The impact of shortened training times on the discipline of vascular surgery in the United Kingdom

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Abstract

Political initiatives and European health and safety working time regulations have combined to reduce the time available for surgical training in the United Kingdom in the future by a third. For the safety of patient care, surgeons must evolve strategies to cope with these reduced training times so that they preserve the current high level of competence exhibited by UK trainees when they attain the right to independent surgical practice recognized by appointment as a Consultant Surgeon. Such strategies include a focus on dedicated training time, the use of simulators, and a move towards progression based on satisfactory completion of a defined curriculum and competency assessment rather than the amount of time served. With insufficient time to train in every aspect of general surgery, a move towards fragmentation into its sub-speciality components seems unavoidable. Such a move offers an opportunity to re-evaluate conventional surgical training and to consider the evolution of a system-specific vascular specialist with patient-focused expertise in vascular surgery, endovascular radiology, and vascular medicine.

Section snippets

The Working Time Directive

The Working Time Directive (WTD) is Health and Safety legislation applicable to all countries in the European Union, which aims to restrict all employees to a maximum 48-hour working week. It does not apply to the self-employed. Doctors in training employed by the National Health Service (NHS) have been allowed delayed implementation, but by 2004 were restricted to 58 hours per week, including 11 hours continuous rest in any 24-hour period. The weekly maximum falls to 56 hours per week in 2007,

Surgical Training in the United Kingdom

Vascular surgery in the United Kingdom is a sub-speciality of general surgery. Graduates from medical school first complete a probationary year in medicine and surgery before entering the Senior House Officer (SHO) grade, where they spend 2 to 3 years acquiring basic surgical skills in rotations around different surgical disciplines such as Accident and Emergency, Orthopaedics, General Surgery, Urology, and others. After passing the Membership examination of the Royal College of Surgeons

Vascular Specialist Training

The current trend in the United Kingdom is to move towards sub-specialization within general surgery. Breast and gastrointestinal surgeons are no longer comfortable with providing emergency care for vascular patients and this has led to a re-evaluation of the way in which vascular emergency services are delivered [3]. Adjacent hospitals are joining forces in clinical networks to provide 24-hour, 7-day per week emergency cover by specialist vascular surgeons, moving either the patient or the

The Use of Simulators

An increasing number of courses outside the workplace are offering simulator training and the simulators are becoming more and more sophisticated with the advent of virtual reality devices in the endovascular field. These simulators offer not just a chance to examine the competence of trainees without putting patients at risk but also a significant opportunity to practice and develop technical skills in the trainee’s own time away from the workplace and the demands of the WTD. Rare is the

Competency Assessment

It is recognized that as training time shortens, it becomes more important to assess the degree of competence achieved in the time available. Failure to achieve the necessary competencies laid down in the surgical curriculum should act as a trigger to prolong training until they are achieved and there is considerable variation in the experience needed for this to happen between different trainees [5].

The existing methods of assessment do not measure technical competence directly, relying

Summary

The limitations in vascular training produced by shortened working hours can be addressed, but need a re-evaluation of traditional general surgical training. More focused training with a smaller curriculum can be achieved in the time available by targeting individual sub-specialist areas within general surgery rather than trying to cover the entire syllabus. Practical skills can be developed on simulators outside the workplace and developments in virtual reality may allow similar simulations of

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