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Rapid Responses: Rapid Responses published:
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So why not train juniors better?
- Saleem Althaf (8 April 2005)
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Who trains junior surgeons while nurse practitioners are being trained?
- Kristian Sorensen (8 April 2005)
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training
- NJ Sarkies (9 April 2005)
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The professionals are already here.
- Angus JM Watson (10 April 2005)
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Strict governance needed
- Iain Varley (10 April 2005)
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Where are they leading us?
- Visahan Yogendran (10 April 2005)
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New professional roles- fashionable or essential?
- Munier Hossain (11 April 2005)
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Conflicts of Interest?
- G S Bhari (12 April 2005)
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Doctors or Dentists - which model of professional?
- Nigel de kare-silver (13 April 2005)
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Low morale amongst junior doctors
- Douglas J Noble (14 April 2005)
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New professional roles in surgery
- Nick J Taffinder (14 April 2005)
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New professional roles in Gastroenterology
- Peter G Thatcher (15 April 2005)
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New Professional Roles in Surgery: Learning from experience
- Andrew N Kingsnorth (26 April 2005)
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Re: New Professional Roles in Surgery: Learning from experience
- Robert C Pearson (9 July 2005)
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Saleem Althaf, Medical Informatics United Kingdom
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Providing cover for politically inspired window dressing is not edifying. At last count there were in excess of 200 applicants for every surgical SHO post advertised in the BMJ (http://www.bmjcareers.com/juniorcomp/images/table1.jpg). Yet the claim is that "The unavoidable reality is that we do not have enough doctors to sustain traditional working patterns. " The article claims that "Our pilots show that intensive focused training can lead to high degrees of expertise in a relatively short time (one to two years), albeit within clearly defined limits." Why then do most training schemes last so long and hospital posts involve drudgery and administrative work chasing investigations, porters and results? Why do so many budding surgeons turn away from thje speciality because there just does not seem to be room for them anymore? The issue is not a fondness for traditional working patterns, it is the lack of worthwhile training. In the "centres of excellence" where the authors ply their trade junior doctors might be a contented lot but in the rest of the UK the situation is not as rosy. Competing interests: Decided after being told by one "trainer" that the bone he was operating on was the femur (for a #NOF), that surgery was not for me. |
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Kristian Sorensen, Research Fellow Canniesburn Plastic Surgery Unit, Glasgow, UK
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I entirely agree with Salteem Althaf. The problem is not the introduction of nurse practitioners but how the training of junior surgeons will shape up. Who trains the junior surgeons while the nurse practitioners are being educated? In our unit a nurse practitioner has a dedicated small procedures list whilst the second year SHOs aren't even given that opportunity. Morale has already hit rock bottom among junior surgeons because of the proposed changes to the specialist training as well as the introduction of the foundation scheme. If surgical training suffers due to the training of nurse practitioners, I cannot envisage a bright future for UK surgery. Competing interests: None declared |
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NJ Sarkies, Consultant Ophthalmologist Addenbrooke's Hospital
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The authors should not be surprised by the 'high levels of initial anxiety and mistrust that emerged,especially among junior doctors, who felt threatened by changes to traditional working patterns.' Young doctors emerging from five or six years of arduous academic hurdles are unlikely to endorse the idea that their work could readily be performed by allied health practitioners with one year of training. The reality is that the individuals who will be able and willing to take on these new roles may have already experienced several years working in their chosen fields as scrub nurses, or operating department assistants before undertaking training in specific techniques. The question is whether surgeons who are going to perform routine procedures need a long academic training. The medical curriculum in many medical schools is swinging towards communication skills and away from anatomy and other traditional medical disciplines. So the doctors of tomorrow may be less well prepared for the acquisition of surgical crafts. I suspect that in my field of ophthalmology the debate will be outflanked by technical advances in automation and robotics which will obviate the need for human intervention in most surgical operations. Already for example, laser surgery for myopia is already largely planned and executed by machines and cataract surgery may also soon be entirely performed by automated devices. Competing interests: None declared |
