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The Surgeon, Journal of the Royal Collegesof Surgeons of Edinburgh and Ireland
www.thesurgeon.net
A survey of UK surgical trainees and trainers; latest reformswell understood but perceived detrimental to surgical training
Sajid Mehmood a,b,*, Saima Anwar c, Jamil Ahmed c, Muhammad Tayyab b, David O’Regan a
a Leeds General Infirmary, The Leeds Teaching Hospitals NHS Trust, Leeds, United KingdombCastle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Hull, East Yorkshire, United KingdomcScarborough General Hospital, Scarborough and NE Yorkshire NHS Trust, Scarborough, United Kingdom
a r t i c l e i n f o
Article history:
Received 28 September 2010
Received in revised form
3 December 2010
Accepted 6 December 2010
Available online 1 February 2011
Keywords:
Surgical training
Reforms
Trainee
Trainer
Modernizing medical careers
* Corresponding author. Academic SurgicalUnited Kingdom. Tel.: þ44 1482622393; fax:
E-mail address: [email protected] (1479-666X/$ e see front matter ª 2010 RoyalSurgeons in Ireland. Published by Elsevier Ldoi:10.1016/j.surge.2010.12.001
a b s t r a c t
Introduction: In the United Kingdom, surgical training reforms as part of modernising
medical careers (MMC) became fully operational in 2007. This study aims to establish the
level of insight and views about MMC based surgical training amongst surgical trainers and
trainees working in the National Health Service.
Methods: An electronic survey consisting of eight questions was disseminated to surgical
trainers and trainees via a web-based link placed on Association of Surgeons in Training
website.
Results: A total of 138 responses were received. Of those, 77% (n ¼ 107) were from trainees.
92% (n ¼ 127) of respondents understood that the purpose of MMC surgical reforms was to
provide structured training. 98% (n ¼ 135) agreed traditional SHO training was poorly
structured. Two-thirds (67%, n ¼ 92) believed that MMC will reduce the total time period to
complete surgical training. 82% (n ¼ 113) recognised work place assessments as an
assessment tool for MMC competencies. 82% (n ¼ 113) were aware that an educational
supervisor is assigned to monitor individual training. 70% (n ¼ 96) understood that training
is a shared responsibility between trainee, educational supervisor and supervising
consultants.
However, 69% (n ¼ 95) of respondents believed the standard of surgical training via MMC
will deteriorate, 18% (n ¼ 25) anticipated no difference, 8% (n ¼ 11) passed no comments
and a mere 5% (n ¼ 7) perceived it as an improvement.
Conclusions: This study confirms a generally good level of insight amongst trainers and
trainees into the aims and structure of MMC based surgical training. However, the majority
believe that ultimately the standard of surgical training is set to fall.
ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and
Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction as an action plan to address serious concerns about the lack of
In the United Kingdom, Modernizing Medical Careers (MMC)
programmewas developed to reform the training of doctors in
Senior House Officer (SHO) grade. These reforms came largely
Unit, Castle Hill Hospiþ44 1482623274.Sajid Mehmood).College of Surgeons of Ed
td. All rights reserved.
structure in traditional SHO training. This cohort of trainees
had poorly planned training with no defined end-point and no
defined educational goals.1,2 MMC system of training devel-
oped a two-year foundation programme, followed by run-
tal, Hull and East Yorkshire NHS Trust, Hull, East Yorkshire,
inburgh (Scottish charity number SC005317) and Royal College of
t h e s u r g e on 1 0 ( 2 0 1 2 ) 9e1 510
through specialty training programme across all specialties.
