Assessment of the modern cardiothoracic surgical team

The concept of the Surgical Team is currently all the rage in the NHS surgical colleges. Health Education England are organising meetings and publishing position papers on how the modern surgical team is essential to provide good quality surgical care to patients.

There have always been surgical teams - when I trained, the surgical team consisted of a consultant, senior registrar, junior registrar, senior house office and junior house officer - all members of the team being doctors.

During the past 20 years, there have been profound changes in the organisation of UK healthcare, in the way doctors are trained as well as a shift in the tasks they perform. A fall in the number of doctors below consultant grade has led to the creation of a myriad of new posts such as advanced nurse practitioners, surgical care practitioners, surgical assistants, physicians associates and others. The specialty of cardiothoracic surgery has been in the vanguard in the development of these posts. In the 1980s and 1990s, newly appointed cardiothoracic surgical consultants helped to create the post of cardiac surgical assistants in their departments after having observed and worked with physicians’ assistants (PAs) during part of their training in the USA.

In the US, the post of PA was originally created in the early 1960s to help attending physicians (Consultants) do their job in smaller non-teaching hospitals where there were no doctors in training. Their training and career path is well defined and is based on the medical model with applicants requiring a University degree. This is followed by a period of higher specialty training at the end of which is a specialty specific national board exam and certification. As in medicine, licensing is devolved to the individual states.

Today in the NHS, cardiothoracic surgical care practitioners are an integral part of the cardiothoracic surgical team.

In the medical profession, all doctors in the UK are registered with the General Medical Council (GMC). The GMC has overarching responsibilities and powers to maintain standards in the training and assessment of both medical students and doctors in training. Completion of training and a successful national summative assessment of knowledge (final exam) are a necessary prerequisite for a doctor/surgeon to be on the GMC’s Specialist register before she/he can apply for a consultant job. The General Medical Council is also planning a National Licensing exam for newly qualified medical graduates from 2018-2019.

Professional Regulation of Physicians Associates is the subject of a private member’s bill that is currently going through parliament. As with the General Medical Council, a function of any new regulator would be the policing of standards of training and assessment.

It is generally accepted that such high standards are required for all members of the surgical team. The Association of Cardiothoracic Surgical Assistants (ACSA), the Society for Cardiothoracic Surgery in GB and Ireland (SCTS) and the Royal College of Surgeons of Edinburgh are all represented on a panel I chair, to design an exam for cardiothoracic surgical care practitioners that meets the very high standards required by professional organisations such as the GMC, in a modern summative assessment of knowledge. The work to develop this exam began in 2014. It is designed to ensure that the exam comprehensively tests the knowledge of cardiac and thoracic surgery that a Cardiothoracic Surgical Care Practitioner is expected to possess in order to do their job effectively and safely. The curriculum of knowledge covers the whole of the surgical journey undertaken by a patient undergoing cardiac or thoracic surgery. The exam will be fair and quality assessed. Unlike in the past where the exam pass mark was set arbitrarily, in this exam, the pass mark will be set by a standard setting process to maintain standards and fairness.

The role of the Royal College of Surgeons of Edinburgh in the development of this exam has been crucial. Royal Colleges of Surgeons (there are 4 in the British Isles) are the institutions that organise exams and award membership and fellowships to surgeons on successful completion of these exams. Possession of these degrees, as evidenced by the postnominals of MRCS and/ or FRCS, indicates that the candidate possesses the requisite knowledge to do the job of a surgeon. In 2016, a Faculty of Perioperative Practice was launched in the Royal College of Surgeons of Edinburgh. One of the broad aims of the faculty is to highlight the fact that the modern Surgical Team does not just consist of doctors. The faculty provides courses for all members of the surgical team and awards membership of the faculty (with accompanying postnominals) when the applicant demonstrates certain competencies. Successful completion of the Cardiothoracic Surgical Care Practitioner Exam will be such a competency.

Simon Stevens, the chief Executive of NHS England recognises the important role that non medical members of healthcare teams contribute to high quality care. The work of this panel, together with the Faculty of Perioperative Practice of the Royal College of Surgeons of Edinburgh, will ensure that Surgical Care Practitioner members of the Cardiothoracic Surgical Team will have the high standards of knowledge required to do their job effectively and safely. This exam is a first in the assessment of non medical members of the surgical team. It is hoped and expected that what is being achieved in the specialty of Cardiothoracic Surgery will serve as a template for all other surgical specialties. n