Clinical Orthopaedics and Related Research®
Clin Orthop Relat Res (2014) 472:1697–1702 / DOI 10.1007/s11999-014-3573-2
A Publication of The Association of Bone and Joint Surgeons®
Published online: 26 March 2014
Ó The Association of Bone and Joint Surgeons1 2014
CORR
1
Curriculum — Orthopaedic Education
Orthopaedic Education in the United Kingdom M. Gavan McAlinden MPhil, FRCS (Tr & Orth), Paul J. Dougherty MD
Introduction
G
raduate medical education in the United Kingdom recently restructured with the goal of improving trainee experience. In 2007, the Modernizing Medical Careers program changed the organizational structure of all postgraduate medical training in the United Kingdom due to concerns about excess length of training and a lack of supervision. The goals were to include standardization of education
Note from the Editor-in-Chief: We are pleased to introduce the next installment of CORR1 Curriculum—Orthopaedic Education. The goal of this quarterly column is to focus on the mechanics of resident education. Dr. Paul J. Dougherty, residency program director at Detroit Medical Center, and Dr. Gavan McAlinden, training program director for Northern Ireland Trauma and Orthopaedic Training, explore the trainee’s intricate path through the United Kingdom’s graduate medical education system. We welcome reader feedback on all of our columns and articles; please send your comments to [email protected]. Each author certifies that he or she, or any member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
and training to produce ‘‘high quality, well trained, accredited doctors’’ [4]. A more formalized structure of feedback and assessment was also implemented to document the progress of trainees [4]. Additionally, the European Union’s European Work Time Directive reduced the number of hours any employee could work (including those in graduate medical education training)—from 56 hours to 48 hours per week. The purpose of this article is to introduce the reader to the educational All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR1 or the Association of Bone and Joint Surgeons1. M. G. McAlinden MPhil, FRCS (Tr & Orth) Department of Trauma and Orthopaedic Surgery, The Ulster Hospital, Dundonald, Belfast, UK P. J. Dougherty MD (&) Department of Orthopaedic Surgery, Detroit Medical Center, 4201 St. Antoine, Suite 4G, Detroit MI 48201, USA e-mail: [email protected]; [email protected]
structure of the United Kingdom, how assessment and feedback are conducted, and just how the European Work Time Directive has influenced orthopaedic surgery education.
Orthopaedic Training: The Foundation Years Medical school is a 5-year program, beginning after secondary (high) school [12]. Graduates obtain a ‘‘Bachelor of Medicine, Bachelor of Surgery’’ which is abbreviated a variety of ways depending on the institution (MB BS, BM BCh, MB BCh, MB BCh BAO, for example). All are equivalent degrees, which allow the graduate to be qualified for further education. After medical school, successful applicants begin the Foundation Years (FY1-2), in which the new physician obtains further education regarding basic patient care skills [6]. These years are similar to an internship in the United States, with broad exposure to different medical areas and medical conditions. During the first 2 years, the trainee is eligible to sit out Part A of the Member Royal College of Surgeons exam.
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Orthopaedic education in the United Kingdom is described as Trauma and Orthopaedic (Tr & Orth), recognizing the need to care for patients who have sustained trauma, and the large dependency on the healthcare system to care for patients with fractures [6, 9].
