A Longitudinal Roadmap for Mastery: Achieving RCEM SLO 6 Procedural Entrustment (2021 Curriculum)
Executive Summary: Transitioning from Exposure to Entrustment
This report details a best-practice, longitudinal roadmap designed for Emergency Medicine (EM) doctors in training to achieve Specialty Learning Outcome (SLO) 6: Deliver Key Procedural Skills, adhering rigorously to the RCEM 2021 curriculum and its assessment frameworks. The foundational strategic shift articulated within the 2021 curriculum is the elevation of assessed quality—measured by the RCEM Universal Entrustment Scale—over mere quantity or procedural volume.[1, 2]
The methodology emphasizes the critical need for Simulation-Based Mastery Learning (SBML), formalized through adoption of a systematic progression model such as the OASIS framework, to ensure structured, deliberate practice, the attainment of proficiency milestones, and the integration of crucial non-technical skills.[3, 4] A specific focus is placed on Point of Care Ultrasound (PoCUS), where the curriculum mandates explicit modality sign-offs and clarifies that verified clinical competence (Entrustment Level) is the primary determinant of progression, taking precedence over indicative scan volume.[2] Successful implementation of this roadmap requires strict adherence to assessment protocols, including the correct delineation between technical assessment (Direct Observation of Procedural Skills, DOPS, filed in SLO 6) and cognitive/contextual assessment (Case-based Discussions, CbDs, or Acute Care Assessment Tools, ACATs, filed in SLO 1).[5, 6]
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I. Strategic Framework: The Paradigm Shift in Procedural Competence
1.1. Defining RCEM SLO 6: Scope, Structure, and Safety Mandates
SLO 6 covers the diverse psychomotor procedures fundamental to independent practice in Emergency Medicine. The curriculum stratifies these procedural requirements across different stages of training, reflecting the complexity, risk profile, and required frequency of intervention.[7]
For ACCS (Core Training), the focus is on achieving proficiency in foundational resuscitation and acute intervention skills. This includes procedures such as Pleural aspiration of air, Seldinger and open techniques for Chest drain insertion, establishment of Invasive monitoring (Central Venous Pressure (CVP) and Arterial (Art) lines), essential vascular access methods (Intraosseous (IO) and femoral vein), manipulation of fractures/dislocations, External pacing, and DC Cardioversion.[7] Core training also mandates initial PoCUS competence in Vascular access and Fascia Iliaca Block (FICB).[7]
As trainees advance into Intermediate and Higher Training, the procedural skill set expands to include advanced, high-stakes, and often low-frequency interventions. These include Advanced airway management, Non-invasive ventilation, Open chest drain insertion, Resuscitative thoracotomy, Lateral Canthotomy, Pericardiocentesis, ED management of life-threatening haemorrhage, Emergency delivery, and Resuscitative Hysterotomy.[7] For all procedures, the expectation is that learners become increasingly expert in the practical procedures previously undertaken, moving from Level 2 Entrustment to Level 3 and 4.[8]
The assessment structure for SLO 6 requires a crucial division of evaluation methods. Technical skill acquisition—the proficiency in performing the physical steps of the procedure—is primarily assessed by Direct Observation of Procedural Skills (DOPS). It is a mandatory administrative requirement for ARCP progression that all DOPS are correctly placed within SLO 6.[6] Conversely, the associated cognitive skills, including knowledge of indications, contraindications, complication management, and overall clinical judgment regarding the procedure, must be assessed separately using broader Workplace-Based Assessment (WBPA) tools such as Mini-Clinical Evaluation Exercises (Mini-CEX), CbDs, ACATs, or Extended Supervised Learning Events (ESLE).[5] These contextual assessments are typically filed under SLO 1 (Clinical Judgement).[6] This dual assessment ensures that competence is verified in both performing the procedure and applying it safely within the clinical context.
