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The challenges of training future surgeons in the current NHS

Following the publication of the Government consultation Modernising Medical Careers in 2003, UK postgraduate medical training for doctors has been extensively reformed. These reforms have resulted in a competence-based training system, centred on a structured syllabus that defines the knowledge, professional behaviours, core clinical procedures, and clinical performance required for training.

General surgical training consists of two years of core surgical training followed by six years of higher surgical training. The specialty training is broad, encompassing a number of subspecialties including breast, colorectal, endocrine, upper gastrointestinal, transplant, and trauma surgery. Said training is traditionally delivered on the job in the form of an apprenticeship, and the trainee is required to participate in operative lists, ward rounds, clinics and endoscopy lists; rotating through placements in different subspecialties.

However, the current working climate of the National Health Service (NHS) is posing a number of challenges to delivering surgical training alongside the provision of routine clinical practice. The implementation of the European Working Time Directive to clinical training in 2009 has limited the maximum working week to 48 hours, and this has invariably impacted on the amount of clinical exposure and experience that can be attained by trainees within the remit of predefined specialty training programmes. This is particularly true for surgical training, which requires trainees to become proficient in operative, as well as clinical, management.

The current working climate of the National Health Service (NHS) is posing a number of challenges to delivering surgical training alongside the provision of routine clinical practice.

The pressures currently being faced by the NHS are also affecting the quality of surgical training. The NHS must meet performance targets, including the 62 day treatment target for cancer diagnoses, and the 18 week target non-cancer diagnoses. These targets require maximum efficiency when it comes to planning consultant surgical lists. Therefore, it is becoming increasingly difficult to plan traditional “training lists” with suitable time and cases allocated towards teaching. In addition, a lack of beds for post-operative care due to urgent admissions is increasingly impacting service provision, resulting in cases being delayed or cancelled on an on-going basis. All of these factors are reducing the opportunities for trainees to participate in a list, and are invariably impacting on the acquisition of surgical skills.

Operative training is affected much more over the winter months, when seasonal clinical epidemics such as influenza often result in critical bed pressures, and have led to many NHS trusts having to cancel elective, non-cancer and non-urgent operations over increasing periods for several years. The NHS has tried to mitigate the impact of these conditions on patient care by commissioning the use of clinical facilities in the private sector for elective referrals, in order to be able to meet NHS targets in surgical care. This commissions consultants’ time to deliver clinic appointments and surgical lists in private hospitals. Furthermore, a reduction in surgical training numbers and increasing rota gaps at all levels of postgraduate medical training has generated a skeleton service within many, if not most, NHS trusts. As such, is extremely difficult to free up surgical trainees to attend and participate in these lists.

In the face of these challenges, surgical training programmes are adapting, and both trainees and trainers have developed innovative approaches to support training. The acquisition of core clinical and surgical knowledge is supported by monthly mandatory surgical teaching programmes in all deaneries.

A number of books support the learning of surgical techniques and procedures, as well as applied surgical anatomy and case-based clinical management. Online learning portals are also becoming more popular for this type of learning. Over the last ten years, acquisition of knowledge relevant to both core and higher surgical training syllabi has been supported by an increasing number of surgical distance learning Masters programmes provided by a number of universities, including Oxford, and these have become increasingly popular with trainees.

Operative training is being successfully supported by simulation in a number of different environments. Procedural training is delivered at junior surgical training days to support acquisition of basic surgical techniques relevant to a number of surgical procedures, such as port site insertion and suturing, as well as basic procedures such as drainage of abscesses and hernias, using simulated models of synthetic materials or meat. Table-top laparoscopic simulator kits are becoming available on the market, which allow trainees to become comfortable with working in the laparoscopic environment. Computer-based simulators are increasingly present in hospitals and training centres, which facilitate a stepwise procedural learning of techniques such as gallbladder removal and endoscopy. Procedural training is also provided outside of training programmes through a number of courses. Trainees are expected to pass a number of core courses as part of their training, including Basic Surgical Training and Basic Laparoscopic Skills courses. However, there is also a wide variety of popular courses available for different surgical procedures, which involve simulated models, live patients and cadavers, and are more often than not paid for by the trainees themselves—keen to develop their surgical competence.

Computer-based simulators are increasingly present in hospitals and training centres

In addition to clinical and procedural training, mentoring by seniors and consultants plays an essential role. Mentoring provides pastoral support, career guidance, and often encourages the acquisition of professional behaviours. The Royal Colleges have acknowledged the importance of mentoring and are introducing structured mentoring programmes that can support all trainees in this way.

In conclusion, it is a challenging time for surgical training in the current clinical environment, especially with a health service under increasing pressure. The Royal Colleges have made recommendations for improving training, and a number of reforms are being instigated including run-through training. There is hope that this may allow some flexibility in acquisition of training around service pressures, but this remains to be seen.

Featured image credit: Surgery by Engin Akyurt. CC0 via Pixabay.

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