Recent Advances in Surgery 37 Irving Taylor
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1Surgery in General2

What's New in Surgical Training1 Chapter

Andrew J Robson,
Gareth Griffiths,
Rowan W Parks
 
INTRODUCTION
Many aspects of postgraduate surgical training in the United Kingdom have changed significantly over the past decade. Some of these were precipitated by the Modernising Medical Careers (MMC) initiative, but others have been due to changes in European Working Time Regulations (EWTR) and General Medical Council (GMC) regulatory developments. This chapter will consider the evolution of defined curricula and assessment, development of selection methodology, training within modern working regulations and the applicability of surgical simulation and courses.
 
CURRICULA IN SURGICAL TRAINING
The concept of a curriculum to guide learning arose in Ancient Greece and its modern format was defined in the 20th century.1 Educational theory suggests several aspects to comprise a curriculum:
  • Definition of the required endproduct, planning training to deliver this and testing trainees to ensure the objectives have been met.
  • The process of interaction between trainers and trainees and how knowledge is shared.
  • The detailed list of knowledge and skills required (syllabus).
  • Development of the required set of adjunctive behaviours and values.
  • The testing strategy.
This approach provides a useful framework on which to base the design of a training programme. The most recent version of the UK General Surgery curriculum will be used as an example.
For most of the 500 years of formal surgical training, the “curriculum” essentially equated to the body of surgical knowledge that existed. Individual practitioners taught their own particular skills to their apprentices. Surgery only evolved into the specialties we know today during the 20th century as technological advances allowed more specialised practice to develop. During this time, the “curriculum” came to be described in terms of the contents of standard texts on the specialties.4
The first attempts at creating a curriculum took place around 2001 when a 12-page General Surgery curriculum was published. This briefly described training programmes and discussed the concept of a general surgeon as being one who could manage an emergency take, was capable of independent practice in general surgery, was trained to an advanced level in one or more sub-specialties within general surgery, and would be able to move between sub-specialties as a consultant.
Following a review of postgraduate medical education, MMC was introduced in 2007. One of the provisions was that all postgraduate medical training should be guided by defined curricula. In response, the Royal Colleges of Surgery established the Intercollegiate Surgical Curriculum Project (subsequently renamed the Intercollegiate Surgical Curriculum Programme—ISCP) and introduced formal curricula to meet GMC standards. The 2007 General Surgery curriculum and its later revisions detail the knowledge, clinical and technical skills required to complete training. An updated 2010 version added more detail on adjuvant skills and behaviours (leadership, judgement and professionalism), emphasised progressive skill acquisition and provided improved clarity.
Within the United Kingdom, the GMC is responsible for regulating all medical training and currently recognises 10 surgical specialties (Cardiothoracic Surgery, General Surgery, Neurosurgery, Oral and Maxillofacial Surgery, Otorhinolaryngology, Paediatric Surgery, Plastic and Reconstructive Surgery, Trauma and Orthopaedic Surgery, Urology, Vascular Surgery) and one sub-specialty (Paediatric Cardiac Surgery). Whilst many of the surgical specialities have special interest areas, it should be noted that the GMC have no formal register of these.
The most recent revision of the General Surgery curriculum (2013)2 lists a specified number of special interest areas, but there are many more commonly discussed as having sub-specialty or even specialty status (Table 1.1).
Although it is recognised that the clinical development of these special interest areas has improved patient care and outcomes, the unintended consequence has been a reduced interest in the generality of emergency general surgery care. Trainees and consultants whose special interest lies outside the gastrointestinal tract have felt increasingly unable to provide emergency general surgery care, the great majority of which involves abdominal or gastrointestinal pathology. Some hospitals have attempted to address this by appointing emergency care surgeons, but this model is not universally supported and there are concerns regarding the long-term career development of surgeons in such posts. These challenges are not unique to surgical specialties, and the recent Shape of Training Review led by Professor David Greenaway has recognised this and proposed a further reform of postgraduate education and training with a greater emphasis on training in the general area of broad specialities with the potential to credential in an area of specialisation.35
Table 1.1   General surgery curriculum (2013)
GMC recognised
2013 curriculum recognised “special interest areas”
Other popularly described interest areas**
General surgery
Upper gastrointestinal (GI) surgery
Oesophagogastric
Colorectal surgery
Bariatric
Breast surgery
Benign upper GI
Transplant Surgery
Hepatopancreatobiliary
Endocrine Surgery
Hepatobiliary
Pancreatic
General surgery of childhood*
Pelvic floor surgery
Advanced trauma surgery*
Functional colorectal surgery
Remote and rural surgery*
Emergency surgery
* May only be developed under the 2013 curriculum alongside one of the main special interests. **This list is not exhaustive.