1.2. Principles of Mastery Learning and Deliberate Practice (DP)
The shift in procedural education acknowledges that reliance on procedural logs alone—which historically measured case exposure—is inadequate for ensuring verified competence and patient safety.[1] Simply logging a high-acuity procedure, such as a pericardiocentesis, does not confirm the trainee understood the indications, managed the setup correctly, or retained the ability to perform the procedure successfully months later.[1]
The best-practice methodology is anchored in Deliberate Practice (DP). DP dictates that learning must involve structured repetition, escalating difficulty, focused feedback from a coach or instructor, and dedicated time for reflection, all ideally conducted in a low-stakes environment like simulation.[4] This strategy moves beyond simply observing procedures to actively targeting the fundamental micro-skills necessary to improve specific aspects of performance, thereby modifying the control of behavior and thoughts relevant to situational factors.[4] Simulation-Based Medical Education (SBME) has proven effective in increasing knowledge, providing practice opportunities, and facilitating both formative and summative assessment.[4]
Furthermore, skill retention is a longitudinal concern. Educational models highlight the concept of Experience Curves, which combine learning curves (practice leading to proficiency) and forgetting curves (skill decay over time).[9] Many high-stakes EM procedures are performed infrequently in clinical practice; therefore, relying solely on clinical exposure to maintain competence is insufficient, as skills can degrade at a startling rate if not consistently reinforced.[9] Consequently, the roadmap requires a structured approach to procedural assessment and practice that ensures the durability of competence over time, replacing piecemeal, episodic practice with a longitudinal framework.[9]
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II. Operationalizing Entrustment: The RCEM Universal Framework
2.1. Deconstructing the RCEM Entrustment Scale (Appendix 5.5)
The Entrustment Scale is the core mechanism by which supervisors describe the observed and predicted capability of the trainee, ultimately defining the level of supervision required for safe, independent practice.[2, 8] Progression through these levels is the overarching assessment goal for achieving proficiency in SLO 6. The scale ranges from requiring immediate, direct supervision (Level 1) to achieving full autonomy (Level 4), though a consultant retains overall clinical responsibility.[8]
The four levels of the universal Entrustment Scale are defined by the location and availability of the supervisor [8]:
Level | Supervision Descriptor (Appendix 5.5) [8] | Clinical Implication |
Level 1 | Direct supervisor observation/involvement, able to provide immediate direction/assistance. | Novice; requires constant, moment-to-moment guidance. |
Level 2a | Supervisor on the 'shop-floor' (e.g. ED, theatres, ICU), monitoring at regular intervals. | Advanced Beginner; requires supervisor presence in the immediate clinical area. |
Level 2b | Supervisor within hospital for queries, able to provide prompt direction or assistance AND trainee knows reliably when to ask for help. | Competent; able to operate safely with distant, in-hospital supervision. Requires robust self-awareness. |
Level 3 | Supervisor 'on call' from home for queries, able to provide directions via phone and able to attend the bedside if required to provide direct supervision. | Proficient; demonstrates capacity for safe remote practice and appropriate escalation. |
Level 4 | Would be able to manage with no supervisor involvement (all trainees practice with a consultant taking overall clinical responsibility). | Expert/Entrusted; achieves consultant-level autonomy and mastery. |
A significant challenge in procedural training often lies in achieving Level 2b, which explicitly requires the trainee to demonstrate reliable judgment regarding when to ask for help.[8] This is a crucial non-technical competency—situational awareness and self-assessment—and supervisors must be trained to assess this judgement accurately, as Entrustment levels are frequently misunderstood or incorrectly assigned by assessors.[10] For a trainee to progress to Level 3 (remote supervision), they must provide evidence through reflective WBPAs that verifies their ability to escalate appropriately and anticipate complications.
