The new General Surgical Curriculum and ISCP

After wide consultation with trainees, trainers, employers and other stakeholders, the new General Surgical Curriculum was approved earlier this year and will be implemented from 4 August 2021. It will be outcome based and will be the biggest change in surgical training since 2007. Trainees can progress at their own rate and complete when they have acquired the capabilities of a Day-1 consultant in general surgery with a special interest. The Multiple Consultant Report (MCR) is new and has been developed as the main assessment tool for this outcomes-based curriculum. Assessment in the MCR will be on progress from the ability to only observe at the start of training, to performance at the level of Day-1 consultant in the complex, integrated skills needed for the day-to-day performance of the role in each of the areas of the job (the Capabilities in Practice). The MCR and trainee self assessment will improve feedback and allow specific and bespoke agreed learning objectives to be more easily developed and delivered, and faster but safe training for many. New training pathways have been developed, emphasizing the commonality of emergency general surgery, but also developing special interests reflecting the needs of patients and the service.     

Workplace‐based assessment: assessing technical skill throughout the continuum of surgical training

The Royal Colleges of Surgeons and Surgical Specialty Associations in the UK have introduced competence‐based syllabi and curricula for surgical training. The syllabi of the Intercollegiate Surgical Curriculum Programme (ISCP) and Orthopaedic Curriculum and Assessment Programme (OCAP) define the core competencies, that is, the observable and measureable behaviours required of a surgical trainee. The curricula define when, where and how these will be assessed. Procedure‐based assessment (PBA) has been adopted as the principal method of assessing surgical skills. It combines competencies specific to the procedure with generic competencies such as safe handling of instruments. It covers the entire procedure, including preoperative and postoperative planning. A global summary of the level at which the trainee performed the assessed elements of the procedure is also included. The form has been designed to be completed quickly by the assessor (clinical supervisor) and fed‐back to the trainee between operations. PBA forms have been developed for all index procedures in all surgical specialties. The forms are intended to be used as frequently as possible when performing index procedures, as their primary aim is to aid learning. At the end of a training placement the aggregated PBA forms, together with the logbook, enable the Educational Supervisor and/or Programme Director to make a summary judgement about the competence of a trainee to perform index procedures to a given standard.     

Modernizing assessment of surgical trainees in the workplace

Surgical training has evolved significantly over the last few decades. The old model of an informal apprenticeship and ad-hoc mentoring by a single or small team of consultant supervisors has been slowly replaced with formal assessment against a standardized specialty curriculum and annual review of competence by a panel of trainers. The introduction of new surgical curricula from August 2021 has continued this modernization of surgical assessment with greater emphasis on quality of interactions between trainer and trainee. The requirement of a fixed number of work-place based assessments to be completed per year has been dropped. There is a move to competency-based assessment rather than time based. Competencies have been divided into core competencies (Generic Professional Capabilities) and key competencies of a speciality (Capabilities in Practice). These will be assessed by a group of consultant supervisors, and structured and constructive feedback will be provided using the multi-consultant report, a tool designed to give defined feedback that can be actioned by trainees. Trainees will be able to measure their performance against tangible goals and see their progressions towards acquiring the skills required of a day one consultant.     

Workplace-based assessment: The need for continued evaluation and refinement

Workplace-Based Assessment (WBA) has been an integral part of the UK Intercollegiate Surgical Curriculum Programme (ISCP) since 2007 (www.iscp.ac.uk). The UK Postgraduate Medical Education and Training Board (now part of the General Medical Council) has defined WBA as ‘the assessment of working practices based on what trainees actually do in the workplace, and predominantly carried out in the workplace itself’ (www.gmc.org.uk). This article reviews the purpose of WBA and the methods in current use. It also discusses the misuse of WBA and possible solutions, including redesign of the rating scales.     

