Surgical training, supervision, and serviceBMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7185.682 (Published 13 March 1999) Cite this as: BMJ 1999;318:682
Laissez-faire attitudes to surgical training and patient care are unsustainable
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For too long the National Health Service has depended on trainees undertaking a significant proportion of unsupervised elective surgery and an even greater proportion of emergency surgery,1 a fact that was formally recognised in 1990 in the calculation of suitable workload figures for a general surgical team in a district hospital.2 The published evidence to support the extent of trainees‘ involvement in specific areas of surgical service is, however, sparse, although periodically it has caused concern.3 4 In this week's issue Aitken et al provide further evidence that a high proportion of colorectal surgery is still being done by trainees. This practice is unsustainable, and doctors and managers must organise to enable more work to done by consultants.
Aitken et al present an audit of colorectal surgery performed in 1990–4 in three parts of the United Kingdom—comprising about a fifth of the population. This shows that consultants supervised only a fifth of the resections performed by trainees and were present at less than two thirds of the total number of operations (p 5 Supervision was even lower in emergency cases, particularly in the two English regions. The authors infer, probably reasonably, that their experience reflects the generality of practice in the United Kingdom. This must be a matter of considerable concern given that the Scottish mortality study,6 carried out in 1992–3, concluded that it was indefensible for consultants to deputise the management of critically ill patients to juniors when nearly half of the cases of death after large bowel surgery had identifiable deficiencies in management and that consultant surgeons and anaesthetists took part in operations for only slightly more than half of the severely ill patients (graded ASA 4 and 5) or those undergoing a second or third operation.
These findings replicate those repeatedly expressed by the National Confidential Enquiry into Perioperative Deaths (NCEPOD).7 However, all these audits took place during the years before the new Calman training arrangements, when some of the trainees undertaking the emergency care may have been relatively experienced—which is much less the case now.
Considerable concern exists that the shortened training time, combined with the restriction on hours of work, will result in surgical trainees being short of the necessary depth and breadth of experience for independent practice at the end of their defined training period.8 To overcome these deficiencies and concentrate the training into the five clinical years now prescribed, the surgical training committees have put considerable effort into developing structured training schemes.9 The English college has developed a wide range of complementary educational courses, the postgraduate medical deans and regional training committees have organised formal annual assessment machinery, and an “exit” examination has been introduced to test the competence of trainees before certification of the completion of specialist training and entry on to the General Medical Council's specialist register.
All this will require considerable consultant involvement. Crofts estimated that in hospitals with a catchment population of 750 000 to increase the proportion of supervised trainee operating from 30% to 70% would require an extra 270 theatre days at an estimated cost of £1.2m.10 This would present a considerable problem to both managers and consultants, both of whom are under pressure to achieve the workload requirements of trusts as cost effectively as possible.
Clinical governance, however, presents a further challenge. For trusts to ensure quality and defend themselves in the face of complaints or potential litigation, trainees may have to have achieved some form of certification of competence in a procedure before being allowed to undertake it without supervision. The present laissez-faire arrangements for patient care are no longer in harmony with the quality-first agenda being promoted by the government.
The present arrangements are therefore unsustainable and unacceptable, and a radical new approach to training arrangements should be considered. Apart from the major expansion in the number of consultants that has repeatedly been stated as a requirement for successfully implementing the new training arrangements, there is a need for dedicated consultant supervised operating lists and consultant involvement in all emergency work, including out of hours. Constructing work programmes which free the consultant from all other daytime duties for periods of up to a week at a time would allow them to supervise all emergency procedures during the day as recommended by NCEPOD. The question arises about how to involve consultants in out of hours emergency work and training.
The time has probably come to consider payments for consultants directly involved in patient management outside the normal working day. With payment for additional duty hours for juniors and growing familiarity with sessional payments for waiting list initiatives and management responsibilities, the concept of financial reward for extra work done is now accepted by consultants. It would seem reasonable for the most stressful and uninviting element of work to be rewarded. General practitioners have largely achieved this. This would encourage full participation in both patient care and training with benefit to both. It would also allow those consultants who want to opt out of the emergency rota to do so without imposing an unrewarded extra burden on their colleagues. Current negotiations on the consultant contract should consider these suggestions.
Over the past few years waiting lists have been a top management priority. Recently emergencies have assumed importance.11 Now it is essential to give priority to the requirements for training (in particular the relation between training and a high quality service) and to organise so that the service is provided by consultants, trainees are properly supervised, and surgical patients receive the benefit of fully trained expertise in their care at all times.