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Orthopaedic training: time for change

Orthopaedic training is being harmed by changing hospital practices and shift systems. In the first of two articles, Professor W Angus Wallace and Clare Marx say new approaches are required

Wallace and Clare Marx say new approaches are required Prof W Angus Wallace is chair of

Prof W Angus Wallace is chair of the Specialty Advisory Committee (Training Committee) in Trauma and Orthopaedics

Committee (Training Committee) in Trauma and Orthopaedics Miss Clare Marx is president of the British Orthopaedic

Miss Clare Marx is president of the British Orthopaedic Association

T he traditional methods of trauma and orthopaedic training over the past 10 years

have been affected by a number of changes which have been introduced into NHS hospitals.

These have been brought in to solve problems related to delivering a service to our patients in what has been perceived to be a more efficient way.

Some have been carried out with

a genuine interest in improving

patient care and some have been brought in out of necessity because of a reduction of staff availability, most recently because of the European Working Time Regulations.

However, none of the changes have been carried out with

a genuine concern for the

quality of training which our trainee surgeons are offered, despite the fact that their day- time salaries are not paid by the NHS hospitals but by the postgraduate deans.


Although patients who are admitted to trauma (fracture) and elective orthopaedic wards in NHS hospitals are under the care of a named consultant orthopaedic surgeon who is primarily responsible for their medical and surgical care, the medical care was, and often still is, devolved to the most junior member of the surgical team – previously the junior or senior house officer, now the foundation year doctor (FY1 or FY2) or the early years surgical

trainee – specialty trainees (ST1 or ST2).

The ST1 and ST2 doctors are in their early years of surgical training and the curriculum to which they have been signed up since 2007 requires them to develop their training specifically in the field of trauma surgery and to become competent at some of the more common trauma operations. As a result, there has been a tendency to move ST1 and ST2 surgeons from elective orthopaedic

surgery to the trauma wards for their early training years, leaving less experienced FY1 and FY2 doctors looking after the elective orthopaedic patients.

The problems encountered at the coal face of trauma and orthopaedic surgery

Over the years we have seen an increasing number of patients with osteoporotic fractures, predominately of the hip, but these patients are being admitted as more elderly patients, often with a number of coexisting medical problems or co-morbidities which make these patients increasingly challenging with regard to their medical care.

These patients fill the trauma wards but it is their initial medical care and the subsequent medical complications which are now the main challenge and we continue to ask our young trainee surgeons to help manage medical conditions which are both difficult and complex.

Recently, discussions between the British Orthopaedic Association and the British

Geriatric Society have resulted in a greater commitment from consultants in healthcare of the elderly to help with the management of these patients but this help is variable across the country. The recent appointment, by the Department of Health, of a national clinical director for trauma care with the specific remit to implement policy change in fragility fracture care, has been accompanied by promoting and £1.3m funding of the National Hip Fracture Database (NHFD) as one of the six national audits to take forward in 2010.

The Department of Health has also agreed that that hip fracture is one of only four diagnoses that will carry a supplement best practice tariff from April 2010 to incentivise change.

Finally, the national clinical director for trauma care has worked to link the NHFD to the Payment by Results (PbR) best practice tariff programme which will be dependent on professionally derived and recorded NHFD metrics and not HES data (time to theatre and orthogeriatrician involvement) to be announced by PbR in November.

The 4 hour waiting time for accident and emergency attendances

In February 2004, the government introduced a new incentive scheme aimed at reducing waiting times in accident and emergency. The target set was that 97 per cent of patients had to be seen, treated or discharged

within four hours. The A&E departments in many hospitals have addressed this target by demanding that a member of the T&O team is available either in the A&E department or available immediately on-call for the A&E department from 08.00 to 21.00 – although this varies from hospital to hospital.

being properly trained but feel they are simply being used as doctors propping up a service. This is reflected in their training performance.

In the Eraut report (2009),

a very comprehensive review

of young surgeons training, Professor Michael Eraut from the

University of Sussex stated in his

needs to be urgently addressed. Developing a parsimonious but effective mode of discourse between trainers, and between trainers and trainees, could be enhanced by initiatives such as using still pictures and short

audio commentaries by trainee and trainer.