Core Specialty Education The next level of training, called Core Specialty Training (CT1 and CT2), is appointed by competitive interview. Core Specialty Training begins after the Foundation Years, and is considered the initial surgical specialty training. There are run-through programs, in which the candidate progresses directly to the later years of surgical training. Those who are in run-through programs are designated as Specialty Trainees (ST) instead of CT1 and CT2. Specialty Trainees may rotate in no more than two related surgical fields for up to 6 months each. The first year, (CT1 or ST1) focuses on the care of trauma patients, the management of simple fractures, and principals of both internal and external fixation. The second year, CT2/ST2, builds on the previous year, developing more extensive surgical skills for fracture fixation (intrarticular, open, and hip fractures for example), and initial exposure to elective types of procedures. During the second year, the trainee is eligible to sit out Part B of the
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Member Royal College of Surgeons exam, consisting of a patient-based simulation exam (objective structured clinical exam) [6, 9]. Alternate Pathway If Unsuccessful Core Training At the end of CT2, trainees who have been unsuccessful in passing the Member Royal College of Surgeons exam or who have not gained a National Training Number for ST3-8 training may apply for a further year in Core Training for experience, undertake a Clinical Fellowship (junior posts which do not have official recognition for training), or apply for a Specialty Doctor/Non-Consultant Hospital Doctor post. Specialty Doctor posts are permanent subconsultant career posts. Doctors who have worked in these posts for several years can apply to the General Medical Council for Specialist registration if they have equivalent experience to a Day-1 Consultant, and have passed the Fellow of the Royal College of Surgeons (FRCS) (Tr & Orth) examination. This, however, is a lengthy process and the award is by no means automatic [3]. Higher Surgical Training Appointment to a Higher Surgical Training program (ST3-8) is by
competitive interview. Scotland and England run a competitive single-center multistation interview. Wales and Northern Ireland each run their own multistation interviews. The job specification is centrally determined by the Orthopaedic Specialist Advisory Committee and ratified by Health Education England. In England, the number of posts is set by the Center for Workforce Intelligence, which may not reflect the needs of the specialty [2]. The devolved regions are able to set their own recruitment numbers. In any given year, between 120 and 150 ST3 s will be appointed. There are generally between five and 10 applicants for each post [5–7, 10]. At the end of the intermediate years, considered ST3-6, the trainee gains experience with various subspecialties, such as foot and ankle, hip, knee, shoulder/elbow, and hand. Rotations are structured for 6 months in length, and may be located at other institutions rather than the main teaching hospital [5–7, 10]. After ST6, 2 additional years of training (ST7-8) are conducted to further refine the skills in general orthopaedic surgery and trauma, along with additional clinical training in a specialty area [5–7, 10]. The trainee is now eligible to take the examination to become a FRCS (Tr and Orth). Trainees should have a minimum of 1,800 cases recorded in their logbooks
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(assisted and performed), encompassing the generality of trauma and orthopaedic surgery [5–7, 10] by the end of ST6. They are also expected to perform a specified number of procedures in 12 index operations [5, 7, 10]. Trainees must show evidence of undertaking one audit each year, including two completed audit cycles. They are also expected to present two research presentations at national meetings and publish two peerreviewed publications. Trainees may undertake full-time research during their training, but will only gain 6 months recognition for this, regardless of the time in research. The recognition of time spent in research is conditional on successful completion of a research degree or publication of the results of research [5]. Upon completion of the 6-year Higher Surgical Training program, a trainee applies to the Joint Committee on Surgical Training for a Completion of Training certification. When this is awarded, the trainee is enrolled on the Specialist Register of the General Medical Council as an Orthopaedic Specialist. This entitles the trainee to practice as an Orthopaedic Specialist in any European Union Member State. At this stage, most trainees elect to undertake a further period of Fellowship training in their chosen subspecialty [5, 7].
Assessment and Feedback One of the main goals of the Modernizing Medical Careers program when it was introduced in 2005 was to provide more standardized assessment and feedback for the trainee. In this more formalized structure, residents must collaborate with faculty to develop written educational agreements for each rotation, enter procedures into a national electronic logbook (e-logbook), and have procedure-based assessments, which form the basis of a determining a trainee’s progress. This involves a considerable commitment for trainers and trainees. A trainee who fails to comply may expect an unsatisfactory assessment of a clinical rotation (called attachment). At the beginning of every attachment, there is an agreement between the trainee and the faculty member concerning the scope and content of practice, the types of procedures, and the assessment methods. At the end of an attachment, a final meeting is held to assess outcomes against these objectives. The supervisor completes a Trainee Assessment form detailing the trainee’s competence in a range of areas: Clinical Skills, Knowledge, Postgraduate activities, and Attitudes. Additionally, each rotation should have a minimum of two consultant supervised clinics and three consultant
supervised theater sessions per week. There should be a minimum of 2 hours of formal teaching per week and trainees are expected to attend a minimum of 70% of teaching sessions. Trainees must undertake a minimum of 40 Workplace Based Assessments and one audit per year. Trainees in ST7 or ST8 must complete courses in Leadership and Management and Medical Education [3, 5, 7]. The Royal College of Surgeons of Edinburg developed an e-logbook to document a trainee’s procedure-based assessments. There are now a wide range of procedure-based assessments available on the Intercollegiate Surgical Curriculum Project [5] website, which houses the curriculum for 10 surgical specialties. These assessments evaluate the preoperative, perioperative, and postoperative steps involved in an operation [5, 6, 11]. The Intercollegiate Surgical Curriculum Project records a trainee’s progress in a webbased system. The e-logbook, procedure-based assessments, and learning agreements and assessment documents form the core of a trainee’s training portfolio [5, 6]. The Annual Review of Competence Progression is a yearly assessment that summarizes a trainee’s progress. The program director, other orthopaedic faculty, and a member of the regional postgraduate department conduct the
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assessment and make recommendations concerning future education [6]. This assessment is the main tool used to determine the successful completion of a training period [3, 6, 10]. Upon completion of training, the trainee receives a Certificate of Completion of Training.
