BJJ News | I ssue 7 | J une 2015
Orthopod’s view
The ideal orthopaedic training scheme: wishful
J. Palan
thinking or a shifting paradigm raining in surger y has traditionally been regarded as an apprenticeship, with long years and diligent hours spent repeating, honing and refining one’s surgical craft, in order to become a master. Indeed, the old medical axiom “see one, do one, teach one” rang true for many a young surgeon in training until quite recently. However, surgical training has faced a number of challenges in recent years, not least with the introduction of European Wo r k i n g T i m e R e g u l a t i o n ( E W T R ) restrictions on hours worked as well as higher levels of patient expectations in an increasingly litigious society, the publishing of individual surgeons’ outcomes after surgery, changes in working patterns and the loss of the traditional ‘firm’ structure. The end result, without question, is a reduction in the level of clinical skill and operative experience of surgical trainees when compared to their trainers. I commend to the reader the Walter Mercer lecture given by Emeritus Professor David Hamblen at the BOA Annual Congress in 1999.[[1]] Professor Hamblen, using Valentin De Boulogne’s painting, The Four Ages of Man, to eloquently and succinctly depict the four stages in orthopaedic surgical training: the undergraduate medical student; the basic surgical trainee; the specialist registrar and finally, the orthopaedic consultant. Even after 15 years or so, the issues raised in his lecture still hold true and continue to pose significant challenges to orthopaedic training in the UK. In the last few years, there has been a change from time-based training to competency-based training.[[2]] It has also been recognised that the UK system of training remains one of the longest training systems in the world, compared to those in other Western countries such as Australia, Canada and the United States.[[3]] Workbased assessments (WBAs) have been introduced as a mandatory requirement for training, as have the eLogbook for recording operations and the use of the Intercollegiate
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Surgical Curriculum Programme (ISCP). The role of simulation in surgical training has also attracted a great deal of publicity and indeed, has been hailed by some as the panacea for training in surgery.[[4]] As the Immediate Past-President of the British Orthopaedic Trainees Association (BOTA), I have spent a considerable amount of time immersed in different training systems and have seen and thought about how training can best be delivered in such a fluid and ever-changing landscape. I propose a ‘wish list’ of ten guiding principles, as a framework for an ‘ideal’ orthopaedic training system. 1. The EWTR should be applied flexibly to surgical trainees, and the working limit of 48 hours should be increased to 56 or even 60 hours per week. This would enable trainees to gain more clinical experience and also allow rotas to be designed more flexibly, thereby removing full-shift patterns of working and returning to on-call rotas. Unfortunately, despite surgical trainees and the Royal College of Surgeons of England vociferously calling for the EWTR to be relaxed for surgical trainees, such pleas have until now, fallen on deaf ears. 2. Abolish full-shift work systems which have been shown to be detrimental to training and which disrupt the relationship between the trainee and trainer. Instead, encourage firm-based models of surgical teams with ‘ownership’ of junior colleagues, thereby encouraging trainees and consultants to work as a team. 3. Not all consultants should be trainers. Being a trainer is not an entitlement but a privilege. Trainers need to have the support and trust of their department in order to train. This support must take the form of time and specific training clinics and lists where training is given the same priority as service provision. A balance must be struck, however, between making the role of trainer too onerous in terms of regulation and paperwork, and letting anyone become a trainer without first demonstrating the commitment, passion and ability to train. It should also be noted that trainers may have
different but equally appropriate approaches to training. Some trainers may be better suited to having more junior trainees who need a greater level of supervision, while others should have more senior trainees who need less supervision. 4. Training lists for clinics and theatres. Trainers must be supported and relieved of some of their service commitments in order to allow them time to train: this needs to be recognised by the NHS. This means having specific clinics in which time is allotted to allow trainees to discuss cases with their trainers and enable Case-Based Discussions (CBDs) and other WBAs to be undertaken appropriately. Theatre lists which are deemed training lists should have less cases or a specific case-mix, based on the training needs of the trainee. This may mean that operating lists are reduced to provide extra time for training to take place. This will be balanced by the fact that consultants who are not trainers would be providing a more service-orientated role and be able to undertake more operations on their lists instead. Furthermore, time to complete the relevant WBA should be included in job planning for trainers so that they are undertaken in the spirit in which they were designed rather than as a tick-box exercise because of a lack of time or opportunity to complete them properly. 5. The role of simulation remains an important aspect of surgical training but cannot be used as a substitute for real operative experience. Simulation, while valuable as a learning tool, will not replace operative experience. Furthermore, access to simulation facilities is, at present, haphazard, and maintaining such equipment can be expensive. In an ideal world, regular access to cadaveric laboratories, sawbones workshops and arthroscopic simulators would be the norm. In this cash-strapped NHS, such lofty ambitions remain an aspiration rather than a reality. 6. Undertaking the appropriate number of WBAs. In London, trainees are expected to complete a minimum of 80 WBAs in one