No time to train the surgeons More and more reforms result in less and less time for training Surgical training in the United Kingdom is beset by fundamental problems raising what has been described as “considerable disquiet amongst trainees and trainers.”1 Basic and higher surgical trainees progress through a system comprehensively reformed five years ago to emphasise structured training, supervision, and regular assessment. So why are senior house officers’ skill levels regarded by trainees and trainers as “very shallow”?2 Why is there insufficient capacity in the system to train surgeons in the way that their trainers want?3 And why is it that, in a recent poll of consultant surgeons, two thirds would not wish to be operated on by a Calman trained consultant colleague?4 In 1993 Sir Kenneth Calman proposed reforms of the registrar grades to bring the United Kingdom into line with a European Union directive on medical training. It was hoped that encouraging structured learning and supervision would compensate for reducing training time.
Editorials A system that generates more claims, and therefore an increased burden on clinicians and managers, is not necessarily a bad system If the financial responsibility for claims changes the behaviour of providers and makes hospitals safer places for patients, then the overall impact may be a reduction of costs, in the wider sense that includes social harm Of course, not all adverse events can or should be prevented: medical care has inherent risks, resources are limited, and principles of cost effectiveness should apply here as elsewhere in the NHS Unfortunately, most NHS hospitals are some distance from having in place comprehensive cost effective mechanisms to increase patients’ safety “Making Amends” implies two ways in which claims may be encouraged Firstly, the proposed basic redress scheme will make claiming cheaper and quicker, and more adverse events may consequently result in a claim Secondly, eligibility for the proposed redress scheme for birth related injuries will be based on a test of causation, not fault, and this should result in more claims being met than at present Providing that healthcare providers see these claims as generating valuable information and use this as a basis for action to improve patient safety, increased claims will have benefits as well as costs But two conditions must be met for this to be plausible: the administrative costs of processing claims must be well controlled and some financial responsibility for claims should remain with the healthcare provider Concerning the first condition, the chief medical officer envisages a streamlined process for dealing with claims under the redress schemes Concerning the second condition, however, financing the redress schemes has been left open The NHS litigation authority has been given the central responsibility for collecting contributions from NHS trusts Whether and how these contributions will be related to the trusts’ experience in reducing patient claims remains unclear This raises complex issues about the relative complexity of trusts’ case mix, and the range of variation in contributions that is desirable, but these issues should be part of the debate about principles, not just about implementation Surely a fair principle is that hospitals with a poor record in patients’ safety (relative to what might be expected) should bear a greater share of the compensation costs, by comparison with hospitals that have a good safety record The challenge for the future is to find ways of harnessing data from the proposed redress schemes to achieve this end Paul Fenn professor of insurance studies Nottingham University Business School, Nottingham NG8 1BB (paul.fenn@nottingham.ac.uk) Alastair Gray professor of health economics and director Health Economics Research Centre, Department of Public Health, University of Oxford, Oxford OX3 7LF Neil Rickman reader in economics Department of Economics, University of Surrey, Guildford, Surrey GU2 7XH Adrian Towse director Office of Health Economics, London SW1 2DY Competing interests: None declared Department of Health, UK Making Amends: a consultation paper setting out proposals for reforming the approach to clinical negligence in the NHS DoH: London, 2003 Capstick JB Making amends—the future for clinical negligence litigation [commentary by Leigh B] BMJ 2004:328:457-60 Towse A, Fenn P, Gray A, Rickman N, Salinas R Reducing harm to patients in the National Health Service Will the government’s compensation proposals help? London: Office of Health Economics, 2003 No time to train the surgeons More and more reforms result in less and less time for training S urgical training in the United Kingdom is beset by fundamental problems raising what has been described as “considerable disquiet amongst trainees and trainers.”1 Basic and higher surgical trainees progress through a system comprehensively reformed five years ago to emphasise structured training, supervision, and regular assessment So why are senior house officers’ skill levels regarded by trainees and trainers as “very shallow”?2 Why is there insufficient capacity in the system to train surgeons in the way that their trainers want?3 And why is it that, in a recent poll of consultant surgeons, two thirds would not wish to be operated on by a Calman trained consultant colleague?4 In 1993 Sir Kenneth Calman proposed reforms of the registrar grades to bring the United Kingdom into line with a European Union directive on medical training It was hoped that encouraging structured learning and supervision would compensate for reducing training time The European Working Time Directive became part of British law in 1998, and it means that 418 soon no doctor may work more than 48 hours a week The combined impact of these two reforms on surgical training is profound Before Calmanisation and the European Working Time Directive a trainee could expect to work over 30 000 hours between becoming a senior house officer and getting a consultant post The Royal College of Surgeons calculates that this will now fall to 8000 hours.5 The chief medical officer proposes reforms that would further reduce this to 6000 hours.6 To become a competent surgeon in one fifth of the time once needed either requires genius, intensive practice, or lower standards We are not geniuses So has there been an increase in the intensity of teaching to compensate for the fivefold decrease in the length of surgical training? Well no, not really The largest ever survey of senior house officers in orthopaedic surgery showed that a third of these trainees were not taught in theatre or clinic.7 That many senior house officers arrive at posts halfway through their rotations without any real comBMJ VOLUME 328 BMJ 2004;328:418–9 21 FEBRUARY 2004 bmj.com Editorials petence in operative skills as basic