Many consultant physicians practice general internal medicine in addition to their medical specialty, and many patients are cared for under the umbrella of general internal medicine. These include the full range of adults admitted as emergencies with acute medical problems, ranging from the young fit person with a severe acute illness, to the frail elderly with multiple disorders. Patients with problems that are not clearly within the remit of a particular medical specialty are referred to outpatient clinics for the opinion of a general physician.
Nearly all trainees following the GIM curriculum to CCT will be doing so in parallel with training in another medical specialty. The GIM curriculum defines the competencies needed for the award of a CCT in general internal medicine, which are needed to allow participation at a senior level on the acute medical take, and to provide advice on the investigation and management of inpatients and outpatients with acute and chronic medical problems.
The curriculum reflects the contexts in which GIM is performed, from the admission avoidance clinic to the admitting unit to the inpatient wards and the outpatient clinics. It emphasises the skills and competencies that need to be acquired in these settings and indicates how these will be assessed as trainees progress through the syllabus.
Entry into general internal medicine training is possible following successful completion of both a Foundation Programme and a core training programme. There are two core training programmes in general internal medicine;
- Core Medical Training (CMT)
- Acute Care Common Stem - Acute Medicine (ACCS-AM)
Please see the Internal Medicine wepbage for information on Internal Medicine stage 1 and stage 2 training.
Penultimate Year Reviews of GIM training
Penultimate Year Assessments (PYAs) have been suspended by the Statutory Education Bodies (SEBs) of England, Scotland, Wales and Northern Ireland in response to the COVID-19 pandemic.
The JRCPTB rcognises that it is critically important that trainees approaching their final year of training know what they need to do to complete their training by their planned date of CCT. The Training Program Directors (TPDs) and trainee members of the GIM SAC propose that this be achieved by implementing a more structured approach to the assessment of GIM training at trainees’ penultimate ARCPs, which should also help to reduce undesirable variation in process and outcomes for trainees in different regions. This structured approach will be termed a ‘Penultimate Year Review’ (PYR).
To support PYRs in GIM, the GIM SAC have developed the following forms to allow trainees to document their GIM training and experience in a standardised manner, which should help those assessing GIM training on penultimate ARCP panels to make consistent assessments. Where Deaneries already have well-developed mechanisms for allowing trainees to provide the necessary information in a structured way, use of these newly developed forms is not mandatory (use will be at the discretion of the local GIM TPD). The two forms are:
- GIM PYR trainee report – this allows trainees to describe their training experience in a way that parallels the GIM ARCP Decision Aid, and to state what they think they need to do in their final year to complete their training (but note that the decision as to what they do need to do is made by the ARCP panel).
- GIM PYR Summary of Training calculator – this spreadsheet allows trainees to document their experience on the acute unselected medical take and in outpatient clinics (or their equivalent).
The GIM SAC recommends that the process of PYRs should operate as follows:
Trainees in GIM should have an ARCP 12-24 months before their planned CCT date. These ARCPs will be penultimate ARCPs, during which the trainee should have a PYR in GIM.
Trainees having a PYR in GIM should complete the <GIM PYR trainee report> and <GIM PYR Summary of Training calculator> (or local equivalent as directed by their GIM TPD) and file these in their ePortfolio in a file headed <GIM PYR>.
The information in the <GIM PYR trainee report> and <GIM PYR Summary of Training calculator> (or local equivalent as directed by their GIM TPD) is considered by the GIM TPD (or other suitable person nominated by them) and used to determine what the trainee needs to do to complete their training in GIM by their planned CCT date.
In line with provision in the Gold Guide (para 4.72), the GIM TPD may seek advice from an External Adviser if they wish to do so.
The requirements for completion of GIM training should be clearly stated in the form documenting the penultimate GIM ARCP. Examples of requirements are as follows:
For all trainees -
- 3 months of GIM (or equivalent) in the final year of training
- MCRs from 3 consultants who practice AIM or GIM, confirming performance in GIM at a level required for completion of training
- Separate GIM ES report
For some trainees -
- Demonstration of curriculum requirements related to clinical governance / management
- GIM focussed audit or QIP
- Valid ALS at time of planned CCT
- Completion of X GIM SLEs
- Multisource feedback
- Sign off of all curriculum competencies
- Evidence of adequate take, continuing care, and clinic experience evidenced in summary of training calculator
- Evidence of 100 hours GIM CPD
ARCP – outcome 5s
Review of ARCP outcomes in GIM and other medical specialties has revealed variation from Deanery to Deanery in the frequency of award of outcome 5s. This seems at least in part to be due to differences in interpretation of the circumstances in which award of an outcome 5 is appropriate. Such variation, which would lead to the same trainee being given an outcome 5 if assessed by one ARCP panel, but not another, is not desirable. Please refer to para 4.91, p72 of the Gold Guide:
- Outcome 5 is a ‘holding position’ to allow missing evidence to be provided for the ARCP panel to review
- The ARCP panel should agree what outstanding evidence is required from the trainee and the timescale in which it must be provided to allow issue of another outcome (which would normally be expected within 8 weeks from the date of the ARCP outcome 5)
- If the ARCP panel considers that an Outcome 1 is likely, it can give authority to the Chair to issue an Outcome 1 subject to the outstanding evidence being provided. If, however, the Chair does not receive the agreed evidence to support an Outcome 1 - or if the panel considers that an Outcome 2, 3 or 4 is likely - then the panel will be reconvened
Maintaining competence in practical procedures
When a trainee has been signed off as competent to perform a practical procedure (clinically independent) it is a matter of their and their Educational Supervisor’s professional judgement as to whether they remain competent to perform that procedure. For clarity and the avoidance of doubt:
- When a trainee has been signed off as competent to perform a practical procedure (clinically independent) at any stage during their training, it is not necessary for this to be demonstrated by further WPBA (DOPS) assessment during GIM training unless the trainee or their Educational Supervisor judge that this would be appropriate.