Assessment of surgical skills of trainees in the UK

Surgical training and assessment in the UK has been criticised in the past for lacking transparency, reliability and validity. The new Intercollegiate Surgical Curriculum Programme (ISCP) has a well-defined, competence-based syllabus and a system of workplace-based assessments and examinations that map to the syllabus. The main aims of workplace-based assessment are to aid learning through objective feedback and to provide evidence that the competencies required to progress to the next level of training have been achieved. Reduction in surgical experience means that more training will need to be undertaken on simulations, although experience and assessment in the operating room must remains the 'gold-standard'. Simulation training will require the provision of properly resourced surgical skills facilities in every hospital. The key to reliable assessment and constructive feedback is well-trained trainers. Training is a skill that must be learned, and assessment and feedback techniques form part of this. In surgery, it has been assumed that all consultants are trainers but this is clearly not the case. Surgeons will need to follow the example of primary care, where trainers are selected from experienced general practitioners who demonstrate enthusiasm and ability. The reward for the trainer should be protected time for training. The reward for the National Health Service will be better trained surgeons.     

Improving core surgical training in a major trauma centre

IntroductionEnglish Major Trauma Centres (MTCs) were established in April 2012. Increased case volume and complexity has influenced trauma and orthopaedic (T&O) core surgical training in these centres.ObjectivesTo determine if T&O core surgical training in MTCs meets Joint Committee on Surgical Training (JCST) quality indicators including performance of T&O operative procedures and consultant supervised session attendance.MethodsAn audit cycle assessing the impact of a weekly departmental core surgical trainee rota. The rota included allocated timetabled sessions that optimised clinical and surgical learning opportunities. Intercollegiate Surgical Curriculum Programme (ISCP) records for T&O core surgical trainees at a single MTC were analysed for 8 months pre and post rota introduction. Outcome measures were electronic surgical logbook evidence of leading T&O operative procedures and consultant validated work-based assessments (WBAs).ResultsNine core surgical trainees completed a 4 month MTC placement pre and post introduction of the core surgical trainee rota. Introduction of core surgical trainee rota significantly increased the mean number of T&O operative procedures led by a core surgical trainee during a 4 month MTC placement from 20.2 to 34.0 (p < 0.05).The mean number of hip hemiarthroplasty procedures led by a core surgical trainee during a 4 month MTC placement was significantly increased (0.3 vs 2.4 [p = 0.04]). Those of dynamic hip screw fixation (2.3 vs 3.6) and ankle fracture fixation (0.7 vs 1.6) were not. Introduction of a core surgical trainee rota significantly increased the mean number of consultant validated WBAs completed by a core surgical trainee during a 4 month MTC placement from 1.7 to 6.6 (p < 0.0001).ConclusionsIntroduction of a departmental core surgical trainee rota utilising a ‘problem-based’ model can significantly improve T&O core surgical training in MTCs.     

How to succeed in the Annual Reviews of Competency Progression (ARCP)

The switch from time-based to competency-based training has required a more robust method of assessment, to ensure that speciality trainees are gaining the competencies required in order to progress through their programme. This has resulted in the development of a system of Annual Reviews of Competency Progression (ARCP), which provide a formal review of all aspects of training and, if this is found to be satisfactory, permits progression. Most surgical speciality programmes run the ARCP as a face-to-face meeting, at which the required evidence of training is reviewed via an online portfolio (e-Portfolio); this is managed via the Intercollegiate Surgical Curriculum Project (ISCP) website. The e-Portfolio is therefore clearly a key document and the outcome of each ARCP will largely depend on its content. In addition to the mandatory Workplace Based Assessments (WBAs) and surgical logbook, the portfolio also contains additional records, such as involvement in research and audit and attendance at relevant courses. Success at the ARCP will require a complete set of evidence of acquisition of the mandatory competencies, but will also be greatly enhanced by the demonstration of ‘added value’. Trainees are therefore encouraged to strive for excellence throughout their training programme, rather than just adequacy and will be rewarded, not only by success at the ARCP but also by a strong and competitive curriculum vitae. This article describes how to prepare the various components of a portfolio for the ARCP, practical advice of what to expect on the day and, on a more personal level, how to cope if things are not going according to plan.     

Operative performance in laparoscopic cholecystectomy using the Procedural-Based Assessment tool

Aims

The Intercollegiate Surgical Curriculum Project (ISCP) has devised assessment tools for index operations to assess trainee technical skills. In this study we used the Procedural-Based Assessment (PBA) tool to evaluate operations performed by trainees.

