The Surgical Training Process
National Selection to ST3: BOA Position
Our Training & Education Strategy
As in all professions, surgical training and education does not end after exams have been passed and certificates issued: once embarked on a career in medicine every surgeon (trainee, SAS grade or Consultant) is on a pathway of continuous personal development and reflection. This is important to sustain the confidence of patients and surgeons alike, and the impending introduction of medical revalidation will lend further substance to the process.
All medical training, including that for surgery, has to have the regulatory approval of the GMC. Because of the skills required in surgery, training must be both knowledge and competency based. Trainee surgeons are therefore required to pass inter alia the intercollegiate FRCS Orth exam and to gain a Certificate of Completion of Training (CCT) confirming that they have achieved all the relevant competences set out in the training curriculum. The CCT is the culmination of a seven year national training programme.
Once awarded the CCT, a surgeon is eligible to be entered onto the GMC Specialist Register and to apply for NHS Consultant posts. Post CCT surgical skills training and education is catered for by revalidation (the details of which are currently being co-ordinated by the Academy of Medical Royal Colleges), which will be regulated by the GMC - http://www.gmc-uk.org/doctors/revalidation.asp.
Some NHS T&O practitioners are qualified to perform surgery, but have been unable to complete the national training programme. Known as Staff and Associate Specialist Grade (or SAS) Doctors, their training and education needs are also covered by the revalidation process. In addition, providing they pass the FRCS exam and meet specific criteria, it is possible for these surgeons to apply to the GMC for a Certificate of Eligibility for Specialist Registration.
The surgical training process
Once a student graduates from medical school, he or she embarks on a further two year period of foundation training to acquire the general skills and competencies needed in a junior hospital doctor. This will involve working with nurses and other allied health professionals in A&E and on hospital wards, delivering the day to day medical service to in and out patients.
Foundation Year doctors will be assigned (by the relevant regional post graduate training Dean) an accredited training supervisor who will assess their performance against a common curriculum (approved by the GMC as the regulator) and education syllabus.
Having acquired the necessary foundation in the practice of hospital medicine, the next stage involves two years of core training. At this juncture the postgraduate doctor in training will have established a clear future medical career preference based on the experience of undergraduate training, aided further by the foundation time. For example, some will opt for general practice, some to be physicians, anaesthetists or radiologists, and some for surgery: their common training curriculum and educational syllabus will be tailored accordingly.
Those contemplating surgery will also have a clear idea of their potential specialty preference, although this is no guarantee: the ratio of core trainee T&O applicants to available places in the next stage of training is currently 7:1. Core Trainees are invited to apply, and are interviewed for posts in the next stage of specialty training.
If they are successful they are allocated a national training programme number and join a regional training ‘rotation’ as Specialty Trainee 3 (ST3 – designating the fact that they are in the third of a seven year formative training programme – which they finish as ST7s). STs are often called Registrars to indicate that they are formally registered in surgical specialty training. At this juncture, the content of the STs’ training curriculum is:
- Endorsed by the Intercollegiate Joint Committee for Surgical Training (JCST - http://www.jchst.org/).
- Approved by the GMC, having been constructed and developed as a collaboration between the relevant JCST Specialty Advisory Committee (SAC) and surgical specialty association.
- For orthopaedic STs, the SAC for T&O and the BOA jointly create and develop the surgical training curriculum.
- Each rotation has a designated Training Programme Director, and each ST is assigned an accredited trainer who must be a Consultant.
- The T&O curriculum is available on line via the Intercollegiate Surgical Curriculum Programme (ISCP - https://www.iscp.ac.uk/ ).
- STs record keep comprehensive records of their training progress and assessments in a electronic log book - http://www.elogbook.org/ .
- The FRCS is taken during years 5 or 6 of the programme.
- During years 6 and 7 of the programme the ST may wish to develop a particular sub-specialty field of expertise beyond the generality of trauma and orthopaedics.
- CCT is awarded in year 7 - http://www.gmc-uk.org/doctors/aboutcct.asp.
- A this juncture the CCT holder is eligible to apply for the GMC’s specialist register and for NHS Consultant posts.
National Selection to ST3: BOA Position
The issue of National selection to ST3 posts was raised at the BOA AGM in Manchester on 13th September.
At a recent SAC meeting it had been decided that the SAC recommend National selection. There was concern expressed by Paul Manning (TPD Forum Chair) regarding consultation and buy in from the TPDs. It was also stated that the issue of national selection had not been on the SAC agenda.
