaching hospital there are many informal teaching sessions within each speciality and all trainees are expected to be actively involved in teaching their peers, medical students and other health care professionals.
Every Thursday morning a CMT presents to the other trainees an interesting medical case. This meeting is chaired by 1 – 3 consultants and is a fantastic opportunity to learn about unusual diseases and learn from any mistakes. It is also a good opportunity for trainees to practise presenting and teaching. It is targeted at those times when the best course of action is not certain and is therefore called “Grey Case” teaching.
There is a large modern post graduate medical education centre providing library, IT and lecture facilities for the trust. The library and computer lab have 24 hour access. There is also a regional simulation centre which provides trainees with the opportunities to gain experience in managing the acutely unwell patient as well as developing their practical procedural skills. There is also a well developed resuscitation skills department who run regular ALS courses to which trainees have priority access. PGME centre is staffed by a manager and 2 administrators who coordinate eportfolios, educational supervision, study leave and teaching programmes. There is also access to an independent counselling and advisory service for trainees experiencing difficulties in any aspect of their professional life. The trust intranet provides access to elearning resources including UptoDate and local and national clinical guidelines.
Performance
All core medical trainees are expected to study for MRCP and the majority can expect to pass PACES by the end of their 2 years of training.
Other Stuff
There is a junior doctors website and very pro active junior doctor committee and doctors mess.
Core Medical Training, Weston General Hospital, Weston-super-Mare
Trainees currently spend a year at Weston-super-Mare, before completing a second year at either the Bristol Royal Infirmary or Southmead Hospital. The posts at the Trust provide broad general medical experience including on-call as part of the medical on-call team and Medical Admissions Unit (MAU) staff. The Medical take runs on an overlapping shift system, currently under review due to the European Working Time Directive. The Trust admits 20 to 30 patients per day via a dedicated MAU staffed by the Acute Medicine team including Acute Medicine Consultants and Specialist Registrars. Out of hours the on-call team comprises a Registrar, CMT/F2 and F1 doctor. Post-take ward rounds occur twice a day (morning and afternoon/early evening).
The speciality experience is three 4-month rotations. Current Core Medical Trainee rotations are Medical Admissions Unit, High Care, Endocrinology, Respiratory Medicine and Care of the Elderly.
GP trainees are currently allocated Cardiology and Gastroentrology. If Core Medical Trainees wish to undertake these specialty rotations, they need to be swapped with GP trainees with the agreement of the GP School and swaps cannot always be guaranteed.
Medical Admissions Unit
Dr A Kamour, Dr P Mamilla – The post is based on the Medical Admissions Unit and gives excellent experience to a broad range of acute admissions.
High Care
A dedicated five-bed High Care Unit gives excellent exposure to patients requiring escalation of care and closer monitoring than ward-based patients.
Respiratory Medicine
Dr O Perello-Bosch, Dr R Srivastava – The post is based on the specialist respiratory ward, with 1 Specialist registrar, 2 F2 and 2 F1 doctors. The CPAP/BiPAP service is based on this ward and usually patients needing this therapy are managed by the respiratory team.
Endocrinology
Dr P Singal, Dr K John - The post is based on the dedicated endocrinology ward as part of a team of 1 Specialist registrar, 1 trust grade, 2 CMT/VTS trainees and 2 F1 posts. Diabetic emergencies are managed on this ward.
Care of the Elderly
Dr H Al-Mahdy, Dr A George - with Acute Medicine on-call - The post involves acute elderly care, stroke, and dementia. On-call for this post is currently 1 in 5 weekends covering Medical Admissions Unit day shift.
Formal and informal teaching opportunities
- Grand Rounds occur weekly on Wednesday lunchtimes. Each team as well as consultant only specialties take turns to present cases of interest. The aim is to have each acute team present once per 4-month rotation
- Scheduled CMT teaching sessions occur weekly on Thursday lunchtimes.
- PACES teaching is organised locally depending on trainee needs.
- Morbidity and mortality meetings occur monthly.
- Additional training occurs via Severn PGME scheduled training days and a developing local programme.
Teaching facilities
Weston Area Health Trust has developed a North Somerset Health and Social Care Academy in partnership with the Regional Workforce Confederation. This Academy helps to deliver and facilitate the training and development of all Health and Social Care Workers but in particular the professionals. Facilities include lecture theatre, conference and seminar rooms and the medical library.
Quality Improvements Projects
A dedicated Quality Improvement Project Hub provides excellent support for staff undertaking audit and quality improvement projects.
Performance
Weston has a good track record with MRCP especially with PACES for those who want to take the exam.
Royal College of Physicians Tutor
Dr Tom Wells, Consultant Medical Oncologist
Director of Medical Education
Dr Gavin Stoddart, Consultant Radiologist