Strengths The European Work Time Directive reduced the number of hours graduate medical trainees could work per week, forcing medical schools in the United Kingdom to implement a more efficient and formalized medical education structure. The Modernizing Medical Careers program is an educational reform meant to alleviate the concerns brought upon by the previous system, in which trainees were caught in education rotations for several years, without progression. A more focused orthopaedic medical education will better serve the needs of the trainee, and ultimately, the patients in the United Kingdom. As it is presently constituted, orthopaedic training takes place within a clear framework, defining what is expected of the trainee, trainer, and training program. The trainee portfolio provides clear and detailed evidence of a trainee’s progress against defined standards, and helps to distinguish between successful and failing
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trainees. The latter can be identified, and targeted training can be instituted. The relationship between trainer and trainee requires a significant investment in time and effort but delivers a clearer understanding of what is needed for training. For a program director, guidelines help confirm that training posts are appropriate for trainees and ensure that provision of training is considered by Medical Management.
Limitations There is no doubt the European Work Time Directive has become a significant obstacle to provision of surgical training, especially in the earlier years of training [1, 8]. To some extent, trainees have compensated for this by attending clinics during their time off. Flouting of the European Work Time Directive has mitigated its effects. There appears to be a growing realization, within the European Union, that the European Work Time Directive needs to be reconsidered. Either special allowances will have to be made for those in Specialty Training, or the training will need to be extended. Medical education is experiential, and gaining enough exposure to patient care is essential to produce safe practicing orthopaedic surgeons. Surgical experience is extremely important, and
enough surgical volume to overcome the learning curve of certain common procedures is essential for every specialty. One survey [1] showed that the case volume had declined to 56% of what had been the previous trainee’s experience. Initial implementation of the Modernizing Medical Careers program was also marred by a poor online application system, in which applicants for training could not successfully apply because of difficulties with the system. Secondly, the number of training slots has been reduced in part because of the more prescribed training requirements, thus creating a mismatch between medical school graduates and the number of training slots available [13]. Prior to the Modernizing Medical Careers program, more autonomy was possible for the trainee to run their own ‘‘list’’ or operating room. Less challenging cases could be performed independently, with indirect supervision of a consultant (faculty or fully trained supervisor). More challenging cases would have been readily available. While having clear guidelines is helpful, setting specified numerical targets in 12 index operations is skewing surgical experience. What started as a competency based training program, allowing each trainee to develop skills at different rates, has now become driven by quantity. Good
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trainees are diverted from gaining a breadth of surgical experience by focusing on ‘‘getting their numbers.’’ In some regions, there may not be enough training opportunities for trainees to gain sufficient experience in index procedures. For example, in Northern Ireland, tendon repairs are generally carried out by a Plastic Surgical service, with an international reputation for tendon repair and rehabilitation. Additionally, Achilles tendon tears are generally treated conservatively by a dedicated team. This is to the advantage of patients, but significantly hinders the ability of a trainee to achieve a target. The target numbers, the number of times a trainee must perform a particular procedure, do not necessarily reflect the complexity of the procedure. For example, the target for carpal tunnel release is 30 [7], while the target for total hip replacement is 40. Does this mean that the former is almost as complex as the latter? A further impediment to a trainee’s surgical experience is the widespread use of the independent sector for provision of elective orthopaedic surgery. In order to meet waiting time targets, the National Health Service transfers patients to the private sector for surgery. These are often more straightforward cases, which would be ideal for training, but are lost to the pool of training.
