The EM Mindset & RCEM 2021 Curriculum
The Modern Emergency
Medicine Consultant in the NHS
Executive Summary
•
This
document synthesizes the core principles, competencies, and philosophical
underpinnings of modern Emergency Medicine (EM) consultant practice in the NHS,
as defined by the Royal College of Emergency Medicine (RCEM) curriculum and key
professional insights. The training and practice of EM are shaped by a
persistent and significant rise in demand for services, with attendances
increasing by 12.2% over a decade and 1 in 2.4 people in the UK attending an
Emergency Department (ED) annually (1).
•
The
purpose of the RCEM curriculum is to train consultants capable of providing
24/7 care to all undifferentiated patients, of all ages, across the full
spectrum of acute illness and injury. The consultant's role is multifaceted,
extending beyond clinical care to encompass leadership of multi-disciplinary
teams, strategic direction of the department, quality improvement, supervision,
and administration. This comprehensive scope is defined by 12 core Specialty
Learning Outcomes (SLOs) that a trainee must be entrusted to deliver by the
point of CCT.
•
A
distinctive feature of EM practice is its unique mindset, characterized as
"playing not to lose." The primary focus is on risk stratification
and the exclusion of rare but life-threatening conditions, rather than simply
identifying the most probable diagnosis. This practice, performed in an
environment of inherent uncertainty, is grounded in the core professional
virtues of Honesty, Humility, and Integrity, which enable sound decision-making
and professional resilience.
1. The Mandate and Context for Emergency Medicine
Training
1.1 Purpose of the RCEM Curriculum
•
The
stated purpose of the EM training curriculum is to produce consultants capable
of providing comprehensive urgent and emergency care to all undifferentiated
patients attending an ED, 24 hours a day, 365 days a year. This mandate
requires consultants to lead the multi-professional resuscitation of critically
ill and injured patients of all ages, from neonates to the elderly, while
simultaneously managing, leading, and supporting the entire multi-disciplinary
team across the full range of physical and mental health presentations (1).
1.2 The Rising Demand for Emergency Services
•
The need
for a robust EM training programme is underscored by escalating service
demands. The curriculum addresses a healthcare landscape defined by:
- High Volume: In 2016-17, there were
27,329,874 attendances at all UK EDs, with 18,205,538 in Type 1 EDs alone
(1).
- Sustained Growth: Between 2006-07 and
2016-17, attendances increased by 12.20%, an average of 1.22% per annum
(1).
- Demographic Drivers: The rise in demand is
partly fuelled by a growing cohort of older patients with complex
co-morbidities, who attend the ED in greater proportion than any other
group (1).
- Population Impact: In any given year, an EM
consultant is responsible for the care of over 27.3 million patients,
meaning approximately 1 in 2.4 people in the UK will attend an ED (1).
1.3 The Evolving Role of the EM Consultant
•
The
modern EM consultant's responsibilities extend significantly beyond direct
patient care. They are required to provide strategic leadership, set
departmental culture, and undertake key teaching, supervision, and
administrative duties. Furthermore, with the expansion of the
multi-disciplinary team to include roles such as Physician Associates and
Advanced Care Practitioners, the training and supervision burden on consultants
continues to increase, reinforcing the need for a training programme that
explicitly develops these skills (1).
2. Defining the Modern EM Consultant: The 12
Specialty Learning Outcomes (SLOs)
•
The RCEM
curriculum defines the capabilities of a consultant through 12 SLOs. These
outcomes holistically describe the professional activities a trainee must be
entrusted to deliver by CCT. They incorporate the General Medical Council's
Generic Professional Capabilities (GPCs) and can be thematically grouped into
four pillars of consultant practice.