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Angus JM Watson, Consultant colorectal surgeon Department of Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL
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Editor- Kneebone and Darzi’s assertion that non-medical practitioners can offer benefits in selected surgical settings should be fully supported (1). The modern colorectal surgical unit could not function without the non-medical professionals who play an integral role in the unit’s activities. Medically-unqualified practitioners in our unit perform unsupervised minor surgery, regularly assist in major surgery, independently perform flexible sigmoidoscopy, run bio-feedback, rectal irrigation and stoma care services, independently see new and return outpatients, organise and staff wound care and pre-assessment clinics. In addition, they are a huge training resource, remain well motivated, do not rotate to another unit after six months and most importantly, they enhance the quality of consultant-led patient care. 1. Kneebone R, Darzi A. New professional roles in surgery. BMJ 2005; 330: 803-4 Competing interests: None declared |
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Iain Varley, SHO Plastic Surgery Northern General Hospital, Herries Road, Sheffield S5 7AU
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In the recent editorial on the role of expanded use of non-medically qualified personnel in surgery, the authors comment on "the extent of hostility", not least from junior trainees(1). They are correct in that there is considerable disquiet amongst us, but do not discuss many of our reasons for concern. As far back as 1997 there was already a paucity of training opportunities for juniors relative to the expectations of trainers(2), and recent political imperatives have pushed more and more surgery out of the training setting into Independent Sector Treatment Centres and similar institutions not accessible to trainees. Also, the structural changes under Modernising Medical Careers and the impact of the European Working Time Directive place further pressure on training(3). In the midst of these changes, the hasty introduction of a training programme for staff which risks reducing the exposure of junior surgeons even more, is unlikely to gain support amongst those of us struggling with the current system. In an era where the concept of core competencies for surgeons is still in its infancy(4), we must concentrate the training where it is needed - in ensuring that junior surgeons gain the abilities and experience they need. The current proposals for the introduction of non-medically qualified practitioners(5) do not control their roles adequately. Without strict governance defining exactly what role within the surgical team they are to have, we risk either prioritising the training of these new personnel over that of the junior surgical staff, or failing to ensure that they are adequately trained in the correct time. Clear regulations on the requirements of training for junior surgeons and such practitioners would go a long way to ensuring the new members become the useful addition to the surgical team that those in favour of such roles aspire to. References: 1)Kneebone R, Darzi A. New professional roles in surgery BMJ 2005;330:803-804 2)Crofts TJ, Griffiths JMT, Sharma S, Wygrala J, Aitken RJ. Surgical training: an objective assessment of recent changes for a single health board. BMJ 1997;314:891 3)Chikwe J, de Souza AC, Pepper JR. No time to train the surgeons. BMJ 2004;328:418-419 4)http://curriculum.jchst.org/syllabus/ 5)http://www.dh.gov.uk/assetRoot/04/10/70/26/04107026.pdf Competing interests: None declared |
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Visahan Yogendran, Registrar Surgery. London
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Dear Author, Any doctor will agree that the hospitals are run by managers who have no clinical experience. They think removing free coffee machines from the operating theatres saves millions to the NHS. I find your suggestion similar. You have not considered any long term implications. As a trainee I would like to bring the following to your attention. 1-In my experience, I have never met a manager to discuss a administration or clinical issue except to discuss the reduction of my salary. They only communicate with you. 2-You will loose the direct contact with the trainee by introuducing more intermediate staff. 3-Your suggestion leads to less pay, less courses will the trainee attend and less good doctors will choose to do surgery. Thank you. Competing interests: None declared |
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Munier Hossain, Staff Grade Ysbyty Gwynedd, LL57 2PW
