Does UK surgical training provide enough experience to meet today’s training requirements?
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2503 (Published 11 May 2015) Cite this as: BMJ 2015;350:h2503
- Charlotte Thomas, year 8 specialty trainee in general surgery, Wales Deanery,
- Gareth Griffiths, chair of the Specialty Advisory Committee in General Surgery, Joint Committee on Surgical Training, London,
- Tarig Abdelrahman, year 6 specialty trainee and education fellow in general surgery, Wales Deanery,
- Cristel Santos, data analyst, Joint Committee on Surgical Training, London,
- Wyn Lewis, head of School of Surgery, Wales Deanery
- wyn.lewis4{at}wales.nhs.uk
Abstract
Charlotte Thomas and colleagues examine whether current guidelines for obtaining a certificate of completion of training are achievable within contemporary UK surgical training
The traditional British surgical apprenticeship, once the envy of the world, has undergone considerable reconfiguration over recent years with a series of initiatives aimed at improving training and shortening its duration.12 At the heart of these changes have been Modernising Medical Careers (MMC) and the Intercollegiate Surgical Curriculum Programme,3 which, between them, modified career structures and introduced curriculum based training programmes. Educational outcomes should now be quantifiable and provide unequivocal proof of a surgeon’s ability.456
Late in 2012, with the first cohort of post-MMC trainees approaching the end of their training, the Joint Committee on Surgical Training published the first specific guidance for certification—the certificate of completion of training (CCT)—in all surgical specialties. The aim of the guidance is to ensure that curricular competency requirements have been achieved and that the new consultant has sufficient experience to practise. These guidelines for certification include indicative operative numbers set at the first quartile of what had been achieved by recent CCT graduates,7 along with the need to show evidence of competence in clinical and operative skills as well as a range of generic professional skills detailed in the curriculum (see box 1).
ISCP
The Intercollegiate Surgical Curriculum Programme is the surgical electronic portfolio and includes all surgical curriculums as well as recording training and skill acquisition. Its use is mandatory for all general surgical trainees and it provides the prima facie evidence necessary for the annual review of competence progression and final certification.389
The first MMC surgical cohort completed their standard six years of structured training in 2013, the year in which the guidelines for certification were published. This cohort of trainees did not have access to the guidelines until the end of their training and the Joint Committee on Surgical Training therefore did not rigidly apply them in deciding whether to recommend the trainees to the General Medical Council for certification. It is, nevertheless, appropriate that their achievements are measured against these guidelines.10
We wanted to know whether these guidelines were achievable within contemporary UK surgical training. To find out, we confidentially examined the information that each trainee had provided when they made their application for certification (see boxes 2, 3, and 4).
We found that 67% of the cohort had achieved the indicative total operative experience of 1600 cases, and that 73% or more of trainees had the requisite experience in the range of individual index procedures. The low rate of completion of workplace based assessments in this cohort meant that we were unable to use these for meaningful confirmation of clinical and operative competence; assessment for certification relied on supervisor reports. Competence and experience in academic aspects of the curriculum were achieved by around 90%, while quality improvement, management, and leadership guidelines were achieved by around 75%. Evidence of teaching skills was presented by 57% of the cohort. Educational conferences and special interest courses were attended by over 90%, but only 50% had advanced trauma life support certification. When all of the guideline credentials were taken into consideration, only one candidate achieved them all.
What we can learn from this work is shown in box 5.
Vigilance needed
Active management of training programmes and trainee vigilance are required to ensure acquisition of the competences and experience required. There is already anecdotal evidence of trainees working to gain competences and additional experience to meet the guidelines. In this way, the guidelines may drive improvements in training.
The indicative numbers were set from what was achievable in the relatively recent past,7 and our findings show that most of the guideline levels continue to be met by the same proportion of trainees. The fact that some trainees are not managing to gain the level of experience described by the indicative numbers emphasises the need to keep these guideline numbers under review. This is particularly the case in the light of changes within surgical practice.
Knowing how many trainees are meeting the guideline requirements will allow trainees, supervisors, and training programme directors to focus their training to ensure that experience, as well as competence, is achieved across the breadth of the curriculum. Trainees who are not, or who believe they are not, progressing as expected need to be identified early on and offered targeted training. The introduction of simulation may help, although there is no suggestion that this should replace actual operative opportunities.
General surgery has many components which form special interests for consultants in independent practice. What unifies general surgery is the ability of all surgeons at certification to manage an unselected emergency general surgery take, treating all common and straightforward cases through to completion. It is therefore important that every trainee in general surgery, regardless of special interest, meets specific guidelines which ensure that each will have sufficient competence and experience to work as a general surgeon.
The level at which to set competences for the more complex procedures with special interests will continue to be a point for discussion. The 2013 curriculum reduced the competences expected for such procedures. The extent to which the Shape of Training report is implemented will dictate whether and what further change is required. These data suggest that reduced levels of expected competence and experience would be required if training times were to be reduced.
The required indicative logbook experience seems high when compared with the requirements of the American Board of Surgery, which mandate just 750 operations performed during the five year residency programme.11 If training time in the United Kingdom were used more efficiently and if innovative working practices enabled a greater proportion of time to be spent actually training then it may be possible to shorten overall training.12 Further work clarifying the relation between experience and competence may also help.