Conclusion Surgical training in the United Kingdom has undergone considerable changes in the last decade. Orthopaedic surgery has generally been at the vanguard of positive developments and a clear, structured pathway is now available for trainees. It remains to be seen whether changes to training produce a better trainee or merely produce trainees with a more detailed portfolio of documentation. Nevertheless, orthopaedics remains an attractive and competitive career for junior doctors, giving selection panels the opportunity to select motivated individuals with the skill-set to become consultants of the future.
References 1. Bates T, Cecil E, Greene I. The effect of the EWTD on training in general surgery: An analysis of electronic logbook records. Ann R Coll Surg Engl. 2007;89(Suppl): 106–109. 2. Centre for Workforce Intelligence. Medical Specialty Workforce Factsheet. Trauma and Orthopaedic Surgery. Available at: http://www. cfwi.org.uk/publications/trauma-andorthopaedic-surgery-cfwi-medical-factsheet-and-summary-sheet-august-2011. Accessed January 18, 2014. 3. General Medical Council. Available at: http://www.gmc-uk.org/doctors/ statistics.asp. Accessed January 20 2014.
4. House of Commons Health Committee. Modernizing Medical Careers, Volume 2. Written evidence. Available at: http://www.parliament.thestationery-office.co.uk/pa/cm200708/ cmselect/cmhealth/25/25ii.pdf. Accessed February 24, 2014. 5. Intercollegiate Surgical Curriculum Programme. Trauma and Orthopaedic Surgery. Available at: https:// www.iscp.ac.uk/surgical/SpecialtySyllabus.aspx?enc=j4VfyFXq6Hwh0 loAlHujtuc5nfiQMyQBM/N8ADu JSMY. Accessed January 18, 2014. 6. Invaparthy P, Sayana M, Maffuli M. Evolving Trauma and Orthopaedics Training in the UK. J Surg Ed. 2013; 70:104–108. 7. Joint Committee on Surgical Training. Guidelines for the award of CCT in Trauma and Orthopaedic Surgery. Available at: http://www.jcst.org/ quality_assurance/Docs/cct_guidelines_to. Accessed January 10, 2014. 8. Marron CD, Byrnes CK, Kirk SJ. An EWTD compliant shift rotation decreases SHO training opportunities. Ann R Coll Surg Engl. 2005; 87(Suppl):246–248. 9. NHS. Person Specification for Higher Surgical Training. Trauma and Orthopaedics. Available at: http://specialtytraining.hee.nhs.uk/ files/2013/03/PS-2014-ST3-TO-Surgery1.pdf. Accessed January 14, 2014. 10. NHS. Specialty Recruitment Applicant Handbook 2014. Available at: http://specialtytraining.hee.nhs.uk. Accessed January 18, 2014. 11. Pitts D, Rowley D, Sher L. Assessment of Performance in Orthopaedic
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Training. J Bone Joint Surg (Br) 2005;87:1187–1991. 12. Queens University Belfast. School of Medicine, Dentistry, and Biomedical Sciences. Available at: http://www.
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qub.ac.uk/schools/mdbs. Accessed January 17, 2014. 13. Tooke J, Ashtinany S, Carter D, Cole A, Michael J, Rashid A, Smith PC, Tomlinson S, Petty-Saphon K.
Aspiring to excellence. The final report of the independent inquiry into Modernizing Medical Careers. Chiswick, London: Aldridge Press; 2008:1–238.
