SLO1 Care for Physiologically Stable Adult Patients

 

Achieving RCEM Specialty Learning Outcome 1: Care for Physiologically Stable Adult Patients

Executive Summary

Specialty Learning Outcome (SLO) 1, "Care for physiologically stable adult patients presenting to acute care across the full range of complexity," represents the fundamental building block of clinical practice in Emergency Medicine (EM) (1). Mastery of this SLO is essential for trainees at all levels and forms the basis for all other clinical learning outcomes. The purpose of the Royal College of Emergency Medicine (RCEM) curriculum is to train consultants capable of providing urgent and emergency care to all undifferentiated patients, a demand which is increasing annually, particularly among older patients with complex co-morbidities (2).

Achieving SLO 1 requires the development of expertise in history taking, clinical examination, decision-making, and the management of individual adult patients. This capability must be applied across the full spectrum of presentations, including physical and mental health problems, complex co-morbidities, and frailty syndromes (1).

Key strategies for developing and demonstrating competence include:

• Mastering the Consultation: Utilising structured consultation models, such as the Calgary-Cambridge Guide, to ensure a patient-centred approach that identifies ideas, concerns, and expectations (ICE) (3). This includes proficiency in non-verbal communication, which is critical for building rapport and is often more impactful than verbal communication (4).
• Adopting Evidence-Based Clinical Practice: Grounding clinical examination and diagnostic reasoning in evidence-based resources to improve accuracy and clinical significance (5).
• Embracing Cultural Safety: Moving beyond basic cultural competency to a framework of cultural safety. This requires a paradigm shift towards critical self-reflection on one's own biases, privileges, and the inherent power imbalances in the clinician-patient relationship, allowing the patient to define what constitutes a safe clinical encounter (6, 7).
• Evidencing Progression: Systematically collecting evidence through a range of Workplace-Based Assessments (WPBAs), such as ACATs, CbDs, and Mini-CEXs, across a diverse case mix. Competence is summatively assessed through RCEM examinations and formal entrustment decisions at the end of Core, Intermediate, and Higher training stages (1).

This document provides a comprehensive synthesis of the curriculum requirements and best practices to guide EM trainees in successfully achieving SLO 1.

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1.0 Understanding SLO 1: Specification and Progression

1.1 Definition and Scope

SLO 1 is defined by the RCEM as the basic building block for patient care within the Emergency Department (ED). It encompasses the development of expertise in history taking, examination, decision-making, and management for individual adult patients. The scope is comprehensive, covering all physiologically stable adult patients across the full range of complexity. By the completion of training, an EM specialist is expected to be an expert in this SLO (1).

This expertise explicitly includes a deep understanding and aptitude in caring for specific patient groups who frequently present with complex needs (1):

• Patients with mental health problems.
• Patients with complex co-morbidities.
• Patients with frailty needs.

1.2 Progression Through Training

The curriculum outlines a progressive development of capabilities. Trainees are expected to demonstrate increasing levels of autonomy and expertise as they advance through the stages of training (1).

Training Stage	Key Capabilities	Level of Supervision
ACCS (Core)	• Gather appropriate information, perform a relevant clinical examination, and formulate a management plan that prioritises patient choice.<br>• Know when to seek help.<br>• Assess and plan for patients with complex medical and social needs.	Direct supervision available. Trainee knows limitations and when to seek help.
Intermediate	• Assess and manage all adult patients attending the ED.<br>• Formulate management plans for patients with complex medical/social needs or frailty syndromes.	Supervisor "on call" from home, available via phone and able to attend the bedside if required.
Higher (HST)	• Be an expert in assessing and managing all adult patients attending the ED.	Able to manage with no supervisor involvement.

1.3 Key Descriptors for Mastery

To achieve SLO 1, trainees must demonstrate proficiency across several domains. These descriptors provide a detailed framework for the knowledge, skills, and behaviours required (1).