2.2. The OASIS Progression Model: A Best Practice Roadmap
To structure the acquisition of procedural skills and map them explicitly to the Entrustment Scale, the OASIS (Observe, Assist, Supervised Performance, Independent Performance, Supervise Others) framework offers a robust, synthesized model for skill acquisition.[3] This framework consciously integrates mastery learning and deliberate practice, supporting progression only after verified competence is achieved, thereby directly enhancing patient safety.[3]
The OASIS framework mandates simulation preparation at critical transitional stages [3]:
1. Observe (Novice/Knows): The trainee watches the procedure with structured commentary and engages in a post-procedure debrief to build cognitive understanding. This is pre-entrustment.[3]
2. Assist (Advanced Beginner/Knows How - Level 1): Before clinical application, the trainee engages in a preparatory task trainer step to practice relevant procedural subtasks and psychomotor skills. Subsequently, they perform selected components on patients under direct guidance.[3]
3. Supervised Performance (Competent/Shows How - Level 2a/2b): This stage includes a preparatory simulated performance step. The trainee first completes the full procedure in a high-fidelity simulated environment with faculty coaching, focusing on decision-making, error recovery, and non-technical skills.[3] Only after this mastery is achieved in simulation do they perform the complete procedure on patients under direct observation (DOPS).[3]
4. Independent Performance (Proficient/Does - Level 3): The learner performs the procedure autonomously with distant supervision (faculty immediately available or on-call). Post-procedure debriefing is required to reinforce learning.[3]
5. Supervise Others (Expert/Is Trusted - Level 4): The highest level of entrustment involves the trainee teaching and supervising junior colleagues under faculty oversight, a process that reinforces their own procedural mastery and develops crucial leadership skills.[3]
This framework operationalizes supervision behaviors, reduces variability in entrustment decisions, and synthesizes the necessary steps to standardise progression toward safe clinical autonomy.[3]
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III. Roadmap for Core Training (ACCS): Essential Procedural Competence
3.1. Required ACCS Procedural Skill Set and Strategy
During Core Training (ACCS), the strategic goal is rapid, safe acquisition of foundational skills, moving trainees to Level 2a/2b Entrustment for procedures critical for acute resuscitation, such as chest drain insertion, invasive monitoring, and basic PoCUS modalities (Vascular Access and Fascia Iliaca Block).[7]
The methodology must prioritize deliberate practice of micro-skills for high-frequency, complex procedures. For example, procedures such as establishing invasive monitoring (Art and CVP lines) require sustained practice on task trainers during the OASIS Assist phase to ensure sterility and technical fluency before attempting the full procedure in the clinical setting.[3] Simulation should be used to practice the non-technical skills surrounding fracture/dislocation manipulation, such as analgesia decision-making and post-procedure monitoring.
3.2. Assessment Compliance: Maximizing DOPS Utility and Logbook Quality
Trainees must maintain rigorous administrative compliance regarding their procedural assessments. All technical DOPS forms related to procedural skills must be correctly filed into SLO 6.[6] Neglecting this administrative requirement risks ARCP progression, regardless of clinical proficiency.
The procedural log is essential, as mandated by the curriculum forms.[11] However, compliance extends beyond mere numerical count. Supervisors should demand high-quality reflective practice associated with the log entries. Reflection must specifically address aspects such as errors made, complications encountered, self-assessed limitations in performance, and, crucially, documentation of instances where the trainee correctly identified the need for senior input. Such reflection provides explicit evidence of the self-assessment and situational awareness required to move from Level 2a to the critical cognitive threshold of Level 2b.[8]
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IV. Roadmap for Intermediate and Higher Training (ST3-ST6): Advanced and Critical Interventions
4.1. Advanced Procedural Skill Requirements and Risk Stratification
Intermediate and Higher Training requires the attainment of Level 3 or 4 Entrustment for procedures that are either complex (e.g., advanced airway management) or Low-Frequency, High-Acuity (LFHA) (e.g., Resuscitative thoracotomy, Resuscitative Hysterotomy).[7] For these LFHA skills, clinical volume is inherently unreliable, making the achievement of competence dependent entirely on structured, high-fidelity simulation.
The strategy for acquiring LFHA competence must rely on Simulation-Based Mastery Learning (SBML), where trainees are required to perform the full procedure in a high-fidelity environment under pressure (OASIS Supervised Performance) until specific, measurable mastery criteria are met—for instance, achieving time-to-completion standards or successfully managing a simulated complication.[1, 3] The focus must be on integrating technical steps with non-technical elements such as communication and teamwork, which are vital for successful outcomes in emergency contexts.[3]
4.2. Maintaining Competence and Combating Skill Decay
A significant programmatic imperative for Higher Training is the mitigation of skill degradation. Given that proficiency decays when skills are not reinforced [9], achieving Level 3 Entrustment once is insufficient for long-term clinical safety, especially for procedures like Pericardiocentesis or Lateral Canthotomy.
