The Shape of Surgical Training: a Personal Perspective by Ian Eardley
created 01 December 2016
It is fair to say that most patients would wish to have a specialist undertaking their operation. I know that I would.
The launch of the Shape of Training Report in October 2013 was heralded as an opportunity fundamentally to restructure medical and surgical training in the UK. The response to the report within surgery has been mixed, with many feeling that it is directed primarily at medicine and general practice, with little that is relevant to the craft specialties in general and surgery in particular.
On one level it is difficult to argue with some of the underlying themes of the report - notably the need to adjust training to deal with changing population needs, the need for greater flexibility, the value of longer placements and the potential for a more personalised approach to progression. Indeed, there are some aspects of the report that surgery is wholeheartedly behind, including the need for an apprenticeship- based training relationship and the introduction of approved, regulated and quality assured credentialing.
At its heart, however, the report calls for shortened training to the level of CST (Certificate of Specialty Training), with the production of “generalists”. This has been perhaps the most contentious aspect, at least within surgery, with the perception that generalists will have a broader remit but less experience when they are certified. The report argues that this is what the service actually needs, rather than the production of ever-greater numbers of super-specialised doctors whose general skills are progressively lost as they become super-specialists. While it is difficult to argue with this premise from the tax-payer’s or the government’s perspective, from the patient’s perspective there remains a need to deliver the same standard of surgical outcomes, however the training is organised.
Trainee organisations have also opposed “Shape”, perceiving within it a desire to create a sub-consultant grade in all but name, and many surgeons that I know have been slightly affronted by its assumptions. After all, the surgical ego has always appeared to drive the specialist agenda, such that surgeons are seen as experts both by themselves and by the patients.
My own view is that there is enough within “Shape” to encourage surgery to engage constructively. Firstly and most obviously there are the aforementioned issues of apprenticeship, credentialing and flexibility. Also, we would be crazy to say that the current format of surgical training is ideal: the early years are not as good as we would wish them to be, and a greater focus on training, rather than staffing the rotas, would enhance those early years considerably and would enable some of the broadening that is proposed in the report. For instance, we would be able to ensure that our trainees had some exposure to A&E, and we might even be able to ensure that those with a surgical interest were able to develop some of the relevant skills in the second year of Foundation. Finally, they might also be able to develop some of those radiological and critical care skills that are so useful within surgery.
So there are things that might persuade us to re-write the surgical curricula. We would need a number of reassurances, however, before we commit to such a significant undertaking:
- First and foremost must be an enhanced commitment to training, especially in the early years, with a reduced service commitment, greater exposure to surgical practice and more practical “hands on” training.
- Secondly, there must be a commitment from the service actually to advertise “generalist” posts. My own specialty of Urology went down this road several years ago in an experiment that was essentially scuppered by the failure to advertise any “generalist” consultant posts.
- Thirdly, the generalist posts need to be re-named (whoever would wish to be known as a generalist?) and, most importantly, their status needs to be enhanced, if necessary by financial remuneration. One has only to look to North America, where academic surgery often struggles to recruit because of the financial attractions of “office” practice.
- Fourthly, a credentialed post- CST system needs to be properly funded as well as quality assured and regulated.
- Finally, such changes cannot take place in a vacuum. There will be an inevitable requirement for greater service re-configuration, given that we cannot staff every hospital to cover each and every surgical special interest area.
Perhaps these requirements are unattainable. But, if they could be delivered, the potential benefits for our future trainees would be considerable. The process is only just beginning and JCST will be at the heart of the discussions within surgery. I’ve outlined my own views, and I’d welcome yours!
Lewis Ashman
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