Background

Currently in the UK there is no generally accepted agreement on what a neurologist needs to do in order to be considered a sub-specialist (e.g. an epileptologist). People may end up earning this title by doing a MD/PhD (ideally with associated clinically relevant components), spending some time in a specialist unit during, or after, specialist training (either in their own training region or going away for a period) or simply being appointed and learning on the job from senior colleagues.

With Shape of Training and the revised Neurology curriculum it is evident that some highly specialised areas will be formally identified as being ‘out of scope’ for the standard training programme. It may become possible to gain a GMC ‘credential’ in some areas post/peri-CCT (but only interventional neuroradiology so far has been identified for this process). At the current time it seems unlikely that GMC ‘credentialing’ will be an option for most of the many and varied areas of sub-specialty neurology practice.

As a result of these factors there have been increasing calls from UK Neurologists for post/peri-CCT advanced clinical training fellowships to become more formally introduced and approved. The Education Committee has now developed a process for the ABN to approve existing or proposed advanced clinical training fellowships.

ABN Approval Process

The flow chart below (fig 1) outlines the process for ABN fellowship initial approval. Informal queries relating to the process ahead of application can be directed to the ABN Education Committee chair.

Fellowships submitted for ABN approval will be reviewed by the ABN Education Committee and the relevant sub-specialty Advisory Group (or Special Interest Group if no suitable Advisory Group exists). This allows the ABN to provide input into the overall educational governance of the post as well as allowing peer review of sub-specialty content prior to approval.

ABN Approved Advanced Clinical Fellowship Template

The approval application template, which can be downloaded below, provides a framework for prospective fellowship hosts to provide the ABN with the information required to make an approval decision.

Completed application templates should be returned to education@abn.org.uk

The information required in this template is analogous (although in simplified form) to the information the GMC require from specialties in the planning and writing of ST curricula. We have adopted the same use of Capabilities in Practice (CiPs) to describe the high level aims of these fellowships. We recommend that potential fellowship hosts make reference to the new JRCPTB Curriculum for Neurology to avoid duplication of training outcomes.

Each CiP must have a set of descriptors associated with that activity. Descriptors are intended to help trainees and trainers recognise the knowledge, skills and attitudes which should be demonstrated by completion of the fellowship. A suggested structure for this is to provide 4 descriptors outlining for each CiP: a) Knowledge, b) skills, c) decision making / MDT leadership and d) provision of ongoing care / management. It is not possible to specify precisely how many CiPs a typical fellowship would entail, but four is likely to be an indicative number for most 1 year posts.

In addition to CiPs prospective fellowship hosts will provide information on the range of clinical presentations and conditions that fellows would expect to develop expertise in during their training. This is once again aligned to GMC processes for postgraduate training curricula.

An indicative range of clinical and educational opportunities must be provided in the template. The number and range of these activities should be designed to allow training fellows to acquire the stated CiPs.

Additional information required on the template includes detail regarding postgraduate governance structures in place at the host site as well as fellowship supervisor credentials.

Example CiPs from already approved advanced clinical training fellowships can be found below.

Fellowship completion and sign-off

CiPs are based on the concept of entrustable professional activities (EPA) which use the professional judgement of appropriately trained, expert assessors as a defensible way of forming global judgements of professional performance.

For each CiP the fellowship educational supervisor (or suitable deputy) will make an entrustment decision and record the indicative level of supervision required with detailed comments to justify their entrustment decision. This process mirrors exactly the GMC recommended assessment strategy for medical specialty training.

Level descriptors for fellowship CiPs

• Level 1 - Entrusted to observe only – no provision of clinical care
• Level 2 - Entrusted to act with direct supervision: The trainee may provide clinical care, but the supervising physician is physically within the hospital or other site of patient care and is immediately available if required to provide direct supervision
• Level 3 - Entrusted to act with indirect supervision: The trainee may provide clinical care when the supervising physician is not physically present within the hospital or other site of patient care, but is available by means of telephone and/or electronic media to provide advice, and can attend if required to provide direct supervision
• Level 4 - Entrusted to act unsupervised

For typical post/peri CCT fellowships it is likely that trainees entering the post will already be at a minimum level 2 for most CiPs. Initial and regular (at least quarterly) appraisal meetings allow assessment against these CiPs and will be used by the supervisor and trainee to judge progress. The final appraisal must include an independent external consultant within the sub-speciality nominated by the ABN Education Committee and relevant Advisory Group / SIG.

A final report written by the fellowship educational supervisor, co-signed by the trainee and external assessor must be submitted to the ABN Education Committee at the end of the fellowship. This report will outline the progress made against all CiPs and provide a final set of entrustment decision levels with supporting evidence.

In order to complete the fellowship successfully the trainee must demonstrate that they are capable of unsupervised practice in all the CiPs. Once a training fellow has achieved level 4 sign off for a CiP it will not be necessary to repeat assessment of that CiP if capability is maintained (in line with standard professional conduct).

At the end of the fellowship and following review by ABN Education Committee the trainee will be provided with an ‘end of fellowship letter’ outlining the Entrustable Professional Activity outcomes for use in their professional portfolio and CV.