Joint Committee on Higher Surgical Training
(JCHST) Working Party
EUROPEAN WORKING TIME DIRECTIVE
The aim of training is to produce an individual
with knowledge and skills to allow practice within a defined clinical
framework working as a member of a consultant team. This implies
that the individual has reached a stage of competence to feel
comfortable and confident about the duties expected of them.
By August 2004 the limit on hours of work will
be 58 with specific constraints relating to defined periods of
rest. By 2009 the hours will be reduced to 48 per week. In addition
to the influence that these constraints will have on training,
there is evidence of government pressure for the total duration
of training to be reduced to achieve the promised increase in
consultant numbers. There is increasing concern in surgical circles
that training to current high standards cannot be achieved in
the time available without an increase in total training time
and an increase in the number of consultants who are available
to be qualified trainers. It must be emphasised that at the present
time there is no evidence to support the suggestion that consultants
who are appointed today are less competent or are more likely
to face suspension or litigation than their predecessors on old-style
senior registrar training.
The Joint Committee on Higher Surgical Training
are determined to maintain the current high standards and do not
support any concept of a sub-consultant or junior consultant grade.
It is interesting to note that in the USA concerns
are being expressed about reducing training time to 80 hours per
week. In Australia trainees are supposed to work 60 hours per
week but it is clear that such restrictions are not obligatory.
There is some debate about how many countries in Europe are compliant
with the Directive. What is clear is that there are many more
trainees and trainers and therefore the opportunities for training
are enhanced.
The Joint Commttee on Higher Surgical Training
believes that insufficent emphasis is placed on the importance
of training and on the status of the trainer. The Committee believes
that within the surgical specialties there is no place for cross-specialty
cover at SpR level. It is clear that the Directive will have a
major effect in smaller hospitals but even in larger institutions
it would appear that within eight and 12 trainees are required
to produce a Directive compliant rota. This implies that there
will be a requirement for an increased number of consultants to
train such a number in addition to any need for an increase for
the provision of service.
It has been confirmed that it would not be possible
to derogate from the 48 hour aspect of the legislation. It is
also not possible to exclude educational activities from the weekly
hours of work.
RECOMMENDATIONS
1. The importance of training has a very
high priority and trainers must be recognised and funded appropriately,
both as regards time and money. Training and education must be
part of individual job plans and should be included within the
new consultant contract.
2. There is an urgent need for training
lists and clinics.
3. A curriculum based training programme
must be introduced as a matter of urgency. Serious consideration
must be given to the job description of a consultant surgeon in
the future. It is likely that more trainees will become specialists
in the generality of their discipline and a smaller number will
become specialists in more narrow areas of expertise. Only once
this is agreed, can the appropriate curriculum development continue.
4. A curriculum based programme must not
be time orientated but should allow the establishment of training
modules each of which can be assessed when the trainee is believed
to be competent in the specific requirements of that module.
A modular system would also allow training in
the more narrow speciality. This could happen after training in
the generality of the discipline has been achieved or, for a smaller
number, could be specifically tailored to the needs of that narrow
speciality.
Inappropriate tasks should be identified and
excluded from work plans so that the maximum available opportunities
for training are used appropriately. This will involve the use
of nurse practitioners in wider areas than currently exist in,
for example, endoscopy. Such a proposal does have implications
as regards nursing recruitment and great care must be taken to
ensure that any plan does not detract from the available training
for conventional surgical trainees.
5. CEPOD and SASM have recommended that
only life-threatening conditions require surgery during the night
and opportunities for training are therefore limited. Only in
transplant surgery, cardiothoracic, neurosurgery and vascular
surgery is it likely that night-time operating is common. Therefore
in many specialities SpRs may not routinely be expected to be
on-call between midnight and 8.00 am. This implies that emergency
cover during those hours will have to be met by consultants. This
requires a significant increase in consultant numbers to provide
this cover and to allow time off during the day after night-time
on-call.
This system appears to work best when consultants
are on-call for emergency over several days. The optimum period
on-call has not yet been identified but probably should be no
shorter than four days and no longer than seven.
6. There is grave dissatisfaction from trainees
who are forced to work on full shifts. It would help meet training
and service requirements if a full team was available to work
on a shift system. However, this would involve a huge investment
to ensure adequate bed availability, theatre time and support
from all hospital departments throughout the day and night.
7. The concept of training/learning contracts
must be introduced. The possibility of a training tariff should
be pursued specifically allocated to units who are committed to
training and who provide good results from training. It is vitally
important that both trainers and training units are accredited
and revalidated on a regular basis. It must also be recognised
that the time and effort involved in training may mean a reduction
in overall activities and should be taken into account in the
annual appraisal programme.
8. It is clear that if the suggestion in
"managing medical careers" of so-called seamless training
is introduced, the same pressures and difficulties will be encountered
but the solutions being recommended should be as effective for
a continuous surgical training programme as it will be for Higher
Surgical Training. The whole question of the future of surgical
training is the subject of a separate report to JCHST.
9. The current bar following the CEPOD recommendation
on operating during the night must be revisited. Where the procedures
concerned are low risk on patients who are reasonably fit, there
is no reason why trainees working on a shift system should or
actually perform operations. One of the major bars to this is
the availability of anaesthetic services for such activities.
10. The more recent proposals from the combined
working party of the Higher and Basic Surgical Curriculum Groups
are well received. There is currently considerable thought being
given at both College and Speciality Association level as to what
the future of Surgical Training will be. It is hoped that, if
these proposals can be brought together, it will be possible to
concentrate time available for training in a more appropriate
way and may help to meet the training requirements for consultants
of the future within the prescribed hours that are available.
11. Two pieces of information have come
recently from the Royal College of Physicians.
(a)
There is clear evidence that to provide 24-hour a
day 7-day a week cover, requires a minimum of 10 junior doctors.
(b)
The concept of an on-call emergency team for night
cover has now been endorsed by the Academy of Medical Royal Colleges.
This would mean that the need for a surgical SpR to be resident
on-call at night would diminish and, if recommendation five above
is agreed, it would significantly help the overall problem.
11 March 2004
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