Methods

Live and simulated laparoscopic cholecystectomies were performed by trainees. Two experienced surgeons assessed each operation blindly and independently.

Results

Eighty-four live (supervised) and 112 simulated (unsupervised) operations were performed by 28 trainees. Mean inter-rater reliability was kappa = .86 and .84 for live and simulated operations, respectively. Construct validity using Mann-Whitney for generic technical skills was significant for live and simulated operations, P ≤ .05. Assessing specific technical skills showed construct validity for simulated unsupervised operations only, Mann-Whitney P < .05, but not for supervised live operations, Mann-Whitney P > .05.

Conclusions

The PBA showed good inter-rater reliability. Assessing generic technical skills, PBA showed construct validity for both types of operations and for specific technical skills in the unsupervised simulated operations. We conclude that the PBA seems to be a reliable and valid assessment tool for generic technical skills in unsupervised simulated and live supervised laparoscopic cholecystectomies.     

Intrathoracic organ transplantation

Thoracic organ transplantation improves survival and quality of life in patients with severe and refractory end-stage heart or respiratory failure. Since the first human-to-human heart transplant in 1967 there have been huge developments in organ preservation, perioperative management and immunosuppression regimes; and outcomes have improved accordingly. As the population ages and medical therapies improve, the number of patients who survive long enough to be considered for transplantation is increasing. At the same time, the number of donor organs available is static, even decreasing in some countries (including the UK), and the average age of donors is increasing. The lack of organs suitable for transplantation is a significant cause for concern and makes it imperative that all available donor organs are optimized. In this article we will summarize the principles of heart and lung transplantation, with emphasis on patient selection and donor and recipient management, as outlined in the Intercollegiate Surgical Curriculum Programme (ISCP) cardiothoracic surgery syllabus.     

Leadership and working in teams

Leadership and working in teams are core aspects of surgical training and practice. They are highlighted in the General Medical Council's ‘General Professional Capabilities’ framework, are a key part of the Intercollegiate Surgical Curriculum Programme, are included in Good Surgical Practice guidance published by the Royal College of Surgeons of England and are incorporated in the ‘Non-Technical Skills for Surgeons’ programme run by the Royal College of Surgeons of Edinburgh. Major healthcare failings, as detailed in a number of public inquiries, underline the importance of prioritizing leadership and teamworking in current undergraduate and postgraduate surgical training. A growing body of research has helped to identify the positive attributes and behaviours that are central to leading and working in the surgical team effectively. Evidence-based tools are increasingly being used for training and assessment as well as ongoing reflective practice for surgeons at all stages of their careers. Surgeons have a duty to promote a safe and positive working environment that enhances the performance of the team and leads to high quality patient care.     

Use of the operative logbook to monitor trainee progress,and evaluate operative supervision provided by accredited training posts

The Surgical Education and Training (SET) program of the Royal Australasian College of Surgeons (RACS) represents a change from a time-based program to a competency-based program and much greater emphasis is placed on formative assessment and timely feedback (to Surgical Training Boards —STBs— as well as to the trainee). It demands early recognition of the trainee who is struggling to progress, the so-called “marginal trainee”. Many of these are simply failing to acquire the desired competencies at the desired or expected rate, although some have more profound underlying deficiencies. SET also places a demand on training posts--with the expectation that they are providing an environment that is conducive to learning and that the trainees are getting adequate learning opportunities. In the domain of operative skills, this largely implies that levels of operative teaching and supervision should be appropriate to the trainee’s stage and ability.     

Fit for surgery? Preoperative assessment

The preoperative assessment and preparation of the surgical patient is important. Surgical risk is dependent on many factors, of which ‘medical fitness’ is among the most important. This article reviews the major surgical risks and discusses how preoperative assessment and intervention helps to reduce these. It is written for the surgical trainee and gives a pragmatic and practical account of the topic.     