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Sir, I read with interest the editorial by Kneebone and Darzi 1 on “New professional roles in surgery”. The authors offer a measured tone in a discussion which has recently been the subject of headline news in professional and lay press. Although strong objection has been raised from trainee surgeons 2, the authors seek to establish the case for integrating these roles in “selected settings” and advocate supporting them by ensuring that “they meet the highest surgical standards”. I dispute Kneebone and Darzi that “we do not have enough doctors to sustain traditional working patterns”. The traditional working pattern has been made unsustainable primarily by the European working time legislations and the changing demographics of medical intake. It is also misleading to claim that we do not have enough doctors. The supply of doctors in UK medical market has reached such extreme that 500 applications for a single medical post is common. Perhaps it might be more appropriate to write that not enough medical posts are available. Suitable training and supervision of these practitioners is also contentious. If consultants are already overstretched with their various commitments who are they going to train and supervise – the practitioners or the Specialist Registrars ? Time is limited, so training and supervision of either is going to eat into the others’ share. They write about “direct referral pathways from primary care”. Is this not in contravention to the Royal College of Surgeons of England recommendation? “We do not support (emphasis my own) the direct referral or transfer of patients for surgical therapeutic procedures to non- medically qualified practitioners working on their own”3. Even in a scenario of inadequate number of medical posts there is presently a surplus workforce available within the health service. With some degree of workforce planning this group can easily be utilized to perform surgery. There has recently been an increase of medical posts to accommodate reduction in working hours. A typical district general hospital now has 7-8 middle grade surgeons instead of 5 in the past. The result is that not enough work is available. Whereas the SpRs are allocated regular trauma and elective theatre sessions to maintain their logbook the non-training surgeons are reduced to doing predominantly out- patient clinics with occasional theatre sessions. If this trend continues it is not inconceivable that at some stage in the future the competency of middle grade surgeons to undertake surgery would be called to question. It is astonishing that we seem to be advocating fresh training of additional staff to fill perceived gaps in surgical workforce while allowing well trained staff to loose their skills. I think we have to ask whether this trend is driven by fashion or expediency. And what about the patients, has anyone asked them4? Ref. 1. Kneebone R, Darzi A. New professional roles in Surgery. BMJ, 2005;330: 803-4. 2. McDermott I. Surgeons Vs surgical care practitioners. Hospital Doctor, 28/10/04, 20. 3. RCS England press notice , 24/3/05. Surgical care practitioners. http://rcs.niss.ac.uk/public/pns/DisplayPN.cgi?pn_id=2005_0008 ( accessed 10/4/05). 4. Claire Rayner: Nurses have better things to do than perform surgery. Independent http://comment.independent.co.uk/commentators/story.jsp?story=590418 ( accessed 10/4/05). Competing interests: None declared |
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G S Bhari, SHO-Paediatrics SA61 2JN
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The authors declare they have no conflict of interest. However, they state: "We write from the perspective of a large university teaching hospital in central London, with a track record of pioneering new roles". I assume this is for non-medically qualified individuals. Why have junior doctors not been offered this fast-track 2 year specialization-eg 'Diploma in Herniorrhaphy'? It's pretty obvious where their loyalties lie (they have an unpublished study to back themselves up), but this would bring into question the loyalties of the BMA, publisher of the BMJ, for allowing the authors the use of this platform. Have junior surgical trainees been offered a similar opportunity to give their opinion about how they are about to be short-changed for their choice of career? Competing interests: Of the opinion that Surgeons should have Medical Degrees |
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Nigel de kare-silver, GP PEC Locality Commissioning Lead PEC IT Lead Gladstone Medical Centre, 5 Dollis Hill Lane, London NW2 6JH
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Kneebone and Darzi's(1) composed article just touches on the wider issue of the future of the doctor as a professional within medicine. The ethis of the Modernising Medical Careers Program (2)recognises the impossibility of training a practitioner, within a lifetime, let alone 5 years of undergraduate medical school, to be a holistic physician and surgeon in the sense of the 1950's graduate. This is underpinned by much work in skill mix (3)and clincial care, both nationally and internationally, over the past ten years. It has long been impossible for the nation state to afford to train and provide doctors to undertake all medical work. It is now, with ever growing medical demand and expectations, possibly wrong not to involve the particular skills and talents of individuals to carry out expert narrow field clinical care. Much medical care involves dealing with people with common conditions. Even for specialist doctors within clearly demarcated clinical fields, icons of rational decision makers, with wide scientific knowledge and