The 2013 General Surgery curriculum is explicit that trainees must develop skills required for independent practice in emergency general surgery. They should also start to develop a special interest (as listed above), but the level of skill required in complex or uncommon procedures has been amended to recognise that it is not possible to train to a level required for independent practice in such conditions within the time allocated whilst also developing adequate emergency general surgery skills. Knowledge and skill levels are now clearly set for each component of general surgery for all trainees regardless of their special interest.
 
ASSESSMENT IN SURGICAL TRAINING
Assessment is integral to a curriculum and is undergoing revision within surgery, partly in response to the changes described above and partly 6because of the development of methodology of assessment systems. In principle, design and content of assessments are dictated by the curriculum and should test abilities appropriately and transparently.
The three main areas requiring assessment are knowledge, clinical skills and technical skills. Knowledge is assessed in Intercollegiate examinations that lead to a Fellowship of one of the Royal Colleges of Surgeons (FRCS). The design and content of the examination are changing to map to the new curriculum with equal emphasis within all sections on emergency general surgery and on the trainee's special interest. The utility, reliability and validity of clinical and oral examinations have been questioned, but it is a widely held view within the surgical community that these formats are important to emulate everyday clinical discussions and to evaluate a trainee's ability to reason and apply sound judgement in decision making. This is what gives the FRCS its high level of face validity. Recognising the need for reliability, structured questions and guidance notes for examiners provide a framework on which to assess each trainee as uniformly as possible and the quality assurance of the whole process is rigorous.
Clinical and technical skills are largely tested in the workplace, although the FRCS examination does also test clinical skills. Workplace-based assessments (WBAs) are divided into case-based discussions (CBDs), clinical encounters (CEXs), direct observation of procedural skills (DOPSs), procedure-based assessments (PBAs) and Multi-Source Feedback (MSF).4 CBDs and CEXs test clinical skills, DOPSs assess simple procedures whilst PBAs test operative technical skills. Trainees are required to undertake a minimum of 40 assessments yearly to demonstrate engagement with training and provide a record of progressive acquisition of skills. Validity of the assessments is enhanced by ensuring each is performed by three or more assessors. The 2013 curriculum requires trainees to build a portfolio of WBAs demonstrating clinical skills in all the components of general surgery (emergency, special interest, and nonspecial interest) and technical skills in emergency surgery and in their special interest.
There is increasing appreciation of the difference between formative assessment (informal, to indicate progress and highlight areas needing development) and summative assessment (formal, to determine achievement as measured against the curriculum). Current WBAs are used interchangeably and there can be confusion as to their true purpose. There is a suggestion, currently being piloted, that WBAs be divided into supervised learning events and assessments of performance. The type of assessment, i.e. CBD or PBA, may not change but the usage and detail of their scoring system would alter to reflect their application in a formative or summative capacity.
The 2013 curriculum is more specific than before in requiring logbook evidence of the breadth of operative experience. Target experience (numbers of cases) has been set at a relatively low level and corresponds to 7the first quartile of a group of recently successful graduates awarded their Certificate of Completion of Training (CCT). The curriculum also requires defined evidence of achievement in research publications and presentations, audit and quality improvement, teaching, management skills, courses and conferences attended. The curriculum details requirements for professional skills, nonoperative technical skills and health promotion—essential adjunctive abilities for safe clinical practice.
Formal recognition of the roles and abilities of trainers has long been a feature of General Practice in the United Kingdom. The GMC is now introducing an analogous accreditation process for hospital practice, which will require recognised trainers to provide evidence that they deliver training to a defined standard.5
Curricula should never reach an endpoint of finalised stability. This would imply stagnation in development of clinical practice. The changes described above represent simply the latest in a continual change process that should reflect both the needs of clinical practice as it develops and the methods of delivering training as they improve. Complex interdependent relationships exist between service provision, curriculum writing, training and assessment methodology. It is clear, however, that collaboration between these components can result in effective improvement, which should contribute to improved patient care.
