No time to train the surgeons

Surgical training in the United Kingdom is beset by fundamental problems raising what has been described as “considerable disquiet amongst trainees and trainers.”¹ Basic and higher surgical trainees progress through a system comprehensively reformed five years ago to emphasise structured training, supervision, and regular assessment. So why are senior house officers' skill levels regarded by trainees and trainers as “very shallow”?² Why is there insufficient capacity in the system to train surgeons in the way that their trainers want?³ And why is it that, in a recent poll of consultant surgeons, two thirds would not wish to be operated on by a Calman trained consultant colleague?⁴

In 1993 Sir Kenneth Calman proposed reforms of the registrar grades to bring the United Kingdom into line with a European Union directive on medical training. It was hoped that encouraging structured learning and supervision would compensate for reducing training time. The European Working Time Directive became part of British law in 1998, and it means that soon no doctor may work more than 48 hours a week. The combined impact of these two reforms on surgical training is profound.

Before Calmanisation and the European Working Time Directive a trainee could expect to work over 30 000 hours between becoming a senior house officer and getting a consultant post. The Royal College of Surgeons calculates that this will now fall to 8000 hours.⁵ The chief medical officer proposes reforms that would further reduce this to 6000 hours.⁶ To become a competent surgeon in one fifth of the time once needed either requires genius, intensive practice, or lower standards. We are not geniuses. So has there been an increase in the intensity of teaching to compensate for the fivefold decrease in the length of surgical training?

Well no, not really. The largest ever survey of senior house officers in orthopaedic surgery showed that a third of these trainees were not taught in theatre or clinic.⁷ That many senior house officers arrive at posts halfway through their rotations without any real competence in operative skills as basic as suturing and tying knots is therefore unsurprising. This alone makes it difficult for them to progress to performing operations like appendicectomies, which most current registrars were doing as pre-registration house officers. The fact that house officers compete with registrars for training time makes this transition impossible for some.

Those surgeons who successfully negotiate the bottleneck between basic and higher surgical training posts find that their training needs are often incompatible with a system geared increasingly to provide service. When registrars need more time than consultants to perform procedures³; when consultants' results are audited irrespective of who performed the operation; when trusts' stars and status depend on output and outcome, where is the incentive to train? And where are the resources? One regional survey indicated that, even with trainees performing every operation, the total number of procedures available was a third less than the minimum recommended by their trainers.³ The increase in theatre time required for increased trainee operating in one specialty was estimated at 270 extra theatre days per year, at a cost to the region of £1.3m.³

Reform after reform of the NHS has been driven and informed by factors frequently very far away from the realities of providing surgical patients with continuity of care and of training the next generation of surgeons. Those of us lucky enough to be under way with our training on good teaching rotations can only feel relief that we are not in the cohort coming behind.

We cannot rely on highly able and motivated trainees and trainers to struggle on like this. Surgical training must be recognised as a priority, and it must be resourced with the time and funding, not only for skills courses and wet labs (where surgeons can practise techniques on appropriate models), but also for dedicated training lists and clinics, just as happened for waiting list initiatives.¹,⁵,⁷ Not all consultants should be obliged to train all trainees¹,⁸; those consultants that do choose to undertake the additional responsibility and workload of training should be better supported.¹,³,⁵,⁸ Why should they not also be rewarded? Senior trainees should benefit from a substantial period of supervised independent operating similar to the old senior registrar grade,¹ and assessment needs to be competency based, not dependent on a fixed time period in the grade.⁵,⁸

Most current trainees are supposed to become the new “generalist” surgeons who will carry out common procedures, referring more complex patients on to “specialist” consultant colleagues.⁹ We are left in the worrying situation where 6000 hours of surgical training in its current state may not be enough to produce these new generalists, let alone provide consultants that can go on to become the kind of specialist consultant surgeon that we take for granted today.