experienced clinical expertise, care is increasingly protocol led. Rather than continue to train, in the historical model of medical practice, for example, ophthalmologists, over a ten year period, to deliver predominantly care in a few conditions, is it not time to take a very different approach? It is reasonable, perhaps, to train cataract practitioners and glaucoma specialists? We currently attempt to provide a workforce which has a wide range of largely redundant medical knowledge in other areas and yet there is an inevitable shortfall in numbers of trained clinciians to deliver the services demanded. Do these personell indeed have to be medics? Of course not. They could be drawn from the workforce of ophthalmology nurses and optometrists working to strict protocols. They could even be recruited directly from schools onto specialist training programs. This model of delivery could be extended further. Narrow field expert care could be delivered within a variety of surgical specialities. Large sections of orthopaedics, gynaecology and urology are the most obvious with medical specialities such as anaesthetics and pathology close by. Clear recruitment criteria, training programs, and supervision need to be designed around these twenty first century health providers but the ability of the health service to deliver health care to the growing demands of the population will be better met. So what of the doctor. What will the role be for this seemingly lonely figure of the future? The doctor is needed as a senior team leader with the skills and ability to deal with the complex out-of-protocol patient, supervise and train, write disseminate and enforce the protocols used by the rest of the clincal work force teams. Doctors, dentists or delivery of health care within the balance of demands of a 21st century health economy? ref: (1) Kneebone R, and Darzi A.New Professional Roles in Surgery. BMJ 2005;330: 803-804 (2) Foundation Program Committee of the Academy of Medical Royal Colleges (DOH) 2005 Curriculum for the Foundation years in postgraduate educationa nd training. http://www.mmc.nhs.uk/filename.asp?file=curriculum-for-the- foundation-years-in-postgraduate-education-and-training.pdf (3) Orme M, Bloom S and Watkins P. Skill Mix in Clinical Care. Clin Med JRCPL 2001;1:259-260 Competing interests: None declared |
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Douglas J Noble, SHO Surgery Oxford Radcliffe Trust
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Dear Editor Roger Kneebone and Ara Darzi indicate that new professional roles in surgery are a controversial issue and that increasing numbers of medically unqualified practitioners are now being trained in surgery (1). It was interesting to note their opinion, that there is often anxiety and mistrust directed at these professionals, especially amongst junior doctors. As a junior surgical trainee in a large teaching hospital I have worked alongside many of these practitioners. They indeed provide a much needed addition to the workforce and aid combating the problem of fewer doctors to sustain traditional working patterns. It has been my experience that these practitioners are frequently highly skilled and trained. Interestingly, they often have high levels of academic and clinical support within their narrowly defined remits. Could this be at the expense of junior surgical training, especially in the operating theatre and outpatient setting? It is often assumed that junior surgical trainees are inherently competent at the roles of medically unqualified practitioners. I have not found this to be the case. Perhaps the mistrust and anxiety, that Kneebone and Darzi suggest, stems from a sense of inadequacy of current surgical training? This in addition to the restraints placed by the EWTD and the constant state of flux of all training programmes only serves to further exacerbate the low morale of junior doctors. Yours sincerely References 1. Kneebone R and Darzi A: New professional roles in surgery. BMJ Volume 330 9th April 2005 Page 803-804 Competing interests: None declared |
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Nick J Taffinder, Consultant surgeon Ashford, Kent TN24 0LZ
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I enjoyed the paper in the BMJ about new professional roles, but I'm afraid I'm one of those opposed to SCPs There is no doubt that SCPs can do it. The question is whether they should. We have plenty of doctors to do the work, they are called HOs, SHOs, registrars etc. I did a minor op list as a HO, under supervision of the SHO, who in turn did a intermediate ops list (hernias etc) under supervision of the reg, who did major surgery under the supervision of the consultant. Over time skills grew, you gained experience and climbed the ladder. Training SCPs will reduce exposure of trainees to procedures. We trained a nurse endoscopist who had to have 50 flexible sigmoidoscopies signed off, grabbing cases from juniors. Junior doctors need experience even more so now with reduced hours, carving off of cases by Independent Training Centres and shorter training. In addition they already have a high degree of expertise after training for 6+ years (unlike SCPs who have will have 1-2 years of training). I'm not being protective of our traditional pigeonholes - SCPs will never threaten my position. I just don't think it is good for future surgical competence and delivers worse healthcare to the patients. Competing interests: None declared |