The principal aim of MMC was to develop a better-structured,
time-capped, and competency-based system for training and
assessment.3
Surgical training reforms as part of MMC became fully
operational in 2007 and share the same fundamental princi-
ples. The MMC based surgical training is developed to be
delivered as per nationally agreed curricula for all surgical
specialties. Record of training assessment and progression is
now officially maintained on intercollegiate surgical curric-
ulum programme (ISCP) website.4 Trainees have assigned
educational supervisors and training is closely monitored at
each level. Formal work-place based assessment tools are at
the heart of structured training and make one of the most
significant differences compared with the old system of
training. A trainee’s progression is assessed by documented
acquisition of competencies through work-place based
assessments throughout the training period and formally
reviewed at annual review of competence progression (ARCP)
meeting, in common with other specilaties.3,4 Current model
Abbreviations: AES – assigned educational superassessments, CBD – case based discussion, CEX directly observed procedural skills, PBA – procedassessment tool, ISCP – Intercollegiate Surgical Cprofessional development
WBA (CBD, DOPS, CEX, PBA, PAT)
AES to monitor individualtraining /
address learning needs
Meetings with AES: Learning agreement and
AES’ report Annual rof compe
progres(ARC
Surgiccurricu
Traincentrtraini
Fig. 1 e Current model of MM
of surgical training incorporating MMC reforms is shown
in Fig. 1.
The implementation of the surgical training reforms was
part of a larger process of implementation of MMC pro-
gramme at national level encompassing the foundation and
specialty training across all specialties. Quite understandably,
such a radical change of reforming the training programmes
and the recruitment system required a robust implementation
strategy by adopting a staged approach. Unfortunately,
implementation of these reforms at national level saw most
unprecedented failure of the central web-based recruitment
system.5 This prompted initiation of an inquiry into the MMC
reforms and their implementation process led by Sir John
Tooke.6 The report of this inquiry, Tooke report, proposed
several recommendations to salvage the MMC programme.7 It
recommended that the structure of postgraduate training,
including the relevant selection and assessment processes,
should provide a broad based platform for subsequent higher
specialist training. The most significant development in
surgical training, as recommended by Tooke report, was un-
visor, WBA – workplace based – clinical evaluation exercise, DOPS – ure based assessment, PAT – peer urriculum Programme, CPD – continuous
eview tence sionP)
Collegeexamination (MRCS)
CPD, teaching, research, audit
Record of operative
experience(ISCP logbook)
allum
eeedng
C based surgical training.
Table 1 e Basic demographic data of respondents, theirhospital base and grade.a
Number of respondents 138
Gender
Male 113 (82)
Female 25 (18)
Age, years, Mean (SD) 35.3 (6.1)
Hospital base
University 76 (55)
DGHb 62 (45)
Grade of respondents
STc: 1e2 or equivalent 13 (9)
t h e s u r g e on 1 0 ( 2 0 1 2 ) 9e1 5 11
coupling of core training from higher surgical training, i.e.
a split in the run-through training. Tooke report promoted
MMC’s key features of providing structure to training in the
form of competency-based assessment, educational supervi-
sion and promoting excellence.7
Surgical training continues to evolve in its structure in the
light of Tooke report in an era of reduced working hours. The
aim of this questionnaire survey was to establish the insight
of surgical trainers and trainees about these surgical training
reforms and to record their views about the resultant quality
of surgical training.
ST: 3e8 or SpRd 87 (63)
SASGe 7 (5)
Consultant 31 (23)
a Data are presented as number (percentage) unless otherwise
indicated.
b District General Hospital.
c Specialty Trainee.
d Specialist Registrar.
e Staff Grade & Associate Specialist.
Methods
A web-based questionnaire survey was undertaken. The
survey questionnaire comprised of 12 questions, four per-
taining to demographic details of the participants and eight
structured questions related to the key features of training
reforms as published on ISCP and MMC websites.3,4 Each
structured question contained four options with one best or
correct response. Participant could only select one response.
There were no open-ended questions.
Surgical trainers and trainees were invited to participate in
the survey via a web-based link placed on the Association of
Surgeons in Training (ASiT) website. All trainers and trainees
from any surgical specialty were eligible to participate.