 
SELECTION INTO SURGICAL SPECIALTIES
Selection into all medical specialties in the United Kingdom underwent significant change with the launch of MMC and an associated computerised recruitment system known as the Medical Training Application Service (MTAS). Prior to this, all selection was carried out at a local or regional level with differing selection parameters and methodology. The traditional 20-minute interview with a panel of several interviewers asking unstructured questions was common. The process was inconsistent, inefficient due to many applicants applying for multiple advertised posts and open to accusations of favouritism and even nepotism.
MMC was revolutionary in its approach. Alongside the introduction of formal curricula for specialty training, a national selection process was initiated and attempts were made to introduce objective criteria into selection methodology. Unfortunately, not only was the selection design too generic and viewed as inappropriate for many specialties, but the computerised 8MTAS system failed to cope with the volume of applications and the whole process collapsed. Nevertheless, many principles of the MMC selection process were valid and have subsequently been modified into a second-generation national selection methodology, which is now used by all surgical specialties in the United Kingdom.
The first task in designing a selection process for specialty training is to clarify the characteristics of the trainees required, who in turn will populate the consultant grade of the future. These characteristics should include a mixture of previous achievements, identifiable abilities and potential for future skill acquisition. With these in mind, a Person Specification is then drawn up listing essential criteria, that all applicants must meet, and desirable criteria, which are used to rank applicants.
The selection process is then designed to test all areas of the Person Specification. First, applicants who fail to meet the essential criteria on the application form are excluded, a process known colloquially as “long listing”. Depending on the capacity of the selection process, it may then be possible to invite all applicants who meet the essential criteria to interview. However, if interview capacity is limited, then “short listing” is required. This uses the application form to examine desirable criteria and scores applicants to create a rank order from which the available interview slots are filled. The risk of short listing is that appointable applicants might be incorrectly excluded.
Given the challenges with short listing, all surgical specialties currently aim to carry out a face-to-face assessment of all applicants. Although this process is generally called the “interview”, it is far removed from a traditional cross table assessment. “Selection Centre” is the proper term for the process, which includes a number of different assessments by different assessors, each testing a different aspect of the Person Specification. Each assessment is scored separately and it is recognised that the greater the number of individual assessments there are, the greater the reliability of the process. Each specialty has designed a slightly different process, but all aim to assess the breadth of the Person Specification.
A number of issues arise in the design of Selection Centres. A balance should be struck between assessing potential versus prior achievements. As selection processes do not have an upper limit of experience as an essential criterion (which would contravene the protected characteristic of age under equality legislation), trainees emerging from Core Surgical training are competing with others who have worked in the speciality for significantly longer. To adjust for this, a number of specialties include an upper limit of experience as a desirable criterion in their Person Specifications and then weight the scoring of previous achievements. These require more achievements from those who have been qualified longer.9
All specialties currently include an assessment of technical skills. This increases the face validity of the process and has support from lay members. It is, however, the most difficult component to standardise and score reliably. A number of specialties include a communication element, using role-play with either an actor or assessor. This is often designed to place the applicant under a degree of stress to assess their ability to work under pressure (an essential criterion).
Some specialties use an applicant self-assessment system for scoring portfolios. This informs the assessment of experience, and the self-awarded scores are validated by the assessors. This has the advantage of transparency and to date has remained a useful tool despite the risk that trainees will, in time, work to meet all the top scoring criteria, so making this aspect of the assessment less useful. The issue of whether to publish the scoring criteria has been widely discussed. Some specialties publish full details, particularly of their methods of scoring portfolios of achievement. Others publish the domains, which are assessed in each component but not the descriptors for each score. It is difficult, however, to keep these descriptors privileged.
The question of assessor consistency, both for individual assessors (appropriately scoring applicants of differing abilities) and between assessors (assessing the same performance by an individual applicant) has been addressed in a number of ways. Assessment scenarios used are structured to provide material which can test differing levels of ability with each scenario accompanied by guidance notes for the assessors on how to conduct the conversation. The score sheets include different domains (mapped to the Person Specification) for every scenario with score descriptors for the type of performance expected for each score within the domains. This standardisation is further enhanced by assessor training, which in General Surgery, is carried out using an online training package.