Training programmes must therefore embed mandatory, scheduled refresher simulation sessions throughout ST4, ST5, and ST6. These sessions should explicitly follow the principles of experience curves, ensuring that skills are re-practiced and reinforced before significant decay occurs.[9] Furthermore, the highest stage of procedural development, OASIS Level 4 (Supervise Others), should be actively fostered in senior trainees. By requiring ST6 doctors to teach and supervise junior colleagues, their own understanding and retention of procedural steps and underlying principles are significantly reinforced, establishing enduring mastery and developing crucial educator competencies.[3]
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V. Achieving PoCUS Competence Entrustment: The Definitive Guide
Point of Care Ultrasound (PoCUS) competence is a mandatory element of SLO 6, requiring a disciplined, multi-stage progression outlined in the RCEM curriculum.[2] The assessment framework for PoCUS is explicitly linked to the Entrustment Scale, and progression is guided by specific milestones.[2]
5.1. PoCUS Curriculum Milestones and Longitudinal Trajectory
The PoCUS roadmap is highly structured, integrating online knowledge acquisition, logbook maintenance, and defined sign-off deadlines. Sign-off for all mandatory modalities is expected by the end of ST5, with any exceptions requiring clear documentation from the supervisor.[2]
PoCUS Curriculum Milestones
Milestone | ACCS | ST3-4 | ST5 (Critical Deadline) | ST6 |
Online Learning/Courses | Complete online modules | Continue relevant online learning or attend relevant course | ||
Logbook & Learning | Commence log book; Commence bedside learning | Consolidate log book; Complete online pathology learning | Consolidate log book | Consolidate logbook; Consider teaching/governance |
Procedural Modality Sign Off | Sign off: Vascular Access, Fascia Iliaca Block | |||
Diagnostic Modality Sign Off | Sign off ELS, AAA, eFAST / FAFF | Sign off ELS, AAA, eFAST / FAFF (if not achieved by ST4) | ||
Integrated Assessment | Sign off 'Shock Protocol' | |||
Scan Frequency (Minimum Aim) | Aim 1 scan per 2 weeks minimum | Aim 1 scan per week | Aim 1 scan per week minimum | Aim 1 scan per week minimum |
The curriculum stipulates indicative numerical targets for scans (e.g., 25 for AAA, 10 for ELS).[2] Crucially, the requirement for a supervisor to record the shortfall on the e-portfolio, should the indicative number not be met, must not impede progression if the appropriate Entrustment Level for the stage of training has been achieved.[2] This demonstrates the definitive curriculum position that the quality of competence and Entrustment attained overrides raw volume statistics.
5.2. Practical Acquisition and Documentation
Trainees must systematically build their PoCUS portfolio. This includes completing mandatory online modules and attending relevant courses or study days.[2, 12] Active participation in informal learning environments, such as PoCUS clubs, and dedicated time for reflection on scans is highly encouraged.[12]
Documentation must be precise. Trainees are required to maintain a detailed logbook that includes reflective notes for each modality (e.g., five reflective notes for AAA and ELS).[2, 11] Furthermore, all diagnostic scans performed must be formally reported in compliance with local departmental guidelines. These reports must explicitly state the operator’s level of competency (Level 1 to 4) according to the RCEM Entrustment Scale, which can be recorded in the patient notes or uploaded to Picture Archiving and Communication Systems (PACS).[13]
5.3. Assessment of Technical Skill and Clinical Integration
Assessment of PoCUS requires the same dual focus as other procedures. Technical proficiency, including probe handling and image acquisition, is assessed primarily through Direct Observation of Procedural Skills (DOPS).[5]
However, the effective application of PoCUS in the ED relies heavily on clinical integration. The knowledge, behaviour, and application of PoCUS in the clinical context—such as the interpretation of images and the resultant decision-making—must be assessed using contextual WBPAs such as Mini-CEX, CbDs, ACATs, and ESLE.[5] The curriculum mandates an integrated assessment of the 'Shock Protocol' at ST5.[2] This requires the trainee to demonstrate the ability to acquire and integrate findings from multiple diagnostic modalities (ELS, AAA, eFAST/FAFF) and utilize them synergistically to guide the management of a critically ill patient, often within a simulated or real clinical scenario.[2]
5.4. PoCUS Governance and Sign-Off Protocol
Local governance is paramount for ensuring standardized, high-quality PoCUS training. A designated consultant, serving as the PoCUS Lead, must have attained a minimum of six months of Level 1 PoCUS competence and holds overall responsibility for the training, administration, and governance of the programme.[2]
Assessments, particularly during higher training, should be seamlessly integrated into the clinical management of a patient, even if simulated, ensuring that image interpretation and clinical application are tested together.[2] This systematic approach ensures that competence is not a theoretical construct but a demonstrated capability within an appropriate clinical presentation.