Consultant surgeons, regardless of whether in clinical super-
visor, educational supervisor or no supervisory role, were
defined as trainers. Doctors working in grades of specialty
training (ST) 1, 2 or equivalent, ST3 to ST8, and specialist
registrar (SpR) were defined as trainees. Doctors in staff grade
and associate specialist (SASG) grade were also eligible to
participate and considered equivalent to trainees in the SpR
tier due to their potential eligibility for certificate of comple-
tion of training (CCT) via article 14 route provision.8
Reminder emails were sent twice to maximise the
response rate. Database was maintained and analysed in
Microsoft Excel. Responses were tabulated and reported as
percentages. Responses from trainees and trainers regarding
their views about standard of MMC based surgical training
were compared using SPSS software (V.17 for Windows; SPSS
Inc, Chicago, IL). Chi-square test was used to compare cate-
gorical variables between the two groups. A p-value of <0.05
was considered statistically significant.
Fig. 2 e Surgical training reforms aim to make training.
Results
A total of 138 responses were received. Of those who respon-
ded, 77% (n ¼ 107) were trainees. Main groups of respondents
included: Specialist registrars/ST3-8 63% (n ¼ 87), consultants
23% (n ¼ 31), ST1-2/SHO 9% (n ¼ 13) and associate specialist/
staff grade 5% (n ¼ 7). Fifty-five per cent of respondents
belonged to university hospitals. Demographic details of the
respondents are given in Table 1. Of those who responded,
there were 113 (82%) males and the mean age was 31 years at
the time of completion of the survey.
Figure 2 shows understanding of the respondents about
the aim of the MMC surgical training reforms. Ninety-two per
cent (n ¼ 127) of respondents understood that the purpose of
MMC based training reforms was to provide structured
training. Fig. 3 pertains to the question asked about the main
finding of English chief medical officer’s report, Unfinished
Business.2 Consistent with his report, a great majority of
respondents (98%, n ¼ 135) agreed traditional SHO training
was poorly structuredwith no limit on time spent in the grade
and thus described as ‘lost tribe’. When asked about their
knowledge of the duration of MMC based surgical training,
some two-thirds of the respondents (67%, n¼ 92) believed that
surgical training reforms under MMC will shorten the total
duration of surgical training compared with old system
(Fig. 4). Nearly half the respondents (46%, n ¼ 64) correctly
recognised that the term specialty registrar (StR), rather than
senior house officer, applies to doctors in initial years of
training in the new nomenclature (Fig. 5).
Next three questions highlight the salient features of
assessment and monitoring in MMC based surgical training
which distinguish it from the traditional training. Eighty-two
per cent (n¼ 113) recognisedwork-place based assessments as
the competency assessment tool in MMC (Fig. 6) and a similar
proportion (82%, n ¼ 113) were aware that an educational
Fig. 5 e Nomenclature of doctors in initial years of training.Fig. 3 e Grade needing reforms, described as ‘lost tribe’.
t h e s u r g e on 1 0 ( 2 0 1 2 ) 9e1 512
supervisor is assigned to monitor individual training at each
level (Fig. 7). Moreover, 70% (n¼ 96) understood that training is
a shared responsibility between trainee, educational super-
visor and supervising consultants (Fig. 8).
When asked for their views about quality of surgical
training as a result of the reforms, interesting results were
received (Fig. 9). Two-third (69%,n¼ 95) of surgical trainees and
trainers believed the standards of surgical training will dete-
riorate, whereas 18% (n ¼ 25) anticipated no difference. Eight
per cent (n¼ 11) passedno commentsabout thequality ofMMC
based surgical training and a mere 5% (n ¼ 7) perceived any
improvement. A comparison of the responses from trainees
and trainers was made and no significant differences in
responses were found (Table 2).