The nearly new curriculum and coming changes to access to the specialist register

The New surgical curriculum has been in place since August 2021, the biggest change in surgical training since 2007. The main changes have been that the curriculum is fully outcomes based: training can end when a person has reached the level of a day 1 consultant in the UK. Feedback to set goals and facilitate progression is also at the core of the new curriculum through the Multiple Consultant Report (MCR). The introduction of the MCR has been very successful with almost complete uptake. The trainee self assessment has also been well taken up, with good correlation between the trainee's own ratings and trainer's ratings. There has been no difference in self rating by sex. Analysis is ongoing and challenges remain, not least educator time and development of ways to improve both the giving and receiving of feedback for all in surgery. New pathways to the specialist register for those not in training are being developed and are discussed in this article.     

Integrating the NAS Milestones and Handheld Technology to Improve Residency Training and Assessment

ObjectiveTo incorporate the use of an intuitive and robust assessment tool in conjunction with the Next Accreditation System Milestones to maximize opportunities for trainee performance feedback and continuous trainee assessment, with the long-term goal of increasing the rate of performance improvement and mastery of knowledge and surgical skills.DesignPilot study.SettingJohns Hopkins Medicine, Baltimore, MD. Primary, tertiary, and quaternary clinical care; institutional environment.ParticipantsExperimental group: two randomly selected postgraduate year-1 integrated training program residents per year for 2 consecutive years from the Department of Plastic and Reconstructive Surgery. Control group: traditionally trained residents from the integrated training program in the Department of Plastic and Reconstructive Surgery. Study duration: 7 years (until residents complete residency training).Anticipated ResultsThis assessment strategy would create large amounts of informative data on trainees, which can be cross-referenced to determine trainee progress. Assessment data would be collected continuously from all faculty surgeons. Comparisons of faculty and resident self-assessments would facilitate resident evaluations. Ease of use of the data collection structure would improve faculty evaluation compliance and timely resident case report completion.ConclusionsImproving the efficiency and efficacy of competency documentation is critical. Using portable technologies is an intuitive way to improve the trainee assessment process. We anticipate that this 2-pronged approach to trainee assessments would quickly provide large amounts of informative data to better assess trainee progress and inform Milestone assessments in a manner that facilitates immediate feedback. Assessments of faculty and resident satisfaction would help us further refine the assessment process as needed. If successful, this format could easily be implemented by other training programs.Applicable Project AreaInnovations in Surgical Education: Milestones     

Abdominal compartment syndrome

Abdominal compartment syndrome (ACS) is a devastating condition for the critically unwell patient. Initially described as solely affecting surgical patients, ACS is now also recognized in the medical intensive care setting. Without prompt and definitive treatment, mortality rates approach 70% as multiorgan failure develops. Over the past decade our understanding, recognition and management of ACS has evolved. The World Society of Abdominal Compartment Syndrome published updated guidelines in 2012 to draw consensus and improve patient outcomes. ACS is the end sequala of raised intra-abdominal pressure (IAP), defined as a sustained IAP >20 mmHg with or without an abdominal perfusion pressure <60 mmHg and associated with new organ dysfunction. Intravesical measuring of IAP is the gold standard diagnostic technique. Surgical decompressive laparotomy and open abdomen with temporary abdominal closure measures is the definitive treatment. This article summaries the updated consensus definitions, pathophysiology, diagnostic investigation and management to help the junior surgical trainee faced with ACS.     

Neurosurgical training in the United kingdom and ireland: assessing progress and attainment

OBJECTIVE: To review neurosurgical training in the United Kingdom and Ireland in the past decade and the methods used to monitor training and assess trainee competence. METHODS: A database was compiled with data from 1990 to 2000 on behalf of the Specialist Advisory Committee in Neurosurgery from trainee logbook operative totals submitted on achieving accreditation or receiving the Certificate of Completion of Surgical Training. RESULTS: During the 11-year period, 109 trainees achieved accreditation or Certificate of Completion of Surgical Training. The median duration of training, including research, was 6.1 years. The total training duration per year did not change overall, although results suggested an increasing trend in the duration of clinical training (excluding research) from 4.8 to 5.6 years since 1997. The median age at accreditation or at receipt of Certificate of Completion of Surgical Training was 35 years 7 months. At completion of training, the Specialist Advisory Committee used operative totals in addition to reports from trainers to analyze the trainees' competence. Despite changes to the training system and a reduction in hours of work, the quality of training, as reflected by median operative totals, did not change during the decade. The database also permitted assessment of operative experience gained within each training program. CONCLUSION: The duration of training and training standards in terms of operative experience have remained constant during the past decade. Operative totals provide an objective method of assessing trainee progress and attainment and enable a comparison of experience offered by different training programs. An alternative method of assessing trainee operative competence that can be used in conjunction with median operative totals is proposed.     