Clin Orthop Relat Res (2014) 472:1697–1702 / DOI 10.1007/s11999-014-3573-2
A Publication of The Association of Bone and Joint Surgeons®
Published online: 26 March 2014
Ó The Association of Bone and Joint Surgeons1 2014
CORR
1
Curriculum — Orthopaedic Education
Orthopaedic Education in the United Kingdom M. Gavan McAlinden MPhil, FRCS (Tr & Orth), Paul J. Dougherty MD
Introduction
G
raduate medical education in the United Kingdom recently restructured with the goal of improving trainee experience. In 2007, the Modernizing Medical Careers program changed the organizational structure of all postgraduate medical training in the United Kingdom due to concerns about excess length of training and a lack of supervision. The goals were to include standardization of education
Note from the Editor-in-Chief: We are pleased to introduce the next installment of CORR1 Curriculum—Orthopaedic Education. The goal of this quarterly column is to focus on the mechanics of resident education. Dr. Paul J. Dougherty, residency program director at Detroit Medical Center, and Dr. Gavan McAlinden, training program director for Northern Ireland Trauma and Orthopaedic Training, explore the trainee’s intricate path through the United Kingdom’s graduate medical education system. We welcome reader feedback on all of our columns and articles; please send your comments to [email protected]. Each author certifies that he or she, or any member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
and training to produce ‘‘high quality, well trained, accredited doctors’’ [4]. A more formalized structure of feedback and assessment was also implemented to document the progress of trainees [4]. Additionally, the European Union’s European Work Time Directive reduced the number of hours any employee could work (including those in graduate medical education training)—from 56 hours to 48 hours per week. The purpose of this article is to introduce the reader to the educational All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR1 or the Association of Bone and Joint Surgeons1. M. G. McAlinden MPhil, FRCS (Tr & Orth) Department of Trauma and Orthopaedic Surgery, The Ulster Hospital, Dundonald, Belfast, UK P. J. Dougherty MD (&) Department of Orthopaedic Surgery, Detroit Medical Center, 4201 St. Antoine, Suite 4G, Detroit MI 48201, USA e-mail: [email protected]; [email protected]
structure of the United Kingdom, how assessment and feedback are conducted, and just how the European Work Time Directive has influenced orthopaedic surgery education.
Orthopaedic Training: The Foundation Years Medical school is a 5-year program, beginning after secondary (high) school [12]. Graduates obtain a ‘‘Bachelor of Medicine, Bachelor of Surgery’’ which is abbreviated a variety of ways depending on the institution (MB BS, BM BCh, MB BCh, MB BCh BAO, for example). All are equivalent degrees, which allow the graduate to be qualified for further education. After medical school, successful applicants begin the Foundation Years (FY1-2), in which the new physician obtains further education regarding basic patient care skills [6]. These years are similar to an internship in the United States, with broad exposure to different medical areas and medical conditions. During the first 2 years, the trainee is eligible to sit out Part A of the Member Royal College of Surgeons exam.
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Clinical Orthopaedics and Related Research1
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Curriculum — Orthopaedic Education
Orthopaedic education in the United Kingdom is described as Trauma and Orthopaedic (Tr & Orth), recognizing the need to care for patients who have sustained trauma, and the large dependency on the healthcare system to care for patients with fractures [6, 9].
Core Specialty Education The next level of training, called Core Specialty Training (CT1 and CT2), is appointed by competitive interview. Core Specialty Training begins after the Foundation Years, and is considered the initial surgical specialty training. There are run-through programs, in which the candidate progresses directly to the later years of surgical training. Those who are in run-through programs are designated as Specialty Trainees (ST) instead of CT1 and CT2. Specialty Trainees may rotate in no more than two related surgical fields for up to 6 months each. The first year, (CT1 or ST1) focuses on the care of trauma patients, the management of simple fractures, and principals of both internal and external fixation. The second year, CT2/ST2, builds on the previous year, developing more extensive surgical skills for fracture fixation (intrarticular, open, and hip fractures for example), and initial exposure to elective types of procedures. During the second year, the trainee is eligible to sit out Part B of the
123
Member Royal College of Surgeons exam, consisting of a patient-based simulation exam (objective structured clinical exam) [6, 9]. Alternate Pathway If Unsuccessful Core Training At the end of CT2, trainees who have been unsuccessful in passing the Member Royal College of Surgeons exam or who have not gained a National Training Number for ST3-8 training may apply for a further year in Core Training for experience, undertake a Clinical Fellowship (junior posts which do not have official recognition for training), or apply for a Specialty Doctor/Non-Consultant Hospital Doctor post. Specialty Doctor posts are permanent subconsultant career posts. Doctors who have worked in these posts for several years can apply to the General Medical Council for Specialist registration if they have equivalent experience to a Day-1 Consultant, and have passed the Fellow of the Royal College of Surgeons (FRCS) (Tr & Orth) examination. This, however, is a lengthy process and the award is by no means automatic [3]. Higher Surgical Training Appointment to a Higher Surgical Training program (ST3-8) is by