4. Trainees describe service

The consequence of this is that ST1, ST2 and ST3 T&O doctors

How are these changes


work as devoid of learning, while trainers argue that most

have been allocated to effectively


The level of concern about

staff the A&E department and this has removed them from training in the ward and operating theatre situation. This may have improved the service to NHS patients but it has actually harmed the training of the T&O early years trainee.

affecting early years T&O training?

trainees’ progress is very high. A significant number of trainees, now due to become consultants, have received less practical experience than their predecessors and feel less confident as a result.

This group began their specialist training before the introduction of EWTD and the government’s waiting list targets initiative. So

The impact of this process needs

aspects of service work provide good learning opportunities. This issue could be addressed by giving methodological attention to groups of cases of the same condition, focussing on (a) their similarities and differences,

and (b) patient pathways from clinic to aftercare and audit. The latter could be usefully enhanced by contributions from nurses, physiotherapists, specialists in imaging and pathology, etc.

The outcome from the analysis

At the British Orthopaedic

Traditionally the T&O early years trainee has been trained on what was effectively an apprenticeship scheme. This scheme meant that they worked within a team – usually a consultant, a senior trainee (ST4-8) and a junior trainee (ST1-3).

The consultant took responsibility for the training of their two trainees and as a team they provided a service for their patients. The scene in hospital has now changed dramatically.

we can now reasonably predict that both the practical experience and the training experience of each successive cohort will decline every year for the next six to eight years.

to be modelled, so that the risks for the quantity and quality of future surgical consultants can be better predicted and contingency plans can be developed for plugging the major gaps in their expertise.

of surgical eLogbooks for early years surgical trainees

Association Meeting on 16-18 September 2009, a number of studies were reported in which current trainees’ surgical logbooks have been compared with those from three to five years earlier. The results are disturbing. Early years T&O trainees are expected to focus during ST1 and ST2 on trauma

In order to fulfil the increasing


The risks associated with the

and those from ST3 onwards

administrative demands, the team is now usually two to four consultants with one to two trainees of any level and with

current use of surgical trainees in emergency and trauma surgery need particularly urgent attention.

develop their training in elective orthopaedics – hip and knee replacement etc. The analysis of their eLogbooks showed the

less opportunity for the trainee


to work as an apprentice to their


The training that does occur



less effective than previously


Early years trainees (ST1 and

In fact, the trainee’s role is very much one of being a “service doctor” rather than a “surgeon in training”. The consequence is that much disenchantment about T&O training is now present in the training ranks – they now do not see themselves as

because of the limited continuity of trainers. When trainers and trainees meet less often

and trainees have several trainers, there may be little or no communication between the trainers involved with the same trainee. This important problem is far from simple, but

ST2) now had a 25% reduction in the number of operations which they carried out. They had a small reduction in trauma operations and a 50% reduction in elective surgical operations. Although the reduction in elective surgical operations could have been expected, there should


have been a 30% expansion in the number of trauma operations carried out.

2. Later years trainees (ST3 and ST4) had a 50% reduction in the elective operations carried out – just the area in which they are being expected to be increasing their experience.

These changes are, in major part, attributed to ST1 and ST2 doctors taking part in hospital at night rotas and in ST3 and ST4 doctors now being seconded to a general on-call pool rather than working as an apprentice and the secondments to the A&E departments in order to solve the 4 hour wait target.


In many hospitals, T&O trainees are no longer trainees; they are service doctors and they are no longer being trained adequately in the specialty of trauma and orthopaedic surgery. If we do not address this now, the UK will have a cohort of poorly trained, inadequate consultant surgeons within the next five years.

In our next article, we will address some of the solutions which might be brought in to address the problems we have identified, recognising that there will be little if any extra funding for the NHS in the next five years.

if any extra funding for the NHS in the next five years. In many hospitals, T&O

In many hospitals, T&O trainees are no longer trainees; they

are service doctors and they are no longer being trained adequately in the specialty of trauma and orthopaedic surgery

and they are no longer being trained adequately in the specialty of trauma and orthopaedic surgery