Core Clinical Skills (ACCS Level):

• Demonstrate professional behaviour and deliver patient-centred care with shared decision-making.
• Take a relevant history, incorporating patient symptoms, concerns, priorities, and preferences.
• Perform accurate clinical examinations and demonstrate appropriate clinical reasoning.
• Formulate a differential diagnosis and a corresponding management plan.
• Explain clinical reasoning to patients, carers, and colleagues.
• Select, manage, and interpret investigations appropriately.
• Recognise the need for specialty liaison and demonstrate awareness of the needs of vulnerable adults.

Mental Health Presentations:

• Assess and manage patients presenting with features of mental illness, including a competent assessment of suicide risk.
• Professionally and compassionately assess a patient in crisis and safely manage acutely disturbed behaviour.
• Work collaboratively with Psychiatry Liaison, Police, and other agencies.
• Understand safeguarding responsibilities and the legal frameworks relevant to the ED.
• Respect patient autonomy while understanding best-interest decisions for patients lacking capacity.

Older Patients with Frailty and Complex Co-morbidity:

• Interact effectively with frail older people, especially those with cognitive impairment, and their families.
• Assess for frailty syndromes (falls, immobility, incontinence, polypharmacy, delirium).
• Recognise physiological pitfalls in the assessment of frail older people (e.g., in trauma).
• Be aware of safeguarding issues, pharmacokinetics in frailty, and the medicolegal framework for managing patients with cognitive impairment.

Observational Medicine:

• Evaluate patients in a Clinical Decision Unit (CDU) or observational setting.
• Estimate risk, utilise diagnostic tests appropriately, and formulate safe discharge plans.
• Communicate effectively with patients in this setting.

2.0 Core Components of Patient Care: A Practical Approach

2.1 Mastering the Consultation

The consultation is described by Pendleton as "the central act of medicine" and is the fundamental tool of practice (3). Effective consultation skills are learnable and can be honed through analysis and reflection.

2.1.1 Aims and Models of Consultation

A good consultation achieves multiple objectives. The model developed by Pendleton and colleagues outlines seven key tasks (3):

1. Define the reason for attendance, including the patient's ideas, concerns, expectations (ICE), and the effects of the problem.
2. Consider other problems, including continuing issues and opportunities for health promotion.
3. Choose an appropriate action based on sound clinical management.
4. Achieve a shared understanding with the patient regarding their condition and management.
5. Involve the patient in management to encourage shared responsibility.
6. Use time and resources appropriately.
7. Establish or maintain a positive doctor-patient relationship.

Numerous models exist to structure the consultation. The Calgary-Cambridge Guide is an evidence-based approach widely used in UK medical schools. It divides the consultation into five stages: initiating the session, gathering information, building the relationship, explanation and planning, and closing the session (3).

2.1.2 The Power of Non-Verbal Communication

Non-verbal communication is a critical component of the consultation, often communicating more about attitudes and emotions than words. When verbal and non-verbal messages are contradictory, the non-verbal message tends to override the verbal one (4). Key elements include:

• Eye Contact: Establishes rapport and influences what a patient reveals.
• Posture and Position: An open posture can encourage communication.
• Tone of Voice: A doctor's tone can signal interest or disinterest and is associated with patient satisfaction and even malpractice claim history (4, 8).

A significant modern challenge to effective non-verbal communication is the extensive use of computers in the consultation. Loss of eye contact while interacting with a screen can decrease patient fluency and increase the risk of missing vital information. Heath recommends several strategies to mitigate this (4):

• Postpone: Deliberately delay using the computer until the patient has completed their opening statement.
• Wait: Use opportune moments (e.g., when the patient is thinking) to look at the screen.
• Signpost (Structure): Verbally signal your intention to look at the records and when you have finished, ensuring the patient understands the process.

