Training issues in coloproctology – the Role of the College

John Hartley, Tutor in Coloproctology, RCS

The Modernising Medical Careers (MMC) process in conjunction with the restrictions imposed by the European Working Time Directive (EWTD) has resulted in an effective shortening of the time spent in surgical training. If the standards required for award of the certification of completion of training (CCT) are to be maintained, there will need to be changes made to the delivery of post graduate surgical training in the United Kingdom.

It seems inevitable that this will require a shift from the acquisition of skills through an apprenticeship model, involving many hours of clinical exposure with a heavy service commitment, towards a more defined pattern of training in which defined surgical procedures are taught and there is rigorous assessment of competencies in such procedures.

Opportunities for the development of surgical skills within the operating theatre must be made maximum use of within a foreshortened training time. However, there is a need to complement these opportunities with formal skills based training outwith the work environment. There are data to suggest that skills acquired in this way will be transferred to the operating theatre. The Raven Department of Surgical Education at the Royal College of Surgeons has extensive experience in the provision of skills based surgical training across specialties. Examples within general surgery include the basic surgical skills and specialist registrar skills courses. The Intercollegiate Surgical Curriculum Project (ISCP) has painstakingly defined the core knowledge and skills required at the different stages of surgical training, which follow the initial foundation years. The years of surgical training stages are conveniently divided into initial (ST1/2), intermediate (ST3/4) and advanced (ST5/6 and beyond) stages. There are numerous resources available to the trainee for the development of core knowledge required in his/her chosen specialty for each stage of training, the so-called “motorway courses” providing an immediate example. However, skills based training in coloproctology has up to this point been poorly provisioned. The remit of the current tutor in coloproctology at the RCS is to develop, in collaboration with the ACPGBI, a program of skills based training for junior surgeons which is compatible with the ISCP.

To this end a steering group was set up which then met at the ACPGBI’s annual meeting last summer in order to draft a proposed two day course. This course aims to deliver training in the core skills required in coloproctology at the intermediate stage of training (ST3/4). This will include basic proctology, including management of haemorrhoidal disease and perianal sepsis, as well as stoma procedures and operations on the abdominal colon. A course has been developed which it is hoped will deliver this curriculum by a combination of didactic teaching, case based discussion, and practical training on inanimate material, animal models and cadaveric material. This course will be piloted at the college in April, with the aim of delivering it biannually thereafter, both at the college and at regional centres. Once this course has been piloted and shown to run successfully, a second course aimed at advanced stage trainees will be developed through a similar process.

At this moment we are caught up in a series of changes and threats to surgical training which many of us feel have been imposed upon us by forces beyond our control, and without proper consultation. The clock cannot be turned back, and it seems very unlikely that these changes will be reversed, so that practical surgical skills will need to be taught in a different fashion. We owe it to our current and future trainees to try make the best of this situation, despite our reservations about the process. Future surgical care for ourselves, our friends and families may be dependent upon the energy, determination and enthusiasm with we which we face these challenges over the next decade.