The Four Pillars of Consultant Practice
|
•
Pillar |
• SLO # |
•
Specialty Learning Outcome Description |
|
• Comprehensive Clinical Care |
•
1 |
•
Care for physiologically stable adult patients presenting to acute
care across the full range of complexity. |
|
•
3 |
•
Identify sick adult patients, be able to resuscitate and stabilise and
know when it is appropriate to stop. |
|
|
•
4 |
•
Care for acutely injured patients across the full range of complexity. |
|
|
•
5 |
•
Care for children of all ages in the ED, at all stages of development
and children with complex needs. |
|
|
•Procedural & Situational Management |
•
6 |
•
Deliver key procedural skills. |
|
•
7 |
•
Deal with complex and challenging situations in the work place. |
|
|
•Departmental Leadership & Management |
•
8 |
•
Lead the ED shift. |
|
•
12 |
•
Manage, Administer and Lead. |
|
|
•Education & Professional Development |
•
2 |
•
Support the ED team by answering clinical questions and making safe
decisions. |
|
•
9 |
•
Support, supervise and educate. |
|
|
•
10 |
•
Participate in research and managing data appropriately. |
|
|
•
11 |
•
Participate in and promote activity to improve the quality and safety
of patient care. |
3. The Structured Pathway to Consultant Practice
•
Progression
through the EM training programme is competency-based and structured in three
distinct stages, reflecting a growing level of responsibility and complexity
(1).
3.1 Core Training (Indicative 2 Years)
- Delivered within the Acute
Care Common Stem (ACCS) programme, shared with anaesthetics, acute
medicine, and intensive care medicine.
- Focus: Developing the skills and
knowledge to care for individual adult patients.
- Key Competencies: Identifying, resuscitating,
and stabilising sick adult patients as part of a hospital team, including
advanced airway and circulatory support skills.
3.2 Intermediate Training (Indicative 1 Year)
- Focus: Developing paediatric
EM-specific skills and beginning to take a leadership role.
- Key Competencies: Refining paediatric
knowledge and skills, leading the multi-professional resuscitation team,
and developing the ability to lead the wider ED team.
- Entrustment Point: By completion, the trainee
is entrusted to function safely as the most senior clinician overnight.
3.3 Higher Training (Indicative 3 Years)
- Focus: Developing mastery in
leadership, complex case management, and wider professional
responsibilities.
- Key Competencies: Leading the entire ED
shift, managing the most challenging cases (often concurrently), and
mastering administrative, teaching, supervision, and research skills to
become a strategic leader within the department.
4. The Philosophical Underpinning of Emergency
Medicine Practice
•
Beyond
the structured curriculum, effective EM practice is defined by a distinct
professional mindset and a commitment to core virtues that enable clinicians to
navigate its unique challenges.
4.1 The EM Mindset: "Playing Not to Lose"
•
The
mindset of an emergency physician differs fundamentally from that of other
specialists. The priority is not necessarily to arrive at a single correct
diagnosis, but to ensure that serious or life-threatening diagnoses are not
missed. This philosophy of "playing not to lose" involves actively
hunting down and excluding or confirming rare but critical conditions, even
when the pre-test probability is low. As Dr. Graham Walker notes, "in
emergency medicine, we don’t spend most of our days saving lives, as most
people think. Mostly we try to predict risk, especially in grey-zone patients.”
(2).
4.2 Navigating Uncertainty with Core Virtues
•
Medicine
is inherently a "science of uncertainty and an art of probability,"
as Sir William Osler stated. Emergency Medicine in particular is a specialty
which must embrace this concept. To practise effectively and sustainably in
this environment, clinicians must rely on a framework of core professional
virtues:
- Honesty: Being honest with oneself
about the limits of knowledge and with patients about the diagnostic uncertainty.
- Humility: Recognising the potential
for error and the importance of seeking advice and support from the wider
team.
- Integrity: Consistently acting in the
patient's best interest, even when faced with complex or difficult
decisions.
•
Adherence
to these principles allows the emergency physician to make defensible
decisions, manage personal and professional risk, and maintain resilience while
practising in the demanding and uncertain world of Emergency Medicine (2).
References
1. Royal College of Emergency Medicine. Purpose Statement - RCEMCurriculum. 2019 Jun 18 [cited 2024]. Available from: The provided source document.
2. Walker G. Emergentology: Risk Stratification and the Unsweet Spot. Emerg Med News. 2011;33(9):21.
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