2.2 Evidence-Based Clinical Examination

SLO 1 requires the ability to perform accurate clinical examinations and show appropriate clinical reasoning (1). To move beyond rote performance, trainees should focus on the evidence base underpinning physical diagnosis. The following resources are recommended for improving understanding of the usefulness and clinical significance of examination findings (5):

• JAMA's "The Rational Clinical Examination" series: A collection of systematic reviews on the evidence-based use of history and physical examination (9).
• "Evidence-Based Physical Diagnosis" (Steven McGee): A key text for understanding the diagnostic power of clinical findings.
• Stanford 25: A resource for revising and refining basic examination skills (5).

2.3 Clinical Reasoning, Management, and Safety-Netting

A rational clerking template should be used to synthesise information efficiently. Crucially, the "Impression and Plan" section must clearly articulate clinical reasoning and thought processes, serving both clinical and medico-legal purposes (5).

Safety-netting is a critical skill described in Roger Neighbour's consultation model and is essential for safe discharge planning (3, 10). It involves asking key questions and providing patients with clear advice (3):

• What do I expect to happen if I am right?
• How will I know if I am wrong?
• What would I do then?

The answers inform the advice given to patients about when and why to return to the ED (10).

3.0 Addressing Complexity: Cultural Safety and Vulnerable Populations

3.1 From Cultural Competency to Cultural Safety

Caring for patients across the "full range of complexity" requires more than just clinical knowledge; it demands an advanced understanding of how cultural and social factors impact the clinical encounter. The traditional model of "cultural competence"—acquiring knowledge about other cultures—is now considered limited and potentially harmful. It can lead to stereotyping, "othering," and a failure to address the core drivers of health inequity (6, 7).

As illustrated in a case vignette, stereotyping a Hispanic female patient as "histrionic" can lead a physician to misdiagnose an acute coronary syndrome as anxiety (7). This highlights the danger of provider bias.

A more effective framework is Cultural Safety. This represents a paradigm shift with the following core principles (6):

• Focus on Power: It acknowledges the inherent power imbalance between clinician and patient.
• Focus on Self: It requires the health professional to critically self-reflect on their own culture, biases, assumptions, and privileges.
• Focus on the Patient's Experience: The patient, not the provider, determines if a clinical encounter is culturally safe.
• Focus on Equity: The ultimate goal is to reduce bias, improve the quality of care, and achieve health equity.

The following mnemonic, REFLECT, can serve as a tool for practising cultural safety:

• Recognise power imbalances in the clinical encounter.
• Examine your own biases, assumptions, and privileges.
• Foster trust through empathy and respect.
• Listen to and validate the patient's unique experience.
• Empower the patient to define what makes them feel safe.
• Critically and continuously self-assess your practice.
• Take action to challenge inequities within the healthcare system.

3.2 Practical Application in the ED

Applying cultural safety involves concrete actions. A proposed three-step paradigm to reduce disparities includes (7):

1. Reduce Provider Bias and Increase Cultural Awareness: Actively work to limit the influence of stereotypes in clinical encounters.
2. Clinically Accommodate Patients: Modify practices based on patient values and needs. This can involve using professional interpreters, respecting preferences for same-gender providers where possible, and engaging in clinical negotiation (7, 10).
3. Promote Workforce Diversity: A diverse workforce enhances cultural awareness and may lead to more effective patient-doctor relationships (7).

These principles align with the RCEM's Best Practice Guideline on Patient Care, which recommends fundamental standards such as warmly greeting patients, introducing oneself by name and role, and using a patient's preferred name (10).

3.3 Specific Vulnerable Populations

The principles of patient-centred care and cultural safety are paramount when caring for patients with mental health conditions and frail older adults. For patients with suspected delirium or cognitive impairment, validated tools such as the 4AT score should be used for screening (5). The approach to these patients must be compassionate, holistic, and attuned to their specific vulnerabilities and complex needs (1).

4.0 Evidencing Competence for SLO 1

4.1 Programme of Learning

Trainees should engage in a variety of learning activities to develop the capabilities for SLO 1, including (1):

• RCEM Learning modules, podcasts, and blogs mapped to the EM syllabus.
• Local teaching programmes.
• Simulation exercises, particularly for developing skills in dealing with distressed patients and relatives.