The next stage of the development of national selection may be to examine the differences in the Person Specifications to identify whether it might be possible to align them more closely. In parallel to this, it may be possible to explore dividing selection into separate generic and specialty-specific components. This would have the theoretical advantage of further improving reliability of the process by increasing numbers and sharing ideas for the generic components whilst retaining individual specialty ownership through the specialty-specific sections. It may also be more cost-effective as the generic component could exclude the least competitive applicants who would then not be accommodated in the specialty-specific section.
What is clear from experience over the last seven years is that progress and improvements have been and are still being made by close involvement of enthusiastic trainers within each specialty. It is essential that future developments continue to have broad support and are not imposed.10
 
SURGICAL TRAINING WITHIN MODERN WORKING REGULATIONS
In response to long working hours experienced by junior doctors in the United Kingdom in the 1980s, a “New Deal” was agreed between the British Medical Association and the Department of Health in 1991. This represented a contractual agreement for a 56-hour working week with a minimum of eight hours rest per day and a 30-minute break every four hours whilst at work. Punitive pay banding supplements were introduced in 2000 that incentivised National Health Service employers to bring working conditions into line with the New Deal, with full compliance required by August 2003.
The European Working Time Directive, adopted by the EU Council of Ministers in 19936 was intended to ensure safe working hours for individuals. It was introduced in the United Kingdom in 1998 and by August 2011, junior doctors were required to adhere to working 48 hours per week averaged over a six-month period. In addition, there was a requirement for one day of rest per week (or two per fortnight) and each working day had to include 11 hours of rest with a 20-minute break every six hours whilst at work. The SiMAP (Spain, 2000) and Jaeger (Germany, 2003) rulings from the European Court of Justice further defined that all time spent on site by an individual must be included for work and rest calculations, and secondly that this applied even if the individual was sleeping.
Today, consultants are subject to the ETWR but not the junior doctors’ New Deal. Both the EWTR and New Deal must be adhered to by trainees in the United Kingdom, but they receive protection under whichever arrangements are more beneficial to them. As working hours are shorter under EWTR but rest breaks are more frequent under the New Deal, this results in a hybrid of the requirements to meet both regulations.
The Temple Report (2010) concluded that high-quality training can be delivered in 48 hours per week, but not where trainees have a major role in out-of-hours services, are poorly supervised and access to learning opportunities are limited.7 The EWTRs have had a variable impact on doctors with an apparent disproportionate effect on surgical specialties. There is also continued debate as to whether patient safety has been improved as a result of full-shift EWTR compliant rotas, whether junior doctors’ health and 11well-being has been affected and whether training has suffered. Some argue that problems exist because EWTR has not been implemented correctly, whereas others maintain that the system is so inflexible as to be incompatible with excellence and training.8
In April 2014, an independent working group, tasked by the Secretary of State for Health to assess the impact of the EWTR on patient safety and training, reported that EWTR had caused greater problems for certain specialties (surgery in particular) and that training in some acute specialties has been very difficult to deliver. Furthermore, local trusts have had mixed success in managing rotas to mitigate the effects of EWTR. Initial broad recommendations from the working group included reviewing best practice in training and sharing successful strategies between trusts, tackling the specific challenges faced by specialties most affected, addressing the lack of flexibility of EWTR, investigating the utility of individual opt-outs and assessing the feasibility of formally separating training and service provision by junior doctors.9
To mitigate against any potential deleterious effects of EWTR on training and continuity of patient care, and to respond to changing patient and disease demographics, it is now necessary to creatively tailor training and service commitments to ensure that trainees acquire appropriate skills and competencies to practice within a realistic professional framework at the point of substantive appointment.
