J.W. Rodney Peyton

The effect of the implementation of the Calman reforms has been to radically transform post-graduate surgical education from an apprenticeship scheme to a training model. Unfortunately the devil was in the detail, or lack of it, and very little thought was given to the impact such a move would have on the lives of trainees and consultants alike. In particular, insufficient account was taken of the educational resources which would be required, not only in terms of local facilities but more importantly in the time required to be devoted to the process by consultant trainers.

Twelve years ago, The Royal College of Surgeons in England was the first to promote faculty development with its “Training the Trainers” Courses under the tutelage of Dr Rodney Peyton MD. These acknowledged the change from the master/pupil to the teacher/trainee relationship and that senior staff who had been “trained to treat” now required to be “trained to teach”. The success of these courses is demonstrated by the fact that they are now run, virtually unchanged, in over 20 countries worldwide and the UK courses are still heavily over-subscribed.

As a natural progression of Calman, the Modernising Medical Careers (MMR) initiative is now being introduced, giving a supposedly “seamless” surgical training from the end of the foundation years through to the award of the Certificate of Completion of Higher Surgical Training. This framework has been underpinned by the production for the first time of a clearly defined syllabus for trainees in all 9 surgical specialities, combined with the development of clear, incremental standards and appropriate competence-based assessment tools. These cover not only speciality-specific competencies, but also so-called generic skills in line with the GMC’s document on good medical practice and the CanMeds model developed by the Royal College of Physicians and Surgeons of Canada.

The introduction of such a curriculum model is itself a truly momentous project, and has been made even more demanding by the impact of the European Working Time Directive. However, this reduction in the hours of work/training has at least had the advantage of forcing much more of the learning to be “on the job”, rather than in set piece “off the job” scenarios such as conferences or even routine “training days”, characterised by multiple lectures in a darkened room with powerpoint slides and little else. Ironically, it has been well known for many years that workplace training is the most productive paradigm for effective, efficient, deep seated learning.

The rapid changes occurring more generally in the National Health Service have had a considerable impact on the work load of consultants. The drive towards a consultant-based service is virtually unstoppable, and the new contract has put more constraints than ever before on the ability of consultants to determine their own method of working. Coupled with this, medicine in the 21 st century is rapidly evolving, requiring consultants to invest increasing amounts of time to keep abreast of surgical developments. Consultants therefore are not just trainers but also, at various times throughout their professional life, trainees.

So far, the gaps in service provision created by the implementation of the European Working Time Directive have not been filled by additional qualified medical or paramedical personnel and it is consultants who have had to plug the gaps. Consequently, they have less time to devote to a traditional system of teaching, which now has to be more effective and professional than previously, particularly with the increased number of consultants which will be required by 2010 to maintain the Service. Indeed, the College estimates a short-fall of around 2700 surgeons throughout the country by that time, due to natural wastage, early retirement and changes in work practice such as job sharing. Against this background it is perhaps surprising that the consultant workforce has continued to deliver a high quality surgical service and maintain an increasing commitment to teaching. This was exemplified by one programme director at a recent meeting between the College and the Deaneries, who stated that consultants are “tired, frustrated ……but still motivated”.

With the curriculum being more explicit, consultant trainers now have a clearer purpose and structure to their training with more definitive guidance on what to teach as well as when and how to assess the progress of trainees. It is not a matter of “one size fits all” but rather the role of the trainer has to adapt to the complexity of the subject being taught and the level of expertise of an individual trainee (see figure 1).

The surgical Demonstrator is a role model and motivator for good professional practice. The Commander, in order to maintain patient safety, provides a lot of direction for trainees whilst letting them develop their expertise. With increasing experience the trainee requires a Coach, guiding reflection on practice, indicating the strengths and particularly weak spots to help correct any deficiencies in performance. Gradually, the trainer can begin to withdraw from a hands-on approach and become a Mentor, to help trainees consolidate skills and develop judgement by reflecting on experience. Thereafter, the role of the consultant is to maintain and further develop their own competence, and to be available for the trainee whenever necessary.

These important and varying roles of the trainer do not come naturally and develop as a result of increasing experience and professionalism as a trainer. The College initiated this support for trainers with its package of courses under the Training the Trainers banner, which has been enhanced by an almost complete revision of the Foundation Course, and updating the Appraisal and Assessment Course to more closely align with the new RITA Process. There is also a greater emphasis on “on the job” competency based assessments throughout.

The College is actively supporting the Joint Committee on Higher Surgical Training (JCHST) Curriculum Project and specifically has been in discussion with a number of Deaneries in phase 2 of the project to undertake an assessment of need in relation to the new curriculum going live in August 2007. In particular it has been gathering evidence to make a case for proper resourcing of training with appropriate reward systems to support consultants and promote high quality teaching, learning and assessment.

Findings from the pilot with the Deaneries have been taken on board by the Inter-Collegiate Faculty Development Steering Group, whose task it is to develop a strategy to help surgical trainers deliver the new curriculum. The function of this group is to clarify the roles and responsibility of surgical trainers and to plan an implementation strategy to motivate, train, equip and resource them as well as planning ongoing faculty support. To this end new educational partnerships are being developed between the Royal Colleges and Deaneries to give practical support to trainers in their place of work as well as to assess the outcomes of training and help maintain standards on a national basis.

Accordingly, a new course from the Training the Trainers’ stable has been developed to Facilitate and Assess Surgical Training (FAST Programme). Its objectives are to help the implementation of the new surgical curriculum by:

Facilitating change in workplace teaching
Enhancing the effectiveness of trainers
Encouraging reflective training practice
Evaluating and sharing learning strategies on a national basis
Establishing an ongoing trainer development programme
Supervising effective assessment of surgical practice

Clinical trainers can deliver effective and efficient training to produce a continuing supply of high quality consultants for the National Health Service. It is essential, if the curriculum project is to succeed, that consultant trainers are adequately supported, properly trained and given the necessary resources of time and backup to do the job properly. Through their funding of the MMC and Curriculum initiatives, the Department of Health has fully acknowledged the size of the task. Similar recognition must be given by the DOH to the needs of the trainers at the coal face, who continue on a daily basis to balance the needs of service delivery and training. Indeed, without such a commitment to Faculty Development for those who are expected to deliver the new curriculum, the project would be doomed from the outset.