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Peter G Thatcher, Locum Consultant Gastroenterologist Worthing and Southlands NHS Trust, BN11 2DH
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I read with interest the editorial on new professional roles in surgery (New Professional Roles, Kneebone & Darzi;BMJ 2005;330:803- 804). It is not only surgical specialities who are exploring new roles. In Gastroenterology, we are training flexible sigmoidoscopists. I am the clinical supervisor for a trainee Non-medical endoscopist (NME) at Worthing Hospital. The trainee was recruited on a national pilot scheme in October 2004, initially funded by the NHS modernisation agency (part of the NHS changing workforce programme). We are one of nine centres involved in this innovative pilot shared with Castle Hill Hospital and Hull University. The 3 year collaboration provides university training to BSc degree level. Our trainee, previously a family planning receptionist, has been in post for approximately 6 months. She has already gained competence in cleaning and disinfecting endoscopes and assists in the endoscopy room. Without doubt, this has made her a valuable member of our team. She is being trained on a colonoscopy simulator and in the past month, has started performing sigmoidoscope withdrawals on patients with direct supervision. Shortly, full procedures will be undertaken with supervision. There are competencies that she has to reach at each stage in her training. These are compliant with JAG training guidelines (Joint Advisory Group on Gastrointestinal endoscopy, Guidelines for the training, appraisal and assessment of trainees in Gastrointestinal Endoscopy and for the assessment of units for registration and re-registration 2004). Like any new role, there are always criticisms and these should be embraced. Do these new roles take away valuable training for doctors? - I don't think so! Should only doctors have a right to perform these procedures? – Definitely not. Nurse endoscopists dispelled these myths a long time ago. Would I be happy to have a flexible sigmoidoscopy by a non- medical endoscopist, trained for three years to BSc degree level in their specialist field? The answer is definitely yes. Will the title “non- medical” remain, I think not! We don’t use terms such as “non-medical ambulance crews or non-medical radiographers”. Such a professional role will command a much more acceptable title for example a flexible sigmoidoscopist or endoscopist. With long waiting lists for procedures, new roles can only benefit the public. In gastroenterology, colorectal cancer screening is the driver for NME role and rightly so. It’s time to applaud and embrace such changes. Competing interests: Married to the educational director of NAASP (National association of assistants in surgical practice) and pilot training a non-medical endoscopist (1 year funding by the NHS modernisation agency). |
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Andrew N Kingsnorth, Consultant surgeon, Honorary Professor of Surgery Derriford Hospital, Plymouth PL6 8DH
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Dear Sir, Unlike Kneebone and Darzi, I write from the perspective of a large District General Hospital with a fledgling medical school. This hospital has successfully pioneered a Hernia Service and treats over 750 abdominal wall hernias annually(1). The Service, now inclusive of all the surgeons within the hospital and supported by a Specialist Nurse Practitioner since 1996, has nurse-led pre- and post-operative clinics, a patient information video and hand-held wireless computers utilising electronic patient records: our results match those of the best international private clinics. As such, we were recruited by the NHS Modernisation Agency's "Action On" General Surgery programme to work on an 18 month Project to develop the role of a Surgical Care Practitioner (SCP) in Groin Hernia Surgery. This role was to complement that of the Nurse Practitioner. The Project involved not only training the SCP in Plymouth but also networking widely with other Units training SCPs in order to exchange ideas and experiences. In brief, our results have been illuminating and unexpected. The individual selected for training was a qualified First Assistant. In tandem with the operative work in Plymouth the trainee SCP undertook the Nation Association of Assistants in Surgical Practice (NAASP) theoretical course which included anatomy, health technology, basic surgical skills, two university-based modules and a practical skills course. The operative experience was supported by the novel development of a severity-scoring system (2) to select "simple" hernias for the SCP trainee on the assumption that a hernia repair would become a "minor" procedure. In addition a competency-based assessment tool was produced for judging competence in the 42 technical steps involved in a groin hernia repair. During the 15 month practical training period the trainee SCP assisted at 150 hernia repairs, performed 60 hernia repairs under direct supervision and subsequently performed 6 hernia repairs under indirect supervision, but only one of these operations was completed without intervention of the consultant trainer. We conclude that training non-medically qualified practitioners to