Discussion
The results of this survey indicate the understanding of the
surgical trainees and trainers about training reforms and their
impact on the quality of training. It is evident that surgical
trainees and trainers have good insight into the new changes
brought into the structure, delivery and assessment of
surgical training. Surgeons demonstrated their knowledge
about the problems with previous training system that led up
to the introduction of these reforms. A majority of them are
Fig. 4 e Duration of MMC based surgical training.
aware that training is better-structured, competency-based,
supervised and closely monitored.
However, our survey found that a majority of surgeons
believe the training standards will be compromised following
MMC reforms. There are several possible explanations for this
perception. The core feature of streamlined training in MMC
leads to substantial reduction in the total number of hours
available for training.9 Similar concerns were being echoed
around the time of implementation of these reforms.9,10 The
common denominator remains the inherent feature of
shortened training period.9 However, the Academy of Medi-
cal Royal Colleges dismissed these concerns stressing upon
appropriate utilisation of training time. Colleges promoted the
concept of training delivery in a more focused manner with
explicit use of trainee-trainer contact time.11 Surgeons’ poor
confidence into requesting quality of MMC based training,
reflects the fear that a new systemmay struggle to deliver the
quality of training it promises. Whereas the training delivery
with close traineeetrainer relationship was envisaged to be
an effective training model, it may not be accepted as
a compensatory measure for a shortened training period.
Training opportunities are further hampered, as some degree
of training time is certainly lost to service provision. Other
factors affecting the trainees’ and trainers’ confidence in the
new systemmay include: un-availability of training lists, mal-
distribution of trainees in sub-specialties/hospitals, validity/
Fig. 6 e Competency assessment tool in MMC based
surgical training.
Fig. 9 e Standard of MMC based surgical training.
Fig. 7 e Person assigned to monitor a trainee’s training.
t h e s u r g e on 1 0 ( 2 0 1 2 ) 9e1 5 13
application of in-training assessment and, understanding and
engagement of trainees, trainers, and trusts.12
It must be acknowledged that the MMC programme
brought several positive changes in training delivery and
assessment. The fundamental principles of MMC govern the
provision of structured, curriculum-based, competency-
assessed and well supervised training.3 Arguably, MMC came
as ananswer to concerns surrounding traditional SHO training
with no defined educational goals. MMC redefined the training
structure of the lost tribe of SHOs. Clearly, the foundation of
current day structured surgical training was laid by MMC
reforms. The principles of MMC system still apply and form
the core principles of training delivery and assessment.
The shortened training period in MMC is, in part, linked to
the European working time directive (EWTD) posing a direct
threat to quality of surgical training. In parallel with early days
ofMMC, awealth of evidence accumulated about the impact of
reduced working hours of EWTD on surgical training.13e17 The
resultant reducedexposure to case-load forced some to believe
surgeons at the time of completion of training would not be
ready for a consultant role.13,18 Surgery is a craft speciality in
which training thrives on the amount of operative experience
gained, in its simplicity. Reduced time in training is perceived
to have direct bearing on this experience, clearly detrimental
to acquisition of sound surgical skills and competence to deal
with operative complications. In addition to directly affecting
Fig. 8 e Responsibility of training is shared with.
training time, EWTD further impacts on training as operating
time is lost to service provision.18 The negative impact of
EWTD has been consistently shown to hamper training
opportunities, competence development and trainee satis-
faction across the surgical specialties.13e17 Moreover, it has
been found to adversely affect the continuity of care.15
Surgeons are left with no choice but to keep a realistic
approach. EWTD has become an obligatory regulation since
August 2009. The un-avoidable fact of a shortened training
periodneeds tobeacceptedandappropriately tackled. Surely, it
providesa strong drive to improve theway training is delivered.
Amore recent comprehensive review of EWTD by Professor Sir
John Temple suggested a number of fundamental changes
to deliver effective training within the constraints of redu-
ced training time.19The recommendationsof theTemple report
include: Re-configuration of a consultant delivered service
explicitly supporting training, training delivered in a service
environmentwith appropriate consultant supervision, training
planned and focused for trainee’s needs, maximising every
possible training opportunity, supervised handover practice,
integrated use of technology and simulation, recognising,
developing and rewarding trainers, and recognising educa-
tional governance on every trust board to ensure excellence in
training.19 Indeed, training delivered in such a way will ensure
competency development in a relatively short period.
