Clin. Oiolnryngol. 1992, 17, 471-472
EDITORIAL
Training-an opportunity for change Dr Goldstein’s place in medical history is established. By successfully proceeding against the Joint Committee in Higher Medical Training, and by pointing out the apparent inequalities between higher training and European certification, he has given us the opportunity to implement a fundamental revision in training in medicine in the UK. Well, not exactly Dr Goldstein himself, but the European Commission which has instituted Article 169 (infraction) proceedings on the Department of Health. This is an informal advance warning to a member state which the Commission considers to have breached community law. The Department of Health, in conjunction with the G M C and the Royal Colleges, has responded positively saying that training will change without saying precisely how. A commission is being set up to create proposals for the way ahead. Whatever they decide, it is certain that there will be a major change in the old FRCS and accreditation procedures. Where we are at the moment, therefore, is in a vacuum and this is the best opportunity since the inception of the National Health Service to put some sense into training. Firstly, what we cannot d o is to adopt the European Council directive of 16 June 1975 (75/362/EEC) in its entirety. This lays down the minimum period of time required for specialization. Already the figures are being revised by the monospecialist committees but, as they stand, it means that it takes 3 years to train an otolaryngologist from the time of full registration. If this seems inadequate consider that the same directive considers 5 years sufficient for the whole of general surgery. 98% of practice in Europe is private. In otolaryngology, it means that after 3 years somebody is trained to be a specialist in tonsillectomy, minor and intermediate nasal surgery, endoscopy and myringotomy. This is enough for European certification and enough to serve a community in a private practice capacity. While the N H S is in existence, however, this is obviously insufficient for our staffing purposes. The specialist in Taunton or lnverness has to have a greater repertoire than his counterpart in Turin or Innsbruck, even though he might not use much more than that repertoire in his own private practice. Yet we are now going to have to certificate trainees in this country 3 years after graduation which means that their repertoire will be much the same as their European counterparts. They could go off into independent practice and be paid by insurers but the fact remains that the U K market is such that few would earn a living, even in London. The current UK training and certification programme is
illustrated in Figure 1. The situation, if and when the proposed reforms go ahead, may look like Figure 2. N o accreditation or certification will be needed for a consultant post but the sporting fact of our system of advisory appointments committees is that the best person usually wins. Some with only a European certificatc (of whatever nationality) may be appointed to a consultant post but that will be because certified or accredited candidates have given the post the thumbs down. This situation is hardly any different from the 1960s when poorly trained doctors from outside the United Kingdom were often appointed to consultant jobs because there were just no other applicants. The problem with U K training at the moment is that it is too long and various SACS have demanded such broad training in our specialty that most new consultants are too well trained in too broad a field. Complaining that training is too good is a contradiction that requires explanation. If everyone does a bit of everything then several things will eventually happen. (1) People will become occasional patient managers or dabblers. (2) Not getting access to material will result in the loss of expertise and proficiency, even in the well trained surgeon. (3) There will be loss of concentration of clinical material for training. (4) There will be an eventual drop in standards. (5) There will be a loss of any significant number of patients for evaluation as to treatment modalities. Various enlightened departments have recognized this and are subspecializing, but this is by no means universal. There are three reasons for not subspecializing. (1) The knock-on effect on private practice. ( 2 ) The feeling of a new consultant that if he is trained in something, he ought to be able to do it. (3) The loss of the wide variety of practice available in otolaryngology. In Figure 2 the expected new training schedule ends with the acquisition of the Intercollegiate Fellowship. At the stage of European specialist certification, the doctor would not be well enough trained to do an N H S j o b as we now know it. He may, however, be well enough trained to take on a staff grade appointment or he may hold some attraction to managers of trust hospitals who want a limited and defined syllabus of work performed. For the majority, however, extra training would be needed while the N H S is in its present form. Our options, therefore,
47 1
412
_
Editoriul _
_
_~
_
~
1 year
IR/12 months
3 years
Intern
Basic training
ENT registrar
Figure 1. Current U K training and certification programme.
3 years
_ _ _ -
~.
-~
T
T
Pt 1 FRCS
Pt 2 FRCS
ENT HST
_
_
7
_
_
Intercollegiate assessment
_
_
_
~
Certificate of accreditation
Figure 2. Post-reform training and
~~
~
I year
I year
3 years
~~
Intern
Basic training
Specialist training
?MRCS
i
European certificate
Independent practice Stalf grade ? Consultant -
~~
certification.
~
+Higher surgical training Exit FRCS
\
-
~ _ _ _ _
Add on specialty
__
are to go for our present broad based higher surgical training or to limit the training to a subspecialty. The broad based training would leave us with very much the status quo but a high grade subspecialty training would perhaps limit the choice of consultant posts available although as a true subspecialist the career rewards might be greater. There would have to be designated training centres and trainers in the main subspecialties such as rhinology, head and neck surgery, otology, otoneurology, paediatrics and facial plastic surgery. Trainees would probably spend a further 2 years in one of these and then get some form of Collegiate recogni-
?FRCS
tion for this further training, analogous to the certificates of Fellowship offered in the United States. Thanks to D r Goldstein, therefore, training has hit the buffers. Perhaps what we put back on the tracks could be better.
