Trainees View

Mike Nelson

Powerpoint File

Introduction:

What is a coloproctologist? What distinguishes a general surgeon with a subspecialty interest from a surgeon with largely tertiary referral practice? Is it their training? Reputation? Historical referral patterns to famous institutions? Ultimately, there are no formal qualifications or accreditation upon which to base such decisions and this has been the driving force behind the present debate.

This abstract looks at the problem of certification in surgery and coloproctology from the view of trainees. This is an important topic which has occupied centre stage in the training debate ever since the introduction of the Calman “Specialist Registrar” grade. Surgical training in the United Kingdom is taking place in an environment of unprecedented change, with several apparently conflicting issues such as working hours reduction (EWTD), service reconfigurations (DTCs) and advances in practice (laparoscopic surgery) conspiring to deprive trainees of the experience deemed invaluable to their predecessors. Additionally, the Modernising Medical Careers concept (MMC) promises to change the situation further and faster than any preceding programs.

Historical Perspective:

In 1996, the Calman scheme currently in use replaced the old “Senior Registrar” and Registrar grades with the SpR – already a specialist! The venerable FRCS gave way to the MRCS, with seamless training, from a defined curriculum, regular assessments, an exit exam (in the case of surgery) and eventually the “ticket” or CCST. Gone forever was the competitive entry to the SR grade, with its punishing work patterns and uncertain career prospects. Or was it? The perceived under-training, particularly in the subspecialties led to the concept of post-CCST fellowships. These were always vigorously resisted as a formal entity by trainees’ forums such as the Dukes’ club, the officers of which successfully argued that such training should be within the Calman six years. Whilst not embracing a return to the SR grade, trainees did widely recognise the need for some form of specialist accreditation with a poll among trainees attending a Dukes’ Club meeting. It has to be borne in mind, however, that those respondents were fairly senior, being trained in a pre-EWTD era, with band-3 jobs, many of whom had sat the Part III exam as coloproctologists.

Current Position:

SpRs and SHOs are facing some of the most challenging conditions ever. The EWTD has hit hard, with shift work patterns reducing significantly the opportunities for training in elective surgery. The Intercollegiate exam is also undergoing changes, one perception being that there is insufficient basic science and MCQs are to be introduced. MMC with its “run-through” training has to be instigated in parallel with the Calman system, and its promised standard is to be the same as the current CCT. Will the spectre of post-CCT training subsequently reappear in a more formal guise? There is certainly the mechanism for this in current MMC literature. Given the accelerated training, it may well be difficult to resist this step and the problems of the SR bottleneck, with a cohort of dissatisfied, disenfranchised CCT holders may recur causing subsequent recruitment problems.

The Future:

So will a future CCT holder actually be employable as a consultant as we know it today? Or will patients demand to be seen by a “specialist”, trained in an accredited unit and examined to a higher standard than the current ICE? A CCST certificate may well be required to distinguish those who have undergone such extended training, meaning they are more qualified than today’s consultants who will teach them! Such anomalies have to be clarfied and addressed before these changes are irreversibly introduced.

Conclusion:

I believe we are at a crossroads in surgical training. We have not seen the variety and intensity of drivers for change before and it is hoped that this discussion will raise the concerns of those currently in training and also those about to enter the uncertainty of MMC. Never before has the end product of surgical training been so nebulous.