t h e s u r g e on 1 0 ( 2 0 1 2 ) 9e1 5

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The Surgeon, Journal of the Royal Collegesof Surgeons of Edinburgh and Ireland

www.thesurgeon.net

A survey of UK surgical trainees and trainers; latest reformswell understood but perceived detrimental to surgical training

Sajid Mehmood a,b,*, Saima Anwar c, Jamil Ahmed c, Muhammad Tayyab b, David O’Regan a

a Leeds General Infirmary, The Leeds Teaching Hospitals NHS Trust, Leeds, United KingdombCastle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Hull, East Yorkshire, United KingdomcScarborough General Hospital, Scarborough and NE Yorkshire NHS Trust, Scarborough, United Kingdom

a r t i c l e i n f o

Article history:

Received 28 September 2010

Received in revised form

3 December 2010

Accepted 6 December 2010

Available online 1 February 2011

Keywords:

Surgical training

Reforms

Trainee

Trainer

Modernizing medical careers

* Corresponding author. Academic SurgicalUnited Kingdom. Tel.: þ44 1482622393; fax:

E-mail address: drsajidm@hotmail.com (1479-666X/$ e see front matter ª 2010 RoyalSurgeons in Ireland. Published by Elsevier Ldoi:10.1016/j.surge.2010.12.001

a b s t r a c t

Introduction: In the United Kingdom, surgical training reforms as part of modernising

medical careers (MMC) became fully operational in 2007. This study aims to establish the

level of insight and views about MMC based surgical training amongst surgical trainers and

trainees working in the National Health Service.

Methods: An electronic survey consisting of eight questions was disseminated to surgical

trainers and trainees via a web-based link placed on Association of Surgeons in Training

website.

Results: A total of 138 responses were received. Of those, 77% (n ¼ 107) were from trainees.

92% (n ¼ 127) of respondents understood that the purpose of MMC surgical reforms was to

provide structured training. 98% (n ¼ 135) agreed traditional SHO training was poorly

structured. Two-thirds (67%, n ¼ 92) believed that MMC will reduce the total time period to

complete surgical training. 82% (n ¼ 113) recognised work place assessments as an

assessment tool for MMC competencies. 82% (n ¼ 113) were aware that an educational

supervisor is assigned to monitor individual training. 70% (n ¼ 96) understood that training

is a shared responsibility between trainee, educational supervisor and supervising

consultants.

However, 69% (n ¼ 95) of respondents believed the standard of surgical training via MMC

will deteriorate, 18% (n ¼ 25) anticipated no difference, 8% (n ¼ 11) passed no comments

and a mere 5% (n ¼ 7) perceived it as an improvement.

Conclusions: This study confirms a generally good level of insight amongst trainers and

trainees into the aims and structure of MMC based surgical training. However, the majority

believe that ultimately the standard of surgical training is set to fall.

ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and

Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Introduction as an action plan to address serious concerns about the lack of

In the United Kingdom, Modernizing Medical Careers (MMC)

programmewas developed to reform the training of doctors in

Senior House Officer (SHO) grade. These reforms came largely

Unit, Castle Hill Hospiþ44 1482623274.Sajid Mehmood).College of Surgeons of Ed

td. All rights reserved.

structure in traditional SHO training. This cohort of trainees

had poorly planned training with no defined end-point and no

defined educational goals.1,2 MMC system of training devel-

oped a two-year foundation programme, followed by run-

tal, Hull and East Yorkshire NHS Trust, Hull, East Yorkshire,

inburgh (Scottish charity number SC005317) and Royal College of

t h e s u r g e on 1 0 ( 2 0 1 2 ) 9e1 510

through specialty training programme across all specialties.

The principal aim of MMC was to develop a better-structured,

time-capped, and competency-based system for training and

assessment.3

Surgical training reforms as part of MMC became fully

operational in 2007 and share the same fundamental princi-

ples. The MMC based surgical training is developed to be

delivered as per nationally agreed curricula for all surgical

specialties. Record of training assessment and progression is

now officially maintained