competitive interview. Scotland and England run a competitive single-center multistation interview. Wales and Northern Ireland each run their own multistation interviews. The job specification is centrally determined by the Orthopaedic Specialist Advisory Committee and ratified by Health Education England. In England, the number of posts is set by the Center for Workforce Intelligence, which may not reflect the needs of the specialty [2]. The devolved regions are able to set their own recruitment numbers. In any given year, between 120 and 150 ST3 s will be appointed. There are generally between five and 10 applicants for each post [5–7, 10]. At the end of the intermediate years, considered ST3-6, the trainee gains experience with various subspecialties, such as foot and ankle, hip, knee, shoulder/elbow, and hand. Rotations are structured for 6 months in length, and may be located at other institutions rather than the main teaching hospital [5–7, 10]. After ST6, 2 additional years of training (ST7-8) are conducted to further refine the skills in general orthopaedic surgery and trauma, along with additional clinical training in a specialty area [5–7, 10]. The trainee is now eligible to take the examination to become a FRCS (Tr and Orth). Trainees should have a minimum of 1,800 cases recorded in their logbooks
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(assisted and performed), encompassing the generality of trauma and orthopaedic surgery [5–7, 10] by the end of ST6. They are also expected to perform a specified number of procedures in 12 index operations [5, 7, 10]. Trainees must show evidence of undertaking one audit each year, including two completed audit cycles. They are also expected to present two research presentations at national meetings and publish two peerreviewed publications. Trainees may undertake full-time research during their training, but will only gain 6 months recognition for this, regardless of the time in research. The recognition of time spent in research is conditional on successful completion of a research degree or publication of the results of research [5]. Upon completion of the 6-year Higher Surgical Training program, a trainee applies to the Joint Committee on Surgical Training for a Completion of Training certification. When this is awarded, the trainee is enrolled on the Specialist Register of the General Medical Council as an Orthopaedic Specialist. This entitles the trainee to practice as an Orthopaedic Specialist in any European Union Member State. At this stage, most trainees elect to undertake a further period of Fellowship training in their chosen subspecialty [5, 7].
Assessment and Feedback One of the main goals of the Modernizing Medical Careers program when it was introduced in 2005 was to provide more standardized assessment and feedback for the trainee. In this more formalized structure, residents must collaborate with faculty to develop written educational agreements for each rotation, enter procedures into a national electronic logbook (e-logbook), and have procedure-based assessments, which form the basis of a determining a trainee’s progress. This involves a considerable commitment for trainers and trainees. A trainee who fails to comply may expect an unsatisfactory assessment of a clinical rotation (called attachment). At the beginning of every attachment, there is an agreement between the trainee and the faculty member concerning the scope and content of practice, the types of procedures, and the assessment methods. At the end of an attachment, a final meeting is held to assess outcomes against these objectives. The supervisor completes a Trainee Assessment form detailing the trainee’s competence in a range of areas: Clinical Skills, Knowledge, Postgraduate activities, and Attitudes. Additionally, each rotation should have a minimum of two consultant supervised clinics and three consultant
supervised theater sessions per week. There should be a minimum of 2 hours of formal teaching per week and trainees are expected to attend a minimum of 70% of teaching sessions. Trainees must undertake a minimum of 40 Workplace Based Assessments and one audit per year. Trainees in ST7 or ST8 must complete courses in Leadership and Management and Medical Education [3, 5, 7]. The Royal College of Surgeons of Edinburg developed an e-logbook to document a trainee’s procedure-based assessments. There are now a wide range of procedure-based assessments available on the Intercollegiate Surgical Curriculum Project [5] website, which houses the curriculum for 10 surgical specialties. These assessments evaluate the preoperative, perioperative, and postoperative steps involved in an operation [5, 6, 11]. The Intercollegiate Surgical Curriculum Project records a trainee’s progress in a webbased system. The e-logbook, procedure-based assessments, and learning agreements and assessment documents form the core of a trainee’s training portfolio [5, 6]. The Annual Review of Competence Progression is a yearly assessment that summarizes a trainee’s progress. The program director, other orthopaedic faculty, and a member of the regional postgraduate department conduct the
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assessment and make recommendations concerning future education [6]. This assessment is the main tool used to determine the successful completion of a training period [3, 6, 10]. Upon completion of training, the trainee receives a Certificate of Completion of Training.