A.G.D.Maran 0lolaryngolog.v Unit, Lauriston Building, The Royal Infirmary, Edinburgh EH3 9 E N , U K
EDITORIAL
Training-an opportunity for change Dr Goldstein’s place in medical history is established. By successfully proceeding against the Joint Committee in Higher Medical Training, and by pointing out the apparent inequalities between higher training and European certification, he has given us the opportunity to implement a fundamental revision in training in medicine in the UK. Well, not exactly Dr Goldstein himself, but the European Commission which has instituted Article 169 (infraction) proceedings on the Department of Health. This is an informal advance warning to a member state which the Commission considers to have breached community law. The Department of Health, in conjunction with the G M C and the Royal Colleges, has responded positively saying that training will change without saying precisely how. A commission is being set up to create proposals for the way ahead. Whatever they decide, it is certain that there will be a major change in the old FRCS and accreditation procedures. Where we are at the moment, therefore, is in a vacuum and this is the best opportunity since the inception of the National Health Service to put some sense into training. Firstly, what we cannot d o is to adopt the European Council directive of 16 June 1975 (75/362/EEC) in its entirety. This lays down the minimum period of time required for specialization. Already the figures are being revised by the monospecialist committees but, as they stand, it means that it takes 3 years to train an otolaryngologist from the time of full registration. If this seems inadequate consider that the same directive considers 5 years sufficient for the whole of general surgery. 98% of practice in Europe is private. In otolaryngology, it means that after 3 years somebody is trained to be a specialist in tonsillectomy, minor and intermediate nasal surgery, endoscopy and myringotomy. This is enough for European certification and enough to serve a community in a private practice capacity. While the N H S is in existence, however, this is obviously insufficient for our staffing purposes. The specialist in Taunton or lnverness has to have a greater repertoire than his counterpart in Turin or Innsbruck, even though he might not use much more than that repertoire in his own private practice. Yet we are now going to have to certificate trainees in this country 3 years after graduation which means that their repertoire will be much the same as their European counterparts. They could go off into independent practice and be paid by insurers but the fact remains that the U K market is such that few would earn a living, even in London. The current UK training and certification programme is
illustrated in Figure 1. The situation, if and when the proposed reforms go ahead, may look like Figure 2. N o accreditation or certification will be needed for a consultant post but the sporting fact of our system of advisory appointments committees is that the best person usually wins. Some with only a European certificatc (of whatever nationality) may be appointed to a consultant post but that will be because certified or accredited candidates have given the post the thumbs down. This situation is hardly any different from the 1960s when poorly trained doctors from outside the United Kingdom were often appointed to consultant jobs because there were just no other applicants. The problem with U K training at the moment is that it is too long and various SACS have demanded such broad training in our specialty that most new consultants are too well trained in too broad a field. Complaining that training is too good is a contradiction that requires explanation. If everyone does a bit of everything then several things will eventually happen. (1) People will become occasional patient managers or dabblers. (2) Not getting access to material will result in the loss of expertise and proficiency, even in the well trained surgeon. (3) There will be loss of concentration of clinical material for training. (4) There will be an eventual drop in standards. (5) There will be a loss of any significant number of patients for evaluation as to treatment modalities. Various enlightened departments have recognized this and are subspecializing, but this is by no means universal. There are three reasons for not subspecializing. (1) The knock-on effect on private practice. ( 2 ) The feeling of a new consultant that if he is trained in something, he ought to be able to do it. (3) The loss of the wide variety of practice available in otolaryngology. In Figure 2 the expected new training schedule ends with the acquisition of the Intercollegiate Fellowship. At the stage of European specialist certification, the doctor would not be well enough trained to do an N H S j o b as we now know it. He may, however, be well enough trained to take on a staff grade appointment or he may hold some attraction to managers of trust hospitals who want a limited and defined syllabus of work performed. For the majority, however, extra training would be needed while the N H S is in its present form. Our options, therefore,
47 1
412
_
Editoriul _
_
_~
_
~
1 year
IR/12 months
3 years
Intern
Basic training
ENT registrar
Figure 1. Current U K training and certification programme.
3 years
_ _ _ -
~.
-~
T
T
Pt 1 FRCS
Pt 2 FRCS
ENT HST
_
_
7
_
_
Intercollegiate assessment
_
_
_
~
Certificate of accreditation
Figure 2. Post-reform training and
~~
~
I year
I year
3 years
~~
Intern
Basic training
Specialist training
?MRCS
i
European certificate
Independent practice Stalf grade ? Consultant -
~~
certification.
~
+Higher surgical training Exit FRCS
\
-
~ _ _ _ _
Add on specialty
__
are to go for our present broad based higher surgical training or to limit the training to a subspecialty. The broad based training would leave us with very much the status quo but a high grade subspecialty training would perhaps limit the choice of consultant posts available although as a true subspecialist the career rewards might be greater. There would have to be designated training centres and trainers in the main subspecialties such as rhinology, head and neck surgery, otology, otoneurology, paediatrics and facial plastic surgery. Trainees would probably spend a further 2 years in one of these and then get some form of Collegiate recogni-
?FRCS
tion for this further training, analogous to the certificates of Fellowship offered in the United States. Thanks to D r Goldstein, therefore, training has hit the buffers. Perhaps what we put back on the tracks could be better.
A.G.D.Maran 0lolaryngolog.v Unit, Lauriston Building, The Royal Infirmary, Edinburgh EH3 9 E N , U K
