Combined infection training - should we be concerned about its impact on infection prevention and control training of microbiologists in the UK?

Introduction

We find ourselves in a period of transition for the training of infection doctors in the UK. In April 2014 the General Medical Council (GMC) approved a Combined Infection Training (CIT) curriculum, designed jointly by the Royal College of Pathologists and the Joint Royal College of Physicians Training Board (JRCPTB). The new scheme recognizes the common competencies of existing infection specialties and combines their training curricula. National recruitment to CIT commenced in August of this year.

The Royal College of Pathologists’ stated aim was to ‘design a training programme which brought medical microbiology, medical virology and infectious diseases closer together’. However, many infection specialists have questioned the motivation for change and remain apprehensive about the truncation of two training schemes.

Recognizing common infection training competencies highlights the similar skills, knowledge, and attributes required by all infection specialists. However, acknowledging differences between medical microbiologists/virologists and infectious disease physicians is equally important as many advertised National Health Service (NHS) consultant posts still have conventional medical microbiology or infectious diseases job descriptions. Therefore, we need to produce trainees with the capability and competencies to fulfil all aspects of these roles. Among the discrepancies between current roles of the microbiologist and infectious diseases physician are laboratory management and infection prevention and control (IPC).

For specialist trainees, the move to CIT will see less time spent in diagnostic laboratories and a shortened period of higher specialist training overall. Whilst CIT offers enhanced clinical training, how well will these heightened clinical skills be used by those taking consultant posts in microbiology or virology? Should we be concerned that CIT enriches clinical aspects of training at the cost of laboratory and IPC skills?

So what is CIT and should we be nervous about its impact on IPC training of microbiologists in the UK?

The previous training model

Until now, UK training in medical microbiology or virology was a five-year run-through programme from ST1 level. This required entrants from foundation training or other training schemes/specialties (e.g. general practice, core medical training, and public health). The curricula and examinations were the remit of the Royal College of Pathologists and trainees were assessed by three summative exams (Year 1 assessment and FRCPath Parts I and II), workplace-based assessments (including multi-source feedback), and satisfactory annual review of competence progression. Trainees spent the majority, if not all, of their training time within microbiology laboratories, embedded in IPC teams.

Infectious diseases training was a four-year programme, with entry at ST3 level from core medical training (CMT) or acute care common stem (ACCS). JRCPTB was responsible for the competency-based curriculum and examination; with knowledge base assessed by the Infectious Diseases Specialty Certificate Examination (SCE). A six-month placement within laboratories (and therefore IPC departments) was included within the syllabus.

Dual accreditation (e.g. infectious diseases and medical microbiology) was available to trainees upon completion of CMT and following attainment of the Membership of the Royal College of Physicians (MRCP). Trainees were required to achieve the competencies of both individual curricula and pass both sets of examinations. The duration of training was usually six years post CMT; the division of this time between the two specialties was decided by Local Education and Training Boards (LETBs).

The CIT model

Trainees now enter CIT at ST3 level from CMT or ACCS, following attainment of the MRCP. The first two years comprise the entirely new Core Infection Training, which includes both clinical and laboratory aspects of infection, and will be examined in a summative assessment aligned with the existing FRCPath Part I and SCE. The Core Infection Training period will broadly consist of six months' experience in each of:

laboratory-based clinical microbiology and virology training;

clinical infection consultation;

infection outpatient clinics;

inpatient infection care.

Finally, trainees complete a further period of Higher Specialist Training (usually two years) in one of four specialties (infectious diseases, medical microbiology, medical virology, or tropical medicine) to gain their Certificate of Completion of Training (CCT). Summative assessment of Higher Specialist Training is the FRCPath Part II for trainees working toward a CCT including microbiology or virology. Figure 1 outlines training pathways. Currently FRCPath Part II continues in its existing format but the future format of this examination is unclear.

Figure 1

Schematic of Combined Infection Training (CIT). ID, Infectious diseases; MM, medical microbiology; MV, microbiology/virology.

Trainees still have the option to obtain dual CCTs (infectious diseases and general internal medicine, tropical medicine and general internal medicine, infectious diseases and medical microbiology, infectious diseases and medical virology) by extending CIT by a year. Nationally, LETBs have taken differing views on recruitment to single and dual accreditation CCTs in 2015. Some LETBs have offered dual accreditation CCT only, whereas others are still offering the option of training in a single infection specialty. The CCT specialty is determined upon entry to CIT, not at a later date.