4.2 Workplace-Based Assessments (WPBAs)

Demonstrating competence requires a portfolio of evidence from WPBAs. Trainees are expected to seek feedback on their care on most shifts, especially for challenging cases involving clinical uncertainty, communication barriers, or complex co-morbidities (1). Key assessment tools include (1, 5):

• Acute Care Assessment Tool (ACAT)
• Case-Based Discussion (CbD)
• Educational Supervisor’s Led End of Placement evaluation (ESLE)
• Mini-Clinical Evaluation Exercise (Mini-CEX)
• Multi-Source Feedback (MSF)
• Logbook of cases

4.3 Summative Assessment and Entrustment

Summative assessment for SLO 1 is achieved through successful completion of RCEM examinations (MRCEM and FRCEM). The culmination of training is a series of entrustment decisions, where the trainee is trusted to perform independently at the level required for each stage (1).

Level of Entrustment	Training Stage	Description of Entrustment
Level 2b	End of Core Training (ACCS)	Entrusted to evaluate a stable patient, formulate a differential diagnosis including a worst-case scenario, and create a management plan. Entrusted to interpret key investigations (ECG, plain radiography) and know their limitations.
Level 3	End of Intermediate Training	Entrusted to evaluate any physiologically stable patient and formulate a safe management plan in all but the most complex cases, with senior support available remotely.
Level 4	End of Higher Training (HST)	Entrusted to evaluate any physiologically stable patient and formulate an expert management plan independently. Able to support others and act as a role model.

References

1. Royal College of Emergency Medicine. SLO 1 – Care for physiologically stable adult patients presenting to acute care across the full range of complexity. RCEMCurriculum [Internet]. 2019 Jan 28 [cited 2025 Nov 13]. Available from: [Source URL]
2. Royal College of Emergency Medicine. Purpose Statement. RCEMCurriculum [Internet]. 2019 Jun 18 [cited 2025 Nov 13]. Available from: [Source URL]
3. Vincent P. Consultation analysis. Patient.info [Internet]. 2025 Mar 14 [cited 2025 Nov 13]. Available from: [Source URL]
4. Silverman J, Kinnersley P. Doctors' non-verbal behaviour in consultations: look at the patient before you look at the computer. Br J Gen Pract. 2010 Feb 1;60(571):76–78.
5. Anonymous. SLO 1. Care for physiologically stable adult patients presenting to acute care across the full range of complexity [Educational Handout]. [place unknown]: [publisher unknown]; [date unknown].
6. Curtis E, Jones R, Tipene-Leach D, Walker C, Loring B, Paine S-J, et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health. 2019 Nov 14;18(1):174.
7. Padela AI, Punekar IRA. Emergency Medical Practice: Advancing Cultural Competence and Reducing Health Care Disparities. Acad Emerg Med. 2009;16(1):69–75.
8. Ambady N, Laplante D, Nguyen T, Rosenthal R, Chaumeton N, Levinson W. Surgeons' tone of voice: a clue to malpractice history. Surgery. 2002 Jul;132(1):5–9.
9. JAMA Network. The Rational Clinical Examination [Internet]. Chicago, IL: American Medical Association; 2025 [cited 2025 Nov 13]. Available from: https://jamanetwork.com/collections/6 Rational Clinical Examination
10. Royal College of Emergency Medicine. Patient Care in the ED. Best Practice Guideline. London: RCEM; 2021 Nov.
11. Royal College of Emergency Medicine. SLO 1 Archives. RCEMLearning [Internet]. [place unknown]: RCEM; 2025 [cited 2025 Nov 13]. Available from: [Source URL]

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SLO1 - CARE FOR THE PHYSIOLOGICALLY STABLE ADULT PATIENT

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2.1 Achieving RCEM SLO 1: Care for Physiologically Stable Adult Patients

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