The Intercollegiate Surgical Curriculum Programme must be considered an important and positive step forward, and the Joint Committee on Surgical Training guidelines aim to produce a safe consultant general surgeon with the skills and experience required for the increasingly demanding arena of NHS clinical practice. If training and clinical experience are to be optimised and made consistent with the needs of future training, then further detailed programme profiling will be required so that surgical rotations can be configured to be fit for purpose.
Box 1: General surgery certification guidelines
The guidelines for certification are mapped to the curriculum, are included in it, and cover the following areas:
Clinical experience and competence
Operative experience and competence
Research
Quality improvement
Medical education and training
Management and leadership
Additional courses
Educational conferences
Box 2: Key findings
155 applicants for certification whose data were analysed
72 months—median length of time in training
1802—median number of operative cases experienced
67%—reached indicative level of total operative experience
73% or more reached indicative level of experience in key procedures*
33% met case based discussion guidelines for clinical competence
3% met procedure based assessment guidelines for the general surgery procedures required by all trainees
No trainee met the procedure based assessment guidelines for the general surgery procedures required by all trainees and for those required in a special interest
7—median number of publications
88% met publication requirements
94% met presentation requirements
80% met the guidelines for number of audits completed
18% met the guidelines for completing an audit cycle
57% met the guideline of having attended a course on teaching
72% had attended an NHS management course
77% had undertaken a management role
23% met all the research, quality improvement, education, and management criteria
97% had attended a course in their special interest
50% had advanced trauma life support certification
91% met the guidelines for attendance at educational conferences
*Infrainguinal bypass was the only exception, in which 56% reached the indicative numbers
Box 3: Our research
We identified 155 consecutive successful applicants for certification in general surgery (119 male, 36 female) with certification dates between 1 November 2012 and 12 December 2013 from Joint Committee on Surgical Training records. Their CVs and online portfolios were analysed with specific reference to the guidelines for certification. We anonymised all data and obtained ethical approval from Cardiff University’s Research Ethics Committee.
We amalgamated this information with operative logbook and workplace based assessment data from the Intercollegiate Surgical Curriculum Programme. We assessed publications as peer reviewed full papers, excluding case reports and letters. First author presentations, both poster and oral, at national or international level were included. These data were then compared with the guidelines set by the Joint Committee on Surgical Training for the assessment of certification.
Box 4: Our findings
The 155 applicants were spread across all UK deaneries and across six special interest areas (colorectal, breast, upper gastrointestinal, vascular, hepato-pancreato-biliary, and transplant surgery). The median duration of specialty training was 72 months.
Trainees’ logbooks showed a wide range of total operative experience during specialty training. The median number of all cases, including assisting, was 1802 (range 783 to 3764). Overall, 67% of applicants reached the indicative experience level of 1600 cases of total operative experience. There were no significant differences when considering the effects of sex, special interest, or training region on total operative experience.
Workplace based assessments for 43% of the applicants were available for review. Only two trainees (3%) had completed the necessary number of procedure based assessments for the six procedures required of all general surgery trainees in the guidelines for certification. No trainee achieved the procedure based assessment criteria for both general surgery and their special interest. A third (33%) of trainees met the guideline requirements for numbers of case based discussions.
However, the guidelines for certification were introduced in late 2012, after the first trainees in this cohort had been recommended for certification, and within a year of certification for the remainder. This group of trainees was also the first to use workplace based assessments. As a result their engagement was low, and there is less demonstrable evidence of clinical and technical competence than would be desirable. Recommendations for certification used supervisor reports as evidence of competence in these areas.
It is also worth noting that the logbook data supplied may have been inaccurate, and that many of the other data are dependent on the accuracy of the submitted paperwork from individual trainees. Some trainees included no details of experience of procedures that they would almost certainly have gained exposure to. The data were not corrected for such cases and so represent a “worst case” view. The workplace based assessment data are also incomplete, because some of this cohort were Calman trainees and did not require workplace based assessments.
The median numbers of publications and presentations were seven and 10 respectively. The certification guideline of three peer reviewed publications and three presentations were met by 88% and 94% of applicants respectively. Taking time out of training for research is not imperative but may be advisable for competitive reasons related to consultant selection; 53% of trainees had achieved a doctorate (MD or PhD) and 22% a masters degree.
Box 5: Key messages
The guidelines for certification have been set at achievable, if challenging, levels.
All of the guidelines can be met individually.
Few trainees met the criteria across related components and only one trainee met all of the criteria.
The criteria set a standard to be achieved and in doing so may drive training.
To make progress to certification, trainees and programme directors need to keep a close eye on trainees’ trajectories towards the guidelines.
Placements and learning agreements should be tailored to ensure the trainees’ actual trajectories match what is required at each stage of training.
The authors have supplied a full report of their research and results, available at http://careers.bmj.com/resources/cms/CCTGraduateAnalysisPaper.pdf.
Footnotes
We thank WH Allum, chair of the Joint Committee on Surgical Training, for his helpful comments in the preparation of the manuscript. We also thank all the staff in the Joint Committee on Surgical Training office for assisting in data collection, and in particular Darren Blake, David Calderon, Paramjit Kaur, Christina Kourousiapkou, and Encarna Manzano.
Competing interests: We have read and understood BMJ’s policy on declaration of interests and declare: None.