The benefits of CIT

The move to CIT re-focuses the emphasis of infection training toward clinical aspects of the diagnosis and management of infection. The duration of specialist training spent in outpatient and ward-based clinical placements will be significantly greater than for those trained in medical microbiology/virology on the previous scheme(s). This should improve the clinical experience gained during training and promote skills such as patient examination, clinical procedures, and clinical reasoning. Trainees will have more face-to-face patient time and a greater training in general medicine. Future (CIT-accredited) consultant microbiologists/virologists may even take on more clinical roles (e.g. joint outpatient clinics).

Concerns

Whilst the benefits of CIT are clear, its potential impact on IPC training cannot be overlooked. IPC is an important and inseparable part of any consultant microbiologist’s job description. Aside from the roles of director of infection prevention and control, and infection control doctor, IPC advice is routinely sought from the duty microbiologist/virologist during routine and out-of-hours work.

For trainees working toward a single CCT in medical microbiology, the move to CIT will see them spending one year less in specialty training (four years instead of five). Additionally, the time spent in laboratory-based placements (working within IPC teams) will be significantly reduced. Trainees on the previous scheme would spend most (if not all) of their training in a clinical microbiology department; this will be reduced to as little as two-and-a-half years during CIT. Many IPC incidents (e.g. admission of a patient with novel coronavirus infection, a CPE patient cluster, or increase in Clostridium difficile incidence) occur unexpectedly and sporadically. By reducing training time, trainees will spend less time working in IPC teams, witness fewer IPC incidents, and experience fewer IPC investigations. They will have less time to immerse themselves in strategic quality improvement (e.g. reducing incidence of device-related Staphylococcus aureus bacteraemia), surveillance schemes (e.g. postoperative surgical site), policy writing, and attending water safety/decontamination meetings. Whereas knowledge of health technical memoranda, national guidelines, and an understanding of pathogen transmission are undoubtedly critical, the medical doctrine of ‘see one, do one, teach one’ remains essential in IPC. Much of the learning is by observation of senior colleagues and CIT reduces trainees' exposure to this.

At the same time as CIT threatens to reduce IPC training, the demands and complexity of IPC are ever increasing. The World Health Organization has recognized antimicrobial resistance as one of the leading threats to human health. Issues such as carbapenemase-producing Enterobacteriaceae and extensively drug-resistant tuberculosis are growing challenges for IPC practitioners within the NHS. The surveillance, early detection, and control of such organisms are becoming increasingly complex. Globalization brings distant threats to the NHS and our patient population is becoming more susceptible to healthcare-acquired infection. The use of invasive devices and iatrogenic immunosuppression is growing and the UK has an ageing population with increasing prevalence of comorbidities (e.g. obesity, diabetes mellitus).5, 6

The technologies available for IPC practitioners are increasingly sophisticated too. Tools such as mass spectrometry, real-time PCR, ribotyping, and whole genome sequencing can allow rapid detection of alert organisms and shed light on routes of transmission. An understanding of the role of such laboratory tests, their characteristics (e.g. sensitivity, predictive values), limitations, and pitfalls are critical. Without a sound understanding of these tests, interpretation of results can be difficult at best and misleading at worst. It is therefore crucial that trainees have sufficient access to laboratories performing such tests during their training to develop competencies. By reducing access, trainees will be less familiar with the rapidly evolving tools available to IPC teams.

Furthermore, IPC teams are coming under increasing pressure and scrutiny. This originates from various sources and includes growing public expectations, mandatory national targets, and the press. IPC and water safety incidents put patients, visitors, and staff at risk and attract negative publicity to a hospital trust. Recent breaches in the Health and Safety at Work Acts 1974 have led to fining of NHS hospital trusts for failing to control legionella. Other high-profile incidents, such as the 2012 cluster of Pseudomonas aeruginosa infections on a neonatal unit in Northern Ireland, highlight the attention that such events attract. It is therefore in everyone’s best interests to ensure that IPC teams have competent, experienced leadership to prevent and manage such events. Additionally healthcare-acquired infections are used by commissioners as key performance indicators and quality indicators for acute NHS hospital trusts in the UK. The financial penalties for a C. difficile infection associated with a lapse in care are substantial, providing financial motivation for hospital trusts to demand high IPC standards.