There is an obvious need for a multifaceted approach to
deliver training in a shortened period. Attitude towards
surgical skills teaching and learning will inevitably change.
Various skills development and assessmentmodels have been
developed. Most of those rely on developing surgical skills in
a non-clinical setting before transferring to the clinical envi-
ronment. An objective surgical training tool, with an ability to
teach generic skills at six progressive levels of competence, is
one of the tested models. In this novel model, surgical skills
exercises with increasing levels of competence, dedicated
trainer-trainee contact, immediate feedback and opportunity
to practise at home ensure rapid acquisition of skills.20 More-
over, encouraging results can be achieved when surgical skills
teaching is contemplated at an early stage in career, possibly at
undergraduate level.21 Surgical simulation has a well defined
role in surgical skills teaching. In addition, training in the
simulated environment does not carry clinical consequen-
ces in case a technical error occurs.22,23 Simulated training
on virtual reality devices has the potential to supplement
Table 2 e Views of trainees and trainers about the standard of MMC based surgical training.a
Standard of MMC basedsurgical training
Trainees þ trainers (n ¼ 138) Trainees (n ¼ 107) Trainers (n ¼ 31) P valueb
Improved 7 (5) 4 (4) 3 (10) 0.18
Worse 95 (69) 75 (70) 20 (65) 0.55
No difference 25 (18) 19 (18) 6 (19) 0.83
No comments 11 (8) 9 (8) 2 (6) 0.72
a Data are presented as number (percentage).
b Chi-square test.
t h e s u r g e on 1 0 ( 2 0 1 2 ) 9e1 514
standard training and can be a useful tool to develop surgical
skills to be applied in real environment.24 Similarly, practising
on animal models in wet lab has been shown to be effective
method of acquiring surgical skills.25
Strategies to maximise operative exposure have been re-
commended. Taking time out of training to gain experience at
overseas centres has been shown to enhance the exposure
and skills substantially, especially in emergency surgery.26 To
substantiate surgical skills in clinical environment, training in
dedicated training theatre lists has been suggested.27 Re-
configuration of services will increasingly allow provision of
such theatre lists. For trainees struggling to demonstrate
competence achievement at the end of training or aspiring to
further their skills in a sub-specialty area of interest, a period
of post-CCT fellowship has been recommended.28
Despite thewidespread concerns surrounding the quality of
MMC based surgical training, these reforms were inevitable
given the problems with traditional training. Traditional
apprenticeship model of surgical training now appears to
be outdated.29 Structured, curriculum-based, competency-
assessed and well supervised training with defined learning
goals at each level of training is the way forward.11,29 Having
already embarked on such a training model, we should now
look to improve the standards, learn from experience and seek
to improve as necessary. It is now time to accept the limita-
tions like EWTD, and implement the strategies to maximise
training.19Goodunderstandingof surgical traineesand trainers
about the new training system means they can be effectively
engaged into implementing all such strategies to promote the
education and training of future surgeons.
Conclusions
This study confirms a generally good level of insight amongst
trainers and trainees into the aims and structure of surgical
MMCtraining.However, themajoritybelieve thatultimately the
standard of surgical training is set to fall in a shortened training
period.We recommend surgeonsmust implement strategies to
maximise skills developmentwithin the constraints of reduced
training times tomaintain thecurrenthigh level ofcompetence.
Disclaimer
Presented to international congress of the Association of
Surgeons of Great Britain & Ireland (ASGBI), Glasgow, May
2009 and published in abstract form in British Journal of
Surgery cited as Br J Surg 2009; 96(S4): 82e180.
Conflict of interest statement
Authors declare no conflict of interest.
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