Training

Training has, and always will, remain an important part of a consultant role. As training and education has matured, roles have become more formalised and curriculums more sophisticated. Clinical and educational supervision is as important as informal teaching, mentorship and apprenticeship.

The curriculum for T&O training is published by the Intercollegiate Surgical Curriculum Programme (ISCP) and authored by the Specialty Advisory Committee (SAC). It provides a framework for the training of doctors to the level of independent consultant in UK training programmes. It is designed to train surgeons in the generality of the trauma and orthopaedic practice, with the ability to develop an interest in a specialist area. 

The ‘Excellence by Design’ regulations produced by the GMC describes updated standards for curricula and assessment processes. The aim is operationalise the move towards a competency-based training scheme for trainees. These ‘high level outcomes’ are described as Capabilities in Practice (CiPs), which are essentially professional tasks within the scope of specialty practice, for example managing a theatre list or a clinic. These are sets of skills that can be developed over the course of training, from novice to expert. Similarly, Generic Professional Capabilities (GPCs) and interdependent essential capabilities that underpin professional medical practice and are common to all who practice medicine, for example leadership and involvement in clinical governance. 

Registrar training is split into two phases (2 and 3). Phase 2 lasts 4 years and aims to provide skills and principles in the full breadth of the specialty. Conversely, phase 3 lasts 2 years and allows trainees to additionally develop more specific specialist areas, trauma assessment and technical skills in their desired sub specialty. At the end of phase 3, trainees are eligible for their certification and recommendation to enter the specialist register. 

At the end of phase 2, trainees should be able to demonstrate knowledge, clinical skills and professional behaviours appropriate with certification and therefore become eligible to sit the FRCS exam. Furthermore, the CIP supervision level should be at least level 3 at the end of phase 2, and level 5 at the end of phase 3. 

Critical conditions are a group of disorders which have significant importance with regards to patient safety and safe practice, and where misdiagnosis would have devastating consequences for life and limb. They include cauda equina syndrome and compartment syndrome. They must be individually assessed with Clinical Based Discussions (CBD) and Clinical Evaluation Exercises (CEX). 

Similarly, index procedures have been identified as being common and important to the specialty, and competence in which is essential to the delivery of safe patient care. The list of such procedures includes arthroplasty, tendon repair etc. Trainees should reach indicative numbers of all procedures, although doing so does not of course imply independent competence. 

The key roles involved in teaching and learning are the Training Programme Director, Assigned Educational Supervisor, Clinical Supervisor, Assessor and Trainee. Their responsibilities are described in the appendix 6 and further information is given in the Gold Guide. The GMC’s process for approving trainers has meant that AES’s and CS’s can now be formally identified and trainees must be placed in approved placements that meet the required training and educational standards of the curriculum. The level of supervision is determined by the supervisor, centring around safe patient care; the autonomy of the trainee subsequently increasing as their capabilities do so. Achievement of supervision level IV in any of the five CiPs indicates that a trainee is able to work at an independent level, with advice from their trainer at this level being equivalent to a consultant receiving advice from senior colleagues within an MDT. 

A combination of formative and summative assessments form the basis of progression at each ARCP. The primary assessment is the relatively new ‘Multi Consultant Review’ (MCR). Mandatory Work Based Assessments (WBA’s), trainee self-assessment of CiP’s and GCP’s, and Multisource Feedback (MSF) form the other formative feedback assessments. These form the trainees portfolio alongside the summative intercollegiate examination and AES reports. 

Trainee progress is monitored by their AES but their CS’s are responsible for ensuring assessment of the CiP’s and GCP’s using the MCR. 

Several meetings should take place between AES and trainee. Objective settings and learning agreements (marking the progress through each placement) should take place at the beginning of each placement with the AES. A midpoint review assesses progress using WBA’s, log book, self assessments and the midpoint MCR. A final meeting takes place towards the end of each placement, for which a final MCR is completed. This then leads to the an AES report which, alongside the trainees portfolio, informs the ARCP panel of a trainees progress. This is a formal Deanery / HEE process overseen by a TPD and SAC representative.