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Cliff Reid <[log in to unmask]> wrote: As a UK trained EP I agree with Craig's comments about the unequal distribution of resuscitation skills amongst existing consultants.... Dear All As a certified list lurker, I almost always read the submissions without feeling the need to add anything. This thread, however, makes me feel the need. I am in a similar position to some others on the list, having trained in the UK, FFAEM in May, awaiting the CCST in Dec, and now in Australia. Along the way I accumulated ATLS, ALS, APLS and even MIMMS and PHTLS certification. I now instruct in ALS, ATLS, and APLS. Why? It was not for the "badging" status of the provider or instructor courses, although in competitive interview situations every little helps. The reason was that the clinical, "on the job" teaching which theoretically should pass on these and other skills was largely absent from the SpR training as I experienced it. I did them because I knew I had to be competent in my management of the seriously ill, and it wasn't coming from anywhere else. I began SpR training after a 6 month locum reg post (minimal teaching anyway, as it was a purely service post), prior to which I completed a surgical training (I had never come across an A&E Reg who had MRCP before I moved to London). In the area I did my SHO rotation, nobody had any constructive advice on what I should do before reg jobs, certainly no suggestions like I make to SHO's when asked now, such as do some paeds, some anaesthetics, and a lot of medicine, and then think about SpR interviews! I did my SpR training over several large teaching hospitals, and several busy DGH's. In few of these was there more than notional clinical teaching. Some hospitals (regions) had immensely better training days etc, but not on the shop floor. I managed to accumulate many of the skills and much of the knowledge to manage patients in resus and elsewhere from constant reading (probably a good thing) but also from doing and teaching the courses. I am now in Australia largely to attempt to bring my skills and knowledge up to what I believe I need to function as a consultant level EP, in an environment that has consistent senior presence from people that not only like to teach clinically, but are very proactive about it! Lists like this seem to attract comment largely from a knowledgeable, keen and articulate audience. Maybe the juniors in your departments are receiving constant clinical teaching that makes the ALS courses etc redundant, but if so it will be a marked change from that which I saw over a quite a range of big and small hospitals (with greater and smaller levels of self-importance!) Two more points: Recently, a very senior (UK) consultant took exception to my comment that the FFAEM goes nowhere near enough testing the clinical acumen and performance of trainees (whatever you think, the FACEM is a lot closer), with the rejoinder that we had all completed a logbook, and therefore we must be clinically competent, and therefore that aspect did not need to be tested. Am I cynical, or does everyone out there really pop in to the consultant's office at the end of every day and say "could you just sign me up for that cardiac arrest / chest drain / DKA we saw TOGETHER earlier?" I accept that we are a young speciality in the UK, and that many talented and committed people are striving to drag our competence and our credibility up by the bootstraps, but complacency about training in this way certainly ain't the way forward. Secondly, it all very well for the list members to consider the guidelines / protocols in the ALS / ATLS etc to be superseded by their clinical acumen, and I would certainly hope this to be true. But please let's not forget that the care that most patients receive in most hospitals in the UK is still from junior doctors, some of which may be very junior, and some of which may be just out of housejobs. Hands up those of you who run departments with 24 hour registrar cover on-site, let alone in the department. Before these courses, the patients that we see were in a whole lot worse situation than they are now. They are designed for junior doctors and nurses, and they explicitly say so. Anyway, that's that off my chest. Back to the sun. Paul Middleton Visiting Reg in Paeds EM Melbourne