 
THE APPLICABILITY OF SURGICAL SIMULATION AND COURSES
Surgical simulation is both a valuable tool for safe acquisition of procedural skills in a nonclinical environment and also a potential strategy to mitigate the effects of the EWTR. Simulation is increasingly used in the selection of candidates into training programmes, as a component of their subsequent training, and also in assessment of progress. The ISCP General Surgery syllabus now includes simulation within PBAs and other specialties are now adopting a similar approach. As part of its 2013–2018 strategic aims, the Joint Committee on Surgical Training specifically aims to maximise the use of simulation techniques in surgical training and ensure that a robust system is in place for its quality assurance, justifying this as an essential step 12in improving patient safety.10 Non-technical assessments within simulated clinical scenarios already form a key component of Intercollegiate examinations leading to Membership or Fellowship of one of the Royal Colleges of Surgeons (MRCS or FRCS respectively). There is a growing appetite for in-training assessment of competency as part of the Annual Review of Competence Progression (ARCP) process, but this has yet to be formalised due, in part, to the current heterogeneous provision of simulation facilities across the United Kingdom.
Simulation tools may be tailored to focus on operative or non-technical aspects of surgical practice. The clinical utility of simulation is well established. Multiple studies, meta-analyses and a recent Cochrane Review11 of operative simulation studies have shown that simulation-based training (laparoscopic, endoscopic, and open surgery), as part of a structured programme and incorporating predetermined proficiency levels, results in skills transfer to the operative setting.12
In developing a surgical simulation curriculum, the validity of the simulator process should be known and the fidelity of simulators should be tailored to the desired educational outcomes. Commercially available products typically provide high-fidelity simulation but are expensive, and this inevitably impacts on accessibility. In essence, at an introductory level, where the primary goals focus on generic manual skills, fidelity appears less important. An example of this is low-resolution ureteroscopic simulator tools, which produce equivalent outcomes but are 185-times less expensive than high-fidelity commercial simulators.13 Conversely, when practising specific operative procedures (such as laparoscopic colorectal surgery14 and endovascular aneurysm repair15), high-fidelity tools are required. The most sophisticated simulator tools are able to replicate the exact anatomy of specific patients. Examples include endovascular aneurysm repair (EVAR) procedures or complex computer-assisted orthopaedic surgery using software that renders the computed tomography/magnetic resonance imaging into a simulator programme.
Within the United Kingdom, surgical simulation is currently predominantly delivered within the framework of dedicated training courses. These courses utilise procedural and nonoperative simulation tools to a variable extent. Many of the most successful simulation-based programmes aim to improve outcomes in nontechnical aspects of surgical practice. At one end of the spectrum lie programmes such as the Nontechnical Skills for Surgeons (NOTSS) and Care of the Critically Ill Surgical Patient (CCrISP) courses that focus on situational awareness, decision making and communication. Courses such as the Advanced Trauma Life Support (ATLS) course combine training and assessment of both nonprocedural and practical skills such as patient resuscitation and intravenous and airway access. Others make use of a graduated approach to realism—the basic upper 13gastrointestinal and basic colonoscopy courses, delivered by the Joint Advisory Group on Gastrointestinal Endoscopy provide lectures followed by low fidelity, then high fidelity simulators and culminating in supervised endoscopy on patients. A minority of courses have been identified as prerequisites for certification in specific procedures (e.g. accreditation to undertake independent endoscopy), and this is likely to increase as simulation becomes more widely available.
A radical approach to surgical training makes use of “boot camps” where trainees receive intensive simulation-based training prior to embarking upon clinical practice. This is most sophisticated in orthopaedic surgery, where early acquisition of technical skills is quicker in “boot camp” trainees compared to traditionally trained residents.16 Furthermore, a modular competency-based curriculum (with frequent evaluations) in orthopaedic surgery appears to drive accelerated surgical competency, knowledge acquisition and professional skills.17 These types of programmes are most definitely in the minority in surgical training across the world but appear promising (albeit expensive) avenues for accelerated training. Examples of adoption of “boot camp” type training courses in the United Kingdom include Cardiac Surgery programmes,18 a Vascular Surgery boot camp for new appointees and the Highland General Surgical Boot Camp in Inverness, Scotland.19
Surgical simulation, within short courses, longer boot camps or as part of a modular and regularly assessed curriculum, should be encouraged to provide safe operative and nontechnical skills acquisition for surgical trainees. For surgical simulation to become widely available in both formative and summative assessment formats, a co-ordinated national scheme is likely to be required to ensure equity of access, consistency of quality, validity of methodology and also value for money.
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