perform hernia surgery is not cost-effective because of the long learning curve. Moreover "simple" groin hernias are not minor procedures. Therefore SCPs are unlikely to contribute significantly to the Hernia Surgery workforce. The results of our Project are likely to be controversial. The prime reason may be that a operative competence can be taught but the ability to carry our that skill requires professional judgement: i.e. the extent to which doctor's work can be delegated is influenced by the type and complexity of the associated decision tasks (3). Five years of training in Medical School equips doctors to make these decisions at a much earlier stage in their postgraduate training. We suggest that our experience could be extrapolated to other areas of "minor" surgery in orthopaedics and coloproctology. A randomised controlled trial of the impact of Nurse Practitioners in General Practice concluded they are used as supplements rather than substitutes and do not reduce the workload of GPs (4). We support the role of non-medically qualified practitioners working as First Assistants where their clinical role is under direct supervision(5). Recent discussions between the Director of Education of the Association of Surgeons of Great and Ireland and the Chairman of NAASP confirmed that SCPs have no wish to operate as independent surgeons (6). Training surgeons of the future is a time- consuming process (7), but should be reserved for those with medical qualifications. Yours sincerely Andrew Kingsnorth References; (1)Kingsnorth AN, Bowley DMG, Porter C. "A prospective study of 1000 hernias: results of the Plymouth Hernia Service". Ann R Coll Surg Engl 2003; 85: 18-22 (2)Kingsnorth AN. "A clinical classification for patients with inguinal hernias". Hernia 2004; 8: 283-4 (3)Cullum N, Spilsburg K, Richardson G. "Nurse Led Care: determining long term effects is harder than measuring short term costs". Br Med J 2005; 330: 682-3 (4)Laurant MGH, Hermens RPMG, Braspenning JCC, Sibbald B, Grol RPTM. "Impact of nurse practitioners on workload of general practitioners: randomised controlled trial". Br Med L 2004; 328: 927-30 (5)Phillips H. "Present problems of service and training". Bulletin Ann R Coll Surg Engl 2005; 87: 81 (6)Lane R. "Message from the President: Surgical Care Practitioners". Association of Surgeons of Great Britain and Ireland Newsletter, Number 9, February 2005. (7)Koperna T. "How long do we need teaching in the operating room? The true costs of achieving surgical routine". Lang Arch Surg 2004; 389: 204- 8 Competing interests: None declared |
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Robert C Pearson, Consultant Surgeon Manchester Royal Infirmary, Oxford Rd, Manchester, M13 9WL
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Professor Kingsnorth raises some interesting issues regarding his experience of working with a trainee Surgical Care Practitioner (SCP) within a hernia service. As a recognised expert in hernia surgery, I am surprised that he would agree to the initial assumption that this was “minor surgery”, a common mistake in others without his experience. My understanding of all ‘Action on’ projects was that units submitted applications to the Modernisation Agency, where a multidisciplinary panel scored and ranked them, before offering support. I was not under the impression that any unit was actively recruited. Professor Kingsnorth is explicit that the person who was recruited was a trainee SCP and thus having to learn basic techniques at the same time as being taught what any experienced SCP would consider to be advanced techniques. The concept of training non medically qualified staff to work independently of the surgical team is not one supported by the National Association of Assistants in Surgical Practice (NAASP). As the draft curriculum for training SCPs has only recently been put out to consultation, there is as yet no formal unified training programme outwith that for Cardiac SCPs. The course which Professor Kingsnorth’s colleague may have attended was possibly one of two being piloted under the auspices of the Modernisation Agency (St Mary’s and Manchester) The conclusion that he draws is thus erroneous. The project in Derriford did not attempt to address whether SCPs could perform hernia surgery, but whether a trainee SCP could learn basic technique and simultaneously apply that to advanced practice. His extrapolation is thus also mistaken; for some years non medically qualified SCPs have been contributing to surgery in a wide variety of fields, contributing to the efficiency of individual units, and reducing the workload of medically qualified surgeons, including performing what is more widely recognised as minor surgery, and the harvest of veins for bypass grafting. The whole purpose of the draft curriculum and the reason behind the formation of NAASP has been to bring together all the strands of previously disparate training paths into one unified approach and a nationally recognised and transferrable qualification. The premature publication of what seems to have been an ill considered project cannot be used to draw inappropriate and ill informed conclusions. Kingsnorth AN, http//bmj.com/cgi/eletters/330/7495/803#104958, 26 Apr 2005 Competing interests: Honorary President, National Association of Assistants in Surgical Practice |
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