Abdominal compartment syndrome

Abdominal compartment syndrome (ACS) is a devastating condition for the critically unwell patient. Initially described as solely affecting surgical patients, ACS is now also recognized in the medical intensive care setting. Without prompt and definitive treatment mortality rates approach 70% as multi-organ failure develops. Over the past decade our understanding, recognition and management of ACS has evolved. The World Society of Abdominal Compartment Syndrome published updated guidelines in 2012 to draw consensus and improve patient outcomes. ACS is the end sequela of raised intra-abdominal pressure (IAP), defined as a sustained IAP >20 mmHg with or without an abdominal perfusion pressure <60 mmHg and associated with new organ dysfunction. Intravesical measuring of IAP is the gold standard diagnostic technique. Surgical decompressive laparotomy and open abdomen with temporary abdominal closure measures is the definitive treatment. This article summarizes the updated consensus definitions, pathophysiology, diagnostic investigation and management to help the junior surgical trainee faced with ACS.     

Clinical features and management of pressure ulcers for the general surgeon

Although widely considered to be preventable, pressure ulcers (PU) are common and cause a significant burden to the individual, their carers and healthcare services. International collaborative panels publish consensus documents and guidelines aiming to standardize PU classification, assessment and management. There is a huge emphasis on prevention, which requires awareness and education for clinicians, patients and carers. Surgeons may be referred patients with PU for advice on surgical options or management of infected wounds. Surgical patients may develop PU after prolonged surgical procedures, during periods of critical illness or in association with their surgical condition. Additionally, as some PU become chronic and non-healing, individuals with PU may be referred for assessment of other medical issues. An awareness and understanding of PU aetiology, management strategies and complications are therefore important for the surgical trainee.     

SE20THE ANATOMY OF COMPLICATIONS IN THE UPPER LIMB

Purpose Specialist trainees and the specialty boards of the College of Surgeons expect that levels of supervision will not remain static during training. As training progresses the level of supervision will change, from an assistant role and direct supervision towards independent practice with consultation available as required. The Summary of Operative Experience may provide a de facto measurement of this. Methodology Assessment of the surgical logbook of an individual trainee to document the changes in the level of supervision that occur during a training term, the factors that influence it, and the degree of variation between posts. Results Upon arrival at a new institution supervision for most cases is direct. For minor and intermediate surgery that supervision is rapidly relaxed once it has been confirmed the trainee has acquired and demonstrated the required skills. In areas of complex surgery (such as neonatal surgery) there is a clear progression observable over the training period. In the early part of the term the trainee is assisting in complex surgery, with the surgeon supervisor operating. By the end of the term those roles may have reversed, but there are significant variations between posts. Conclusion It is possible to use the operative logbook as an indicator of the supervision provided by training centres to trainees. This could provide one mechanism to enable specialty boards to confirm that supervision for trainees is appropriate to their needs as they progress through their training. It also allows an indirect measure of the quality of the post for specialty training.     

Leadership and working in teams

Leadership and teamwork are essential components of surgical practice and now recognized in the Generic Professional Capabilities framework from the GMC. Surgical application of these skills can be usefully explored through the NOTSS (Non-Technical Skills for Surgeons) taxonomy. This identifies the essential elements of performance in key areas: exchanging information; establishing a shared understanding and co-ordinating team activities (for teamwork); and setting and maintaining standards, supporting others and coping with pressure (for leadership). In addition, there are a number of well-evidenced tools and techniques which can be utilized to improve performance. This includes team briefing and debriefing, closed loop communication, SBAR (situation, background, assessment, recommendation), graded assertiveness and ‘flying by voice’. Practising and integrating these techniques into surgical practice can improve individual and overall team performance. Finally, to optimize our performance requires careful balancing of each non-technical element to stretch and develop teamwork while providing support and maintenance of a healthy working environment. And of course, always aligning these developments with the goal of improvement in patient care.