The BOA President undertook a series of comprehensive telephone consultations over the following weekend from a variety of surgeons involved in 
training. This included Mark Goodwin (SAC Chair), Paul Manning (TPD Forum Chair), David Machin (BOTA President) Ian Eardley (JCST Chair), Phil Turner (Head of Schools), and Mike Reed (TPD).
On Monday 22nd September this was discussed further at the BOA Executive and a conference meeting/call was conducted prior to BOA Council the following day.
Present at this meeting was Martyn Porter, Tim Briggs (BOA Vice-President), Colin Howie (Vice-President elect), Joe Dias (Immediate Past President), David Stanley (Hon Sec) and Mike Kimmons (BOA CEO). Ian Eardley joined part way through. Paul Manning, Mark Goodwin and the David Machin were on the phone.
This was further discussed at BOA Council in the afternoon.
The discussions were wide ranging.
Arguments in favour of National selection were:
- Trauma and Orthopaedics was the only specialty not to have moved to national selection.
- National selection was preferred by BOTA.
- Possibly reduced manpower and costs.
- Potentially more transparent.
Arguments against National selection were:
Lack of clarity regarding points awarded to national ranking: it appeared that there was considerable variation of the mean local scores and it was uncertain whether the score was a reflection of the candidate or the marking of the deanery. Colin Howie pointed out the variation of the mean score and SD of the centre was greater than the threshold of the candidate to be appointed to the post. He also pointed out on the frequency distribution that 8 marks could have a substantial effect on the ranking and yet this variation could be seen between regions.
That the decision in 2012 to move to one interview may have resulted in a lack of fairness.
That the TPDs were not in favour of national selection and that the SAC consultation of TPDs had not been adequate.
Council were concerned about moving to National Selection without a clear understanding of the metrics used in the assessment and without clarity regarding TPD and BOA membership buy in.
Council considered four options:
- National Selection
- 2012 (single interview)
- 2011 (two interviews)
- Local interviews (two interviews) but review of national rank before offer (Core model)
All but one voted for Option 4 and one for Option 3. There were no votes for Option 1- National Selection.
The view of BOA Council and the membership is that they consider it reasonable and sensible given the uncertainty to go back to a system that had been seen to work well before changing to a single interview system. There is little evidence for moving to a national selection process that has no buy-in from TPDs and consultants who have been involved in the interview process over the last two years. This will also provide all parties with the opportunity to explore metrics and canvas opinion over the following twelve months to ensure a comprehensive consultation has been carried out before such major decisions are made.
Our Training and Education Strategy
Given the complexity of pre CCT surgical training and education, and the BOA’s close involvement in ensuring excellence in both, our strategy focuses on three principal areas:
- Training Standards – for curriculum setting and development.
- Education Delivery – through instructional courses for STs geared to a four year cycle of FRCS coverage, and CESR instructional courses for SAS doctors.
- Feedback from Training Programme Directors to inform both standards and delivery.
- For post CCT core T&O surgical skills training and education, the BOA has synchronised its Congress instructional coverage to a five year revalidation cycle. In order effectively to oversee this considerable body of work we have refashioned our governance structure to include:
- A small Education Board charged with overall policy direction, priority setting, resource allocation – Chaired by a member of and with direct access to the BOA Executive Group.
- A Training Standards Committee – to develop and deliver the T&O surgical training curriculum in close collaboration with the SAC for T&O.
- An Education Committee – to design, co-ordinate and oversee delivery of pre and post CCT instructional courses.
The BOA's Education Board, mentioned above, has recently defined the BOA's Training and Education Strategy in terms of 4 Domains and 10 Projects. The Domains are:
- Undergraduates, Foundation Year Doctors and Core Trainees
- Pre-CCT
- Post CCT, SAS and Fellows
- Nurses and Allied Health Professionals
Each of the 10 projects are aligned with these domains, details of which can be seen in the MindMap on the right.
Looking ahead, our members’ pre and post CCT training and education needs will be met by specific project-based events, run by our newly formed Events Team who will work closely with a suitably qualified Educational Adviser. In addition, our members' e-learning and CPD/CME recording requirements will be integrated into our website during the second phase of is development.
Thus the detail of our strategy in this area continues to build – and remains a work in progress - as we refocus our requirement for professional Education expertise and define our enabling information systems process requirements. The current state of play is well captured in a newsletter article written recently by the last Education Board Chair and current BOA President, Professor Joe Dias (see pages 19 - 21 in BON Issue no. 49 in public documents below).
The final draft version of our Training and Education Strategy can be viewed by clicking
here.