The role of laboratory centralization should also be examined. Microbiologists are increasingly being expected to provide remote clinical and IPC advice. They may be at a different site from the patients/IPC incident or from the laboratory. This means less time spent with IPC nursing or clinician colleagues, a reduced familiarity with clinical areas or side-room availability, and a less direct route to senior management when required. These are potential challenges for even the most experienced IPC practitioner and should not be underestimated.

In the past, trainees could enter the medical microbiology/virology training scheme via various routes (e.g. general practice vocational training scheme, ACCS, public health) and this produced a heterogeneous group of doctors with a mixed skillset. Individuals could bring a variety of clinical and non-clinical transferable skills and valuable insight to underpin their IPC training. This is no longer the case with CIT, as trainees can only be recruited from CMT or ACCS.

Workforce planning to ensure adequate numbers of infection specialists with IPC training will be also be difficult. LETBs are taking local decisions to recruit to dual and/or single accredited CIT and there is no transparent national-level planning of numbers of trainees within each specialty stream of CIT. For example, whether there are high numbers of trainees dually accredited in infectious diseases/general medicine but too few in medical microbiology or virology. Without this gap analysis and forward planning, the future IPC workforce could be at risk.

Alternative options for IPC in the future

Supporters of CIT argue that allied health professionals, such as infection control nurse consultants, will take on the responsibility of IPC in the future. The MSc and Diploma in Healthcare Infection Control are available to provide ‘knowledge, skills and experience to individuals working in the field of Infection Prevention and Control’. Whereas the input from our allied health professional colleagues is extremely valuable, at present there are no quality assured, formally assessed, training schemes that provide IPC qualifications/accreditation. The exception is Higher Specialist Scientific Training (HSST) as part of modernizing scientific careers: ‘a five-year work based programme supported by an underpinning part-time doctoral level programme’. IPC competencies and techniques feature heavily on the HSST curriculum and include areas such as surveillance and epidemiology of healthcare-acquired infection, disinfection and sterilization, ventilation, and reporting of incidents. However, the number of microbiology or virology HSST trainees is very small. Nationally, seven microbiology/virology HSST trainees were recruited by the National School of Healthcare Science in 2014. It therefore seems unlikely that sufficient consultant clinical scientists will be trained in the near future to significantly reduce the burden of IPC responsibilities across NHS hospital trusts.

Moving forward

It is not constructive to criticize the impact of CIT on IPC training without suggesting solutions to improve the situation. After all, CIT has already been implemented and we must work together to optimize training for all infection trainees. The medical microbiology CIT curriculum claims ‘an increasing priority for infection prevention and control, including antimicrobial stewardship’. Since a major concern is the reduction in time spent in higher specialist training (especially laboratory placements), an obvious solution would be to increase the minimum duration of CIT. An increase in the duration of time spent within diagnostic and regional reference laboratories should be considered. This could take the form of a fellowship period ‒ an additional time period (e.g. one year) organized at a regional level, to facilitate IPC learning and experience for senior trainees within the higher specialist training period. Such fellowships could be located over a large geographical area (e.g. LETB boundaries); allowing trainees a period of concentrated IPC training in placements such as regional epidemiology units, NHS hospital trusts, estates departments, food and water laboratories and regional reference laboratories. It would provide trainees with more opportunities to manage hospital and community outbreaks, manage surveillance programmes, and gain reference laboratory experience. Trainees could work alongside regional experts for longer periods to benefit from their insight and experience.

Although national planning for the proportion of trainees within each infection specialty would reduce LETB recruitment flexibility, it would enable more accurate workforce planning within microbiology and virology. This mitigates against the threat of too few infection specialty consultants with sufficient training and an interest in IPC.

Conclusions

The face of infection training has changed at a time when the world of IPC is becoming more challenging. IPC practitioners are facing threats of globalization, antimicrobial resistance, laboratory centralization, and increasing targets and external pressures. To meet these demands, trainees need adequate IPC training and, crucially, experience. The roles and responsibilities of IPC in the NHS seem unlikely to be dominated by allied healthcare professionals in the foreseeable future. Therefore we have a responsibility to ensure adequate IPC training. Although there are clear benefits of CIT for infection trainees, are they at the cost of IPC, and is this cost too high?

Conflict of interest statement

None declared.

Funding sources

None.