Analysis: Theatre of the absurd

May 10, 2002

Surgical apprenticeships are disintegrating. So what now, Claire Sanders asks

Keeping human and sheep heads in separate rooms is just one of the many challenges faced by Paul O'Flynn, a lecturer at the Royal College of Surgeons.

Mr O'Flynn is an ear, nose and throat consultant based at London's Royal National Throat Nose and Ear Hospital. But last year he was contracted one day a week to the Raven department of education at the college to help build a core curriculum for higher surgical training in ENT.

"Once I'd signed up I found the college had many other plans in store for me," he said.

As well as the main curriculum, Mr O'Flynn is running one-day core skills courses for students in the first couple of years of their higher surgical training.

"I've got eight students here today," he said. "The students use the latest equipment on animal heads and human heads - which for regulatory reasons have to be kept separate. They also practise on each other. It is crucial for surgeons to know what it is like to be a patient."

Consultants from throughout Britain teach on the course. Duncan Ingrams is one, up from Royal Gwent Hospital in Newport, Wales.

"The equipment here is fantastic," he said. "Back in Wales I might just have one trainee keen to specialise in this area and it is hard to give them the experience and training they need."

Postgraduate medical education is undergoing a sea change and the Raven department, which celebrates its tenth anniversary this year, is developing a series of programmes to respond to these changes.

The college is responsible for supervising the training of surgeons in approved posts and examines trainees to ensure high standards. It is busy responding to the radical agenda for change and expansion, set out in the July 2000 National Health Service Plan. It is also responding to the Bristol inquiry report, welcoming the recommendations on better patient liaison, information systems, consent procedures and communication skills.

The changes are being watched closely by the medical schools, whose students will not only progress through the system but will be taught by many of the consultants struggling to treat patients, carry out research and teach postgraduates.

"We are seeking to professionalise surgical training through from basic to higher training," said Andrea Kelly, deputy head of the department. "Traditionally surgeons learnt through a system of apprenticeship, but that is breaking down and we are seeking to put in place a curriculum that tells young doctors and their consultant trainers what is expected of them."

Courses developed at the college are run in 120 training centres around the country as well as in London. The college is also introducing online courses for trainee surgeons.

The apprenticeship style of learning, where house officers learn on the job and are assessed at the end of a certain period, is under strain. The reduction in the number of hours junior doctors can work as a result of the European Union working time directive has significantly reduced the amount time spent training. As no one wants to increase the training period, young doctors are getting less hands-on experience.

This is crucial for surgeons as much of the work is practical and requires long hours of practice. As the college's annual report says: "Unlike other medical specialties, surgery demands craft-based skills in the operating theatre." Ms Kelly said: "We run a sculpture course here for surgeons working in plastic surgery and facial reconstruction. Much of the work is very artistic."

Students on Mr O'Flynn's course practise bone filing a raw egg. The trick is to file away the shell, leaving the membrane intact. One student has even been able to insert a grommet into the preserved egg membrane. It is the sort of manual dexterity that improves with practice.

The Calman reforms of higher training for specialist registrars, which were widely welcomed as introducing clearer curricula and assessment procedures for postgraduate medicine, when combined with the impact of the working time directive, have meant that doctors are reaching consultant level without sufficient training.

Peter Leopard, chairman of the working party responsible for producing last November's report, The Surgical Workforce in the New NHS , said:

"Consultants are asking for extra training. We are seeking to get clear litigation figures to find out if these younger consultants are making more mistakes as a result of the poorer training."

The report says that in all nine surgical specialities there will be a shortfall of 1,454 surgeons between the consultant numbers required by 2009 and the numbers due to finish training in that year. Government plans to bring in overseas consultants worry the college. "The extra numbers of consultants promised by the government will largely come from overseas. We have serious concerns about quality. In many European countries trainee doctors are not allowed to treat real patients until after they have qualified in their speciality. This could mean that the first patient they treat is a UK one," Mr Leopard said.

The college has long been calling for an increase in the number of training places in hospitals to meet the demand for more doctors.

And there is a great deal of frustration at criticisms levelled at the royal colleges, particularly in the government consultation document on the new Medical Education Standards Board first proposed in the NHS Plan.

Introducing the consultation document, health minister John Hutton was critical of postgraduate medical education. "Until now, the postgraduate medical education system has had little or no input from the NHS or patients. It has grown up piecemeal and does not have a single authoritative body to ensure consistent standards across the UK. Nor have decisions been informed by any quality assurance or accountability framework," he said.

The college, and nearly all other medical bodies, while welcoming a single body, is seriously concerned at the proposal that the new body will report to the secretary of state and not to Parliament.

Sir Peter Morris, the president of the college, said: "If this proposal were to be implemented in full, it would have to be regarded as one of the more sinister plans to issue from the government, with the capacity to do an enormous amount of harm to our postgraduate education and training programmes in surgery, and bring about a further deterioration in the profession's morale."

The college also pointed out in its response: "Had the previous or current government acted on the college's advice regarding the need for an increase in trainees and consultant numbers, and the provision of more facilities in surgery, the current problems in service provision would not have arisen."

There are not enough training places for young doctors coming through the system. "We are carrying out a scoping exercise of training capacity and believe more posts could be created. Consultants are saying to us that they could take more trainees. The problem is that the government is restricting training posts, making it harder for doctors to complete their training at a time when we desperately need to increase numbers," Mr Leopard said.

He pointed out that NHS workforce planners had been restricting training places to encourage doctors into general practice to overcome the chronic shortage there and that there had been fears that there were not enough consultants to teach the new trainees.

For Mr O'Flynn and the ENT trainees, politics are an ever-present fact of life. "But my real interest is to send these surgeons away able to use all the latest equipment," he said. "ENT work is not all about tonsils, it is often about removing cancers and other life-saving operations."


* First: study for five years and pass an initial medical degree and get provisional registration with the General Medical Council

* Second: do pre-registration year as a junior house officer and get full registration with the GMC

* Third: do basic surgical training, with two years as senior house officer, leading to member of the Royal College of Surgeons exam, which qualifies trainees for higher surgical training

* Fourth: to complete higher surgical training spend six years as a specialist training grade registrar. After four years a trainee can enter the intercollegiate examination that leads to the award of the fellow of the Royal College of Surgeons diploma in one of nine specialities. At the end of six years, holders of the FRCS diploma qualify for the award of the Certificate of Completion of Specialist Training

* Finally: CCST leads to entry on to the GMC specialist register and makes the holder eligible for a consultant post.

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