as suturing and tying knots is therefore unsurprising This alone makes it difficult for them to progress to performing operations like appendicectomies, which most current registrars were doing as pre-registration house officers The fact that house officers compete with registrars for training time makes this transition impossible for some Those surgeons who successfully negotiate the bottleneck between basic and higher surgical training posts find that their training needs are often incompatible with a system geared increasingly to provide service When registrars need more time than consultants to perform procedures3; when consultants’ results are audited irrespective of who performed the operation; when trusts’ stars and status depend on output and outcome, where is the incentive to train? And where are the resources? One regional survey indicated that, even with trainees performing every operation, the total number of procedures available was a third less than the minimum recommended by their trainers.3 The increase in theatre time required for increased trainee operating in one specialty was estimated at 270 extra theatre days per year, at a cost to the region of £1.3m.3 Reform after reform of the NHS has been driven and informed by factors frequently very far away from the realities of providing surgical patients with continuity of care and of training the next generation of surgeons Those of us lucky enough to be under way with our training on good teaching rotations can only feel relief that we are not in the cohort coming behind We cannot rely on highly able and motivated trainees and trainers to struggle on like this Surgical training must be recognised as a priority, and it must be resourced with the time and funding, not only for skills courses and wet labs (where surgeons can practise techniques on appropriate models), but also for dedicated training lists and clinics, just as happened for waiting list initiatives.1 Not all consultants should be obliged to train all trainees1 8; those consultants that choose to undertake the additional responsibility and workload of training should be better supported.1 Why should they not also be rewarded? Senior trainees should benefit from a substantial period of supervised independent operating similar to the old senior regis- trar grade,1 and assessment needs to be competency based, not dependent on a fixed time period in the grade.5 Most current trainees are supposed to become the new “generalist” surgeons who will carry out common procedures, referring more complex patients on to “specialist” consultant colleagues.9 We are left in the worrying situation where 6000 hours of surgical training in its current state may not be enough to produce these new generalists, let alone provide consultants that can go on to become the kind of specialist consultant surgeon that we take for granted today Joanna Chikwe specialist registrar (j.chikwe@medschl.cam.ac.uk) Anthony C de Souza programme director (t.desouza@rbh.nthames.nhs.uk) John R Pepper chairman of London Deanery Cardiothoracic Speciality Training Committee (m.shah@rbh.nthames.nhs.uk) Cardiothoracic Surgery, Royal Brompton Hospital, London SW3 6NP Competing interests: None declared Murday A, Hamilton L, Magee P, Hyde J The conflict between service and training in cardiothoracic surgery: a report of a short-life working group of the Society of Cardiothoracic Surgeons of Great Britain and Ireland London: Society of Cardiothoracic Surgeons of Great Britain and Northern Ireland, 2000 De Cossart L, Wiltshire C, Brown J An audit of the operative skills of SHOs on BST programmes Ann R Coll Surg Eng 2001;83(suppl):S326-7 Crofts TJ, Griffiths JM, Sharma S, Wygrala J, Aitkin RJ Surgical training: an objective assessment of recent changes for a single health board BMJ 1997;314:814 Morris Stiff GJ, Clarke D, Torkington J, Bowrey DJ, Mansel RE Taining in the Calman era: what consultants say Ann R Coll Surg Engl 2002;84(suppl):345-7 Phillip H, Fleet Z, Bowman K The European Working Time Directive— interim report and guidance from The Royal College of Surgeons of England Working Party London: Royal College of Surgeons, January 2003 Donaldson L Unfinished business: proposals for reform of the senior house officer grade NHS consultation paper London: Department of Health, August 2002 British Orthopaedic Association Education and training for SHOs: a snapshot of the moment and recommendations for the future London: British Orthopaedic Association, July 2002 Liaison Group of the Specialist Training Authority, Joint Committee of Postgraduate Training for General Practice and the General Medical Council Policy statement Taking stock: the challenges facing medical training and education within a changing NHS London: Specialist Training Authority, December 2002 Department of Health Modernising medical careers: the response of the four UK health ministers to the consultation on unfinished business London: DoH, February 2003 Prognosis after cochlear implantation Children benefit the most as many adults M BMJ 2004;328:419–20 BMJ VOLUME 328 ultichannel cochlear implant systems were approved by the Food and Drug Administration for adults in 1985 and for children in 1990 NHS funding became available in the early 1990s About 4000 patients have received implants in the United Kingdom (50 000 worldwide) Children now outnumber adults by 2:1 Cochlear implants are reliable, and cochlear implant surgery is safe despite recent concerns regarding a risk of meningitis The numbers of suitable candidates is rising as selection criteria change, and it is timely to consider the benefits and risks of the technique 21 FEBRUARY 2004 bmj.com A cochlear implant takes the place of the damaged organ of Corti and stimulates the spiral ganglion cells directly Acquired causes of hair cell loss include infection such as rubella, cytomegalovirus infection, mumps, measles, meningitis, and middle ear infection, drug toxicity, trauma, and autoimmune disease, as well as Menière’s disease and cochlear otosclerosis Congenital hair cell loss may be due to recessive inheritance or may be the result of failure of normal intrauterine development of the inner ear due to causes of which some are known, some as yet unidentified 419 ... every operation, the total number of procedures available was a third less than the minimum recommended by their trainers.3 The increase in theatre time required for increased trainee operating... care and of training the next generation of surgeons Those of us lucky enough to be under way with our training on good teaching rotations can only feel relief that we are not in the cohort coming... cannot rely on highly able and motivated trainees and trainers to struggle on like this Surgical training must be recognised as a priority, and it must be resourced with the time and funding, not