How training has changed…
By Phil Turner
BOA Past President
When I celebrated my retirement from the NHS, I was introduced to my former self as a cardboard cut-out, created with tremendous skill by the daughter of a colleague. It was based on a photograph of me taken in 1977, when I was in my fourth year as a medical student during my paediatric attachment. This started me thinking about how the NHS has changed in my career lifetime, particularly training and education.
Career progression
When I was working my way towards a career in surgery, every step of progression was a hurdle to be cleared. Even the first post as a Junior House Officer required an interview and competition was intense for what were perceived as the best jobs. I had to apply for Anatomy Demonstrator, Senior House Officer, Registrar, Tutor Lecturer and toughest of all – Senior Registrar. One simple error of judgment or technical failure would become common knowledge and could result in a rapid redeployment into general practice or community medicine. It felt like you were negotiating a game of ‘Snakes and Ladders’ where all the ladders had been removed.
A curriculum
How did you know what you needed to know? There was a vague syllabus along with all the anxieties described above, but they were not combined into a curriculum. The BOA led the field by producing the ‘Blue Book’, which tried to match the two. Orthopaedics was at the forefront again with the first Orthopaedic Curriculum and Assessment Programme (OCAP), which preceded the Intercollegiate Surgical Curriculum Programme (ISCP) by several years. Despite all the misgivings of current trainees, the present system of assessments, waypoints and career support is infinitely better.
Examinations
The award of the post-nominal FRCS was hard-won. A basic science examination, concentrating on knowledge with no test of judgment or decision-making was called ‘Part One’, which could be sat as many times as you could afford it. A previous and unidentified BOA President was successful at the eleventh attempt. The second part was more clinically-based, but covered every surgical specialty. Preparation courses helped, but that brittle confidence could soon be broken by examiners who seemed to take delight in leading you gently towards a well-camouflaged trap door. Success was marked by having a sherry with the examiners and permission to apply for a specialty training post – the FRCS was an entry level qualification, not an exit exam.
Orthopaedics was the first to develop a specialist examination towards the end of training. Many who had already been appointed as consultants willingly subjected themselves to this scrutiny. The intercollegiate examination that now marks recognition as a ‘day one consultant in the generality of the specialty’ is matched to the curriculum with extensive training of the examiners, who are themselves assessed on a regular basis. To my mind it is a fair, transparent and relevant test, which could not be said of my experience.
Training trainers
When I started my anatomy demonstrator post, we had a brief induction to the department and an introduction to our cadaver, who would be the subject of our teaching for the next eight months or so. We were expected to know how to teach because we had been taught. There was no educational theory or practical lessons, no learning objectives other than the students passing their exams, no supervision and no feedback. It was at this point that I began to take training and education seriously, although I was self-taught. The first time I received any formal educational training was when I graduated to being a table demonstrator on basic AO courses. Now there are superb programmes and resources for all stages of training, with the BOA once again at the forefront with the TOTS and TOES courses.
Work-life balance
I am sure trainees are tired of hearing their aging consultants bleating on about how they were on call 1 in 3 going to 1 in 2 if anyone was away. A weekend would run non-stop from first thing on Friday to close of play on Monday, with no compensatory rest periods. However, you were usually looking after your team’s patients and not the whole hospital, the camaraderie kept you going and for surgical trainees, this was the ideal opportunity to get into theatre. We suffered terrible fatigue, but I don’t think many got to the stage of burnout. There is no doubt that work came first and home life a very poor second. The present focus on work-life balance and well-being is totally deserved, and an absolute necessity to develop and maintain a skilled and dedicated workforce.
Throughout my career, training and education in the NHS has improved immeasurably. At least in this specific area, it remains world class.