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VI. Implementation and Governance for Educational Leaders
6.1. Standardizing Entrustment Decisions
The consistency of procedural assessment is often undermined by the misapplication and misunderstanding of the Entrustment Scale, which is documented as a challenge for both Emergency Medicine and non-EM assessors.[10] To ensure reliable and accurate assessment, mandatory, recurring supervisor calibration sessions are required. These sessions must clarify the explicit behavioral anchors distinguishing each Entrustment Level, particularly focusing on the cognitive aspect of Level 2b—the trainee's demonstrated self-awareness and reliable judgment regarding escalation.[8] Educational supervisors must be trained to audit trainee e-portfolios to verify the correlation between technical DOPS (SLO 6) and cognitive WBPAs (SLO 1) to confirm that holistic competence, encompassing both skill and judgment, has been achieved.[6]
6.2. Resource Allocation for Deliberate Practice
To fully realize the goals of the RCEM curriculum, training programmes must transition away from relying on opportunistic clinical exposure and toward formalized, protected time for deliberate practice. This necessitates adopting structured frameworks, such as the OASIS progression model, and allocating dedicated resources for Simulation-Based Mastery Learning.[3, 4] Programme Directors must secure budget and infrastructure, including high-fidelity simulators and dedicated task trainers, to support the mandatory preparatory simulation steps required by the OASIS framework for both the Assist and Supervised Performance stages.[3] This programmatic commitment to simulation is necessary to meet the standards of procedural proficiency and patient safety, moving beyond minimum requirement setting toward competency verification.[1]
6.3. Audit and Quality Improvement
Continuous audit is essential to monitor trainee progression and the efficacy of the training programme. Departments should track procedural entrustment levels for all core procedures, focusing specifically on meeting the critical ST5 deadline for full PoCUS sign-off.[2] Furthermore, educational leaders should formalize the integration of senior trainees (ST6) into the teaching faculty, utilizing the OASIS Level 4 (Supervise Others) stage. This peer-assisted learning strategy promotes the development of educator and leadership skills in senior trainees while concurrently ensuring sustainable teaching resources and bolstering the overall departmental training capacity.[3]
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1. Beyond the numbers: Reimagining procedural proficiency in emergency medicine residencies - PMC - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC10685390/
2. Appendix 3 RCEM Point of Care Ultrasound (PoCUS) Curriculum 2021, https://rcemcurriculum.co.uk/wp-content/uploads/2021/06/Appendix-3-PoCUS-for-2021-RCEM-curriculum.pdf
3. Skill progression models in emergency medicine training: a ..., https://pmc.ncbi.nlm.nih.gov/articles/PMC12487538/
4. Deliberate Practice in Medical Simulation - StatPearls - NCBI Bookshelf - NIH, https://www.ncbi.nlm.nih.gov/books/NBK554558/
5. Ultrasound Education & Training – 2021 Curriculum - RCEM, https://rcem.ac.uk/ultrasound-education-training-2021-curriculum/
6. Emergency medicine | GMC, https://www.gmc-uk.org/cdn/documents/sat---ssg--emergency-medicine-2021-curriculum---dc13727_pdf-87179601.pdf
7. SLO 6 - Proficiently deliver key procedural skills needed in ..., https://rcemcurriculum.co.uk/deliver-key-procedural-skills/
8. Appendix 5 5.5. Assessment of Specialty Learning Outcome 6 - Procedural skills | RCEMCurriculum, https://rcemcurriculum.co.uk/wp-content/uploads/2021/07/Appendix-5-SLO6-Procedural-skills.pdf
9. Experience Curves as an Organizing Framework for Deliberate Practice in Emergency Medicine Learning - NYSIM, https://nysimcenter.org/sites/default/files/nysimcenter/uploaded_files/Experience-Curves-as-an-Organizing-Framework.pdf
10. New Poster Makes Entrustment Levels Easy to Understand - RCEM, https://rcem.ac.uk/college-news/new-poster-makes-entrustment-levels-easy-to-understand/
11. RCEM Curriculum - Kaizen Assessment Forms, https://rcemcurriculum.co.uk/wp-content/uploads/2021/10/Kaizen-Assessment-Forms.pdf
12. Ultrasound Mastery: A Guide to PoCUS Competency - RCEMLearning, https://www.rcemlearning.co.uk/foamed/ultrasound-mastery-a-guide-to-pocus-competency/
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2.6 Mastering SLO 6 Delivering Procedural Skills.
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