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There is currently considerable concern about the attractiveness of hospital medicine as a career and experiences in core medical training (CMT) are a key determinant of whether trainees continue in the medical specialties. Little is understood about the quality and impact of the current CMT programme and this survey was designed to assess this. Three key themes emerged. Firstly, the demands of providing service have led to considerable loss of training opportunities, particularly in outpatients and formal teaching sessions. Trainees spend a lot of this service time doing menial tasks and over 90% report that service takes up 80-100% of their time. Secondly, clinical and educational supervision is variable, with trainees sometimes getting little consultant feedback on their clinical performance. Finally, 44% of trainees report that CMT has not prepared them to be a medical registrar and many trainees are put off acute medical specialties by their experiences in CMT.

A recent survey of UK core medical training (CMT) training conducted jointly by the Royal College of Physicians (RCP) and Joint Royal College of Physicians Training Board (JRCPTB) identifi ed that trainees perceived major problems with their training. Service work dominated and compromised training opportunities, and of great concern, almost half the respondents felt that they had not been adequately prepared to take on the role of medical registrar. Importantly, the survey not only gathered CMT trainees' views of their current training, it also asked them for their 'innovative and feasible ways to improve CMT'. This article draws together some of these excellent ideas on how the quality of training and the experience of trainees could be improved. It presents a vision for how CMT trainees, consultant supervisors, training programme directors, clinical directors and managers can work together to implement relevant, feasible and affordable ways to improve training for doctors and deliver the best possible care for patients.

The aim of this study was to evaluate the quality of feedback provided to specialty trainees (ST3 or higher) in medical specialties during their workplace-based assessments (WBAs). The feedback given in WBAs was examined in detail in a group of 50 ST3 or higher trainees randomly selected from those taking part in a pilot study of changes to the WBA system conducted by the Joint Royal Colleges of Physicians Training Board. They were based in Health Education Northeast (Northern Deanery) and Health Education East of England (Eastern Deanery). Thematic analysis was used to identify commonly occurring themes. Feedback was mainly positive but there were differences in quality between specialties. Problems with feedback included insufficient detail, such that it was not possible to map the progression of the trainee, insufficient action plans made and the timing of feedback not being contemporaneous (feedback not being given at the time of assessment). Recommendations included feedback should be more specific; there need to be more options in the feedback forms for the supervisor to compare the trainee's performance to what is expected and action plans need to be made.

Due to normal growth and development, hospitalised paediatric patients with infection require unique consideration of immune function and drug disposition. Specifically, antibacterial and antifungal pharmacokinetics are influenced by volume of distribution, drug binding and elimination, which are a reflection of changing extracellular fluid volume, quantity and quality of plasma proteins, and renal and hepatic function. However, there is a paucity of data in paediatric patients addressing these issues and many empiric treatment practices are based on adult data. The penicillins and cephalosporins continue to be a mainstay of therapy because of their broad spectrum of activity, clinical efficacy and favourable tolerability profile. These antibacterials rapidly reach peak serum concentrations and readily diffuse into body tissues. Good penetration into the cerebrospinal fluid (CSF) has made the third-generation cephalosporins the agents of choice for the treatment of bacterial meningitis. These drugs are excreted primarily by the kidney. The carbapenems are broad-spectrum beta-lactam antibacterials which can potentially replace combination regimens. Vancomycin is a glycopeptide antibacterial with gram-positive activity useful for the treatment of resistant infections, or for those patients allergic to penicillins and cephalosporins. Volume of distribution is affected by age, gender, and bodyweight. It diffuses well across serous membranes and inflamed meninges. Vancomycin is excreted by the kidneys and is not removed by dialysis. The aminoglycosides continue to serve a useful role in the treatment of gram-negative, enterococcal and mycobacterial infections. Their volume of distribution approximates extracellular space. These drugs are also excreted renally and are removed by haemodialysis. Passage across the blood-brain barrier is poor, even in the face of meningeal inflammation. Low pH found in abscess conditions impairs function. Toxicity needs to be considered. Macrolide antibacterials are frequently used in the treatment of respiratory infections. Parenteral erythromycin can cause phlebitis, which limits its use. Parenteral azithromycin is better tolerated but paediatric pharmacokinetic data are lacking. Clindamycin is frequently used when anaerobic infections are suspected. Good oral absorption makes it a good choice for step-down therapy in intra-abdominal and skeletal infections. The use of quinolones in paediatrics has been restricted and most information available is in cystic fibrosis patients. High oral bioavailability is also important for step-down therapy. Amphotericin B has been the cornerstone of antifungal treatment in hospitalised patients. Its metabolism is poorly understood. The half-life increases with time and can be as long as 15 days after prolonged therapy. Oral absorption is poor. The azole antifungals are being used increasingly. Fluconazole is well tolerated, with high bioavailability and good penetration into the CSF. Itraconazole has greater activity against aspergillus, blastomycosis,...

In 2009, the Royal College of Physicians (RCP) undertook the coordination of recruitment to core medical training (CMT) for the first time. Given the recent history of medical recruitment in the UK, this was a high risk and politically sensitive area.Before 2007, and again in 2008, trainees could make unlimited numbers of applications to individual trusts or deaneries, and there was massive reduplication of recruitment work. In 2007, the Medical Training Application Service (MTAS) was introduced in an attempt to coordinate recruitment, and became synonymous with disaster. Coordinated recruitment has the potential to make much more efficient use of resources, especially the valuable time of applicants, recruitment staff and consultants. With unlimited applications, finite interview capacity results in competent, but 'weak on paper' applicants being excluded by shortlisting, and high-achieving applicants getting multiple interview offers which they do not need and are therefore wasted (up to 40% in 2008). The Department of Health invited bids to pilot nationally coordinated recruitment for 2009, and the RCP responded to this challenge for CMT recruitment, believing there were important benefits for applicants, patients and the service.Applicants for CMT posts in England applied for Core Training Level One (CT1) posts in January 2009 via a national web-based system (Konetic Powered Recruiting). The system allowed electronic flagging of eligibility issues, which greatly improved the efficiency of longlisting. At this point the intention was to offer a guaranteed interview to all applicants between deaneries, while using an invigilated test (machine marked test, MMT) to move applicants if necessary, to utilise all of the interview capacity. Additionally the MMT would provide a knowledge score to contribute to overall assessment. The proposed MMT was an established test of applied knowledge, problem solving and professional judgement, developed for general practice recruitment (see www.gprecruitment.org.uk/recruitment/ assessment_process.htm for further information). The intention was to use the MMT only as a knowledge score, and not for exclusion (historically general practice (GP) recruitment excluded the lower 10-15% on the basis of the MMT result).In the event, although data collected from CMT applicants who also applied for GP training in 2008 had already shown that the MMT had good predictive value for CMT appointability, the Modernising Medical Careers Programme Board required that the MMT should be used only as a pilot, and that applicants should be allowed to apply to two deaneries. Because of insufficient CMT interview capacity (over 4,000 interviews would have been required to allow all eligible applicants to have two interviews), this re-introduced the unavoidable need for shortlisting. The electronic application system allowed refinement and shortlisting based on applicant selection from drop-down lists. Inevitably, over 40% of applicants were excluded from either their first or second choice deanery and ...

Acute care in the NHS is increasingly delivered by junior doctors who receive little educational supervision. There is a continuing dramatic increase in the numbers of trust doctors. Staff grades are also increasing in number and face many frustrations.

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