Career Focus

Flexible training in cardiothoracic surgery

BMJ 1997; 314 doi: (Published 01 February 1997) Cite this as: BMJ 1997;314:S2-7077
  1. Merrick Anna, specialist registrar
  1. specialist registrar,Department of Cardiothoracic Surgery,St George's Hospital,London, SW17 0RE

    Women are still under represented in the surgical specialties, possibly because the training is not renowned for compatibility with family life. Cardiothoracic surgery's first flexible trainee, Anna Merrick, discusses part time working in an acute specialty

    Flexible training exists in order to allow fewer people to leave medicine and to allow personal fulfilment for those with wider interests and additional commitments. There are inadequate places for all who want to train less than full time. Flexible training is well established in many other specialties.

    I was appointed as a career registrar at St George's Hospital just before Calman training was implemented in the specialty so I am an extra registrar. There have been flexible trainee anaesthetists within the department for some time so the concept of part time working was already accepted; only its application to cardiothoracic surgery was new. Although my role is not yet completely worked out I have found support and understanding from my fellow registrars, who treat me as an equal partner, and other medical staff, though my position is less well understood by nursing staff.

    Cardiac surgery is a specialty renowned for long hours and intensity of workload. Historically it has attracted macho workaholics who apparently needed no sleep and never saw their families. This perception of cardiac surgeons was unintentionally fuelled by the BMJ letter last year signed by all cardiothoracic trainees, stating their desire to work 100 hours a week and requesting to be considered “less equal” than other surgical trainees.(1) It is probably not essential to be a hyperactive person who cannot fit into a nine to five routine in order to be a cardiac surgeon, but these were the characteristics of the pioneers of cardiac surgery. Different specialties attract people of different character so flexible trainees are likely to have the same characteristics: they just have additional commitments for which they must make time.

    Are long hours inevitable?

    The reason for the long hours is that each operation takes four hours and two operations are usually performed each day. This fills an eight hour working day even before any patients operated on the previous day can be reviewed or those to be operated on the following day can be assessed. Outpatients can be accommodated by having a working day set aside for this. Reorganising cardiothoracic surgery to fit into a conventional nine to five day would mean doing only one operation each day or handing over to an additional team. Both options would cost more - we would need more surgeons, junior and senior, who would need more facilities. These facilities would lie dormant for the remaining 16 hours a day and the length of training would increase. Partial shift systems have been advocated as a way of reducing junior doctors' hours but result in loss of continuity of care and require more participants than the number of registrars in most cardiothoracic units.(2)

    Long hours are intrinsic to cardiac surgery and current pressures to reduce hours of work will inevitably lead to some dilution of experience. The six year period of specialist training is already a relatively short time in which to learn the whole of cardiothoracic surgery to a level of proficiency adequate for independent practice. Trainees currently work 100 hours a week not because they want to work such long hours, nor because they have nothing else to do with their time, but because they want to end up as competent surgeons and because the theoretical alternative of having an eight to ten year apprenticeship - that is, being a junior doctor for an extra two to four years - is even less appealing.

    The current organisation of cardiac surgery thus creates a problem for flexible working. The major difficulties are the problem of defining a time limited role in a specialty where acute problems arise 24 hours a day, and the requirement for fixed hours, not simply less hours. These are in addition to the problems of flexible training in any specialty such as continuity of care, the potential to be used only as a “fill in” when a full timer is away and the lack of understanding of the role by other staff.

    Is flexible training flawed?

    Many surgeons believe the concept of flexible training in surgery is flawed because of the perceived lack of continuity of care and inflexibility of hours. They envisage a flexible trainee dashing off in mid operation, Cinderella-like as the clock strikes three, to fetch a child from nursery. Operating lists frequently overrun and the registrar is required as an assistant for most procedures and is not there merely for educational purposes. Emergency procedures usually start in the theatre that finishes its routine list first, and will not just necessarily involve the on call staff. Acute surgical specialties demand ongoing management of patients, not just sessional work as in some other specialties. It would be inappropriate for instance to operate on a patient on Monday and then not have another session until Wednesday.

    Another problem of flexible training in cardiothoracic surgery is working longer hours than you get paid for. For those with children flexible training may not be financially viable. A full timer working 100 hours a week is paid for 72 hours and thus works 28 hours for free. A flexible trainee who works for 70% of the hours of a full time post is paid for 50 hours and so works 20 hours for free. But if the flexible trainees actually have to pay someone else during those 20 hours - for example, £6 per hour childcare - they will actually be paying to go to work. This dilemma must be balanced against gaining the necessary experience to become a competent cardiothoracic surgeon.

    If additional duty hours were paid at 100% for all doctors or basic pay was higher the problem would be solved but limited resources mean someone else would lose out - and doctors are already relatively well paid in comparison with other NHS staff.

    Requirements for success

    To be successful flexible training requires the support of consultants and juniors. Some adjustment to the running of existing sessions may also be required - for instance, the presence of an extra doctor may allow more patients to attend a clinic. The essence of flexible training is compartmentalisation: ringfencing time for work so that time is set aside for other commitments such as looking after a baby. A flexible trainee is extra to the normal complement and therefore has an undefined role. A carefully thought out timetable with specified sessions is required. The timetable needs to coincide with existing protected teaching time (now mandatory for training) and be flexible enough to allow for changes in timing of teaching sessions from week to week. It is important that the timetable is seen to be fair to the other specialist registrars (containing proportionally the same amounts of operating, ward rounds, outpatients, study and so on). In addition, flexible trainees need to be allocated patients for whom they have specific responsibility. This necessitates hand over of patients for the days the flexible trainee is not there. Hand over requires good communication and teamwork and is a familiar task to cardiothoracic surgeons. For instance there is a twice daily hand over of patients on the cardiac intensive care unit between the on call surgeons and anaesthetists and the daytime intensive care team. Flexible training requires additional domestic support to allow for operating lists or clinics which run late. Domestic flexibility is particularly important in the case of higher surgical trainees if an unusual case is scheduled for a time when the flexible trainee is usually off.

    Funding gets easier

    The proposed change in funding of flexible trainees (trusts to pay flexible trainees' additional duty hours instead of deaneries) will supposedly make funding easier to obtain. However under Calman no extra national training numbers will be available for flexible training. Any specialist registrar can elect at any point to train flexibly, subject to having suitably “well founded reasons.” This is logistically easy in specialties in which the trainees now have no service commitment, such as radiology, but it is not clear how this will work in specialties such as cardiothoracic surgery. Cardiothoracic trainees have a large service commitment and replacement of a full timer by a part timer would therefore lead to inadequate surgical cover. It has been suggested that each specialty would have dedicated slots for flexible trainees but this would be unsatisfactory in cardiothoracic surgery because being a small specialty the slots would sometimes be empty and at other times oversubscribed.

    Flexible trainees should not be regarded as being any less committed than full time trainees. Their reason for training flexibly represents an outside interest which potentially increases their worth to the NHS and to patients. Fitting a flexible trainee into a clinical department requires some effort, but the level of organisation and review of current working patterns which results can be of benefit only to the trainers, the other trainees, and the patients. There is a lot of work to be done before flexible training is accepted as an ordinary part of training, especially in a specialty where the trainees provide a significant service commitment. This must be achieved if the haemorrhage from clinical medicine of expensively trained, mainly female, junior doctors is to be stemmed and all doctors allowed to reach their potential both within and outside medicine. I am the first flexible trainee in cardiothoracic surgery - I hope I will not be the last.


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