- A trainee and their Educational Supervisor can sign off relevant procedural competencies (clinically independent) in the GIM curriculum e-Portfolio with a statement such as, ‘competency demonstrated during CMT training and has been maintained’
The curriculum for each specialty defines the process of training and the competencies needed for the award of a certificate of completion of training (CCT). The curriculum includes the assessment system for measuring trainees’ progress comprising workplace based assessment and knowledge based assessment.
A new curriculum for GIM - to be known as Internal Medicine Stage 2 - will be implemented in August 2022. Trainees already in training in 2022 will need to transfer to the new curriculum unless in their final year of training. The new curriculum is available below.
Previous versions of the curriculum are no longer available online but copies can be requested from email@example.com.
The ARCP decision aid for each specialty defines the targets that have to be achieved for a satisfactory ARCP outcome at the end of each training year. The version below has been revised and replaces all previous documents from August 2017. The changes include:
- Improved guidance notes
- Clarification that ACATs should each include a minimum of 5 cases
- Guidance on sampling, individual sign off and group sign off of competencies
- Clarification of the procedures for which obtaining clinical independence is desirable but not mandatory and skills lab training or satisfactory supervised practice is the minimum requirement
- Footnotes revised to give a clearer definition of clinical independence and to reflect the British Thoracic Society guidelines on ultrasound for pleural procedures
In addition, the CMT and GIM advisory committees have produced guidance on interpretation of DOPS which is available in the forms and guidance section of this page.
GIM training during the COVID pandemic
We recognise that many trainees have contributed to the NHS response to COVID by working on take or caring for inpatients in ways that have provided them with experience and training in GIM. This time may be recognised for training in GIM if the trainee has maintained their portfolio to evidence experience and training, including appropriate WPBAs and Multiple Consultant Reports (MCRs), and demonstrating (e.g. with reflective notes) the learning obtained. Any trainee wanting such time to be recognised for training in GIM should discuss the matter with their Educational Supervisor and raise it at their next ARCP. The ARCP panel will determine the amount of training to be recognised.
Requirement for GIM training in the final year of training
To assure that trainees are up to date and fit to practise GIM at the time of their CCT it is a requirement that they undertake some GIM training in the year before they obtain their CCT. The minimum requirement is for three months involvement in the acute unselected take (minimum 12 on take shifts) concurrent with specialty training, or four weeks attached to an acute medicine service with no concurrent specialty duties. In the final year of training all trainees require completion of a minimum of three ACATs; a minimum of two MCRs by physicians who have worked with the trainee in acute / general medicine confirming that they are practising GIM to the level expected for award of CCT; and a specific GIM Educational Supervisor’s report.
Definition of external GIM teaching or study
External GIM teaching or study is clinical teaching or study that is not within the area of a trainee’s specialty for example, a teaching session on acute kidney injury would be appropriate as GIM teaching for a respiratory medicine trainee but not for a renal medicine trainee. The word ‘external’ does not mean that the teaching or study has to be delivered away from the trainee’s base department or hospital: it refers to the content of teaching or study and not its physical location. Some contribution from online learning modules or courses can count towards external GIM teaching or study, but these would not normally be expected to amount to more than 25% of the total hours of teaching or study. Management and leadership courses do not count as appropriate for GIM teaching or study because they are not clinically based. By convention, ALS (and similar) courses do not count towards GIM teaching or study.
Summary of training calculator
The following calculator is designed to allow trainees to calculate their acute medical take and outpatient (or outpatient-equivalent) experience in a manner consistent with the 2009 GIM decision aid that will be used at ARCPs and PYAs. The GIM SAC recommends this to trainees and assessors as an easy means of providing information that is required to inform these assessments, although its use is not mandatory.
Clarification regarding DOPS assessment of procedures
The CMT and GIM advisory committees have produced the following guidance on interpretation of DOPS sign off.
Dual CCT training in Cardiology and General Internal Medicine (GIM)
Guidance on indicative training time for dual training programmes.