Strengths The European Work Time Directive reduced the number of hours graduate medical trainees could work per week, forcing medical schools in the United Kingdom to implement a more efficient and formalized medical education structure. The Modernizing Medical Careers program is an educational reform meant to alleviate the concerns brought upon by the previous system, in which trainees were caught in education rotations for several years, without progression. A more focused orthopaedic medical education will better serve the needs of the trainee, and ultimately, the patients in the United Kingdom. As it is presently constituted, orthopaedic training takes place within a clear framework, defining what is expected of the trainee, trainer, and training program. The trainee portfolio provides clear and detailed evidence of a trainee’s progress against defined standards, and helps to distinguish between successful and failing
123
trainees. The latter can be identified, and targeted training can be instituted. The relationship between trainer and trainee requires a significant investment in time and effort but delivers a clearer understanding of what is needed for training. For a program director, guidelines help confirm that training posts are appropriate for trainees and ensure that provision of training is considered by Medical Management.
Limitations There is no doubt the European Work Time Directive has become a significant obstacle to provision of surgical training, especially in the earlier years of training [1, 8]. To some extent, trainees have compensated for this by attending clinics during their time off. Flouting of the European Work Time Directive has mitigated its effects. There appears to be a growing realization, within the European Union, that the European Work Time Directive needs to be reconsidered. Either special allowances will have to be made for those in Specialty Training, or the training will need to be extended. Medical education is experiential, and gaining enough exposure to patient care is essential to produce safe practicing orthopaedic surgeons. Surgical experience is extremely important, and
enough surgical volume to overcome the learning curve of certain common procedures is essential for every specialty. One survey [1] showed that the case volume had declined to 56% of what had been the previous trainee’s experience. Initial implementation of the Modernizing Medical Careers program was also marred by a poor online application system, in which applicants for training could not successfully apply because of difficulties with the system. Secondly, the number of training slots has been reduced in part because of the more prescribed training requirements, thus creating a mismatch between medical school graduates and the number of training slots available [13]. Prior to the Modernizing Medical Careers program, more autonomy was possible for the trainee to run their own ‘‘list’’ or operating room. Less challenging cases could be performed independently, with indirect supervision of a consultant (faculty or fully trained supervisor). More challenging cases would have been readily available. While having clear guidelines is helpful, setting specified numerical targets in 12 index operations is skewing surgical experience. What started as a competency based training program, allowing each trainee to develop skills at different rates, has now become driven by quantity. Good
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trainees are diverted from gaining a breadth of surgical experience by focusing on ‘‘getting their numbers.’’ In some regions, there may not be enough training opportunities for trainees to gain sufficient experience in index procedures. For example, in Northern Ireland, tendon repairs are generally carried out by a Plastic Surgical service, with an international reputation for tendon repair and rehabilitation. Additionally, Achilles tendon tears are generally treated conservatively by a dedicated team. This is to the advantage of patients, but significantly hinders the ability of a trainee to achieve a target. The target numbers, the number of times a trainee must perform a particular procedure, do not necessarily reflect the complexity of the procedure. For example, the target for carpal tunnel release is 30 [7], while the target for total hip replacement is 40. Does this mean that the former is almost as complex as the latter? A further impediment to a trainee’s surgical experience is the widespread use of the independent sector for provision of elective orthopaedic surgery. In order to meet waiting time targets, the National Health Service transfers patients to the private sector for surgery. These are often more straightforward cases, which would be ideal for training, but are lost to the pool of training.
Conclusion Surgical training in the United Kingdom has undergone considerable changes in the last decade. Orthopaedic surgery has generally been at the vanguard of positive developments and a clear, structured pathway is now available for trainees. It remains to be seen whether changes to training produce a better trainee or merely produce trainees with a more detailed portfolio of documentation. Nevertheless, orthopaedics remains an attractive and competitive career for junior doctors, giving selection panels the opportunity to select motivated individuals with the skill-set to become consultants of the future.
References 1. Bates T, Cecil E, Greene I. The effect of the EWTD on training in general surgery: An analysis of electronic logbook records. Ann R Coll Surg Engl. 2007;89(Suppl): 106–109. 2. Centre for Workforce Intelligence. Medical Specialty Workforce Factsheet. Trauma and Orthopaedic Surgery. Available at: http://www. cfwi.org.uk/publications/trauma-andorthopaedic-surgery-cfwi-medical-factsheet-and-summary-sheet-august-2011. Accessed January 18, 2014. 3. General Medical Council. Available at: http://www.gmc-uk.org/doctors/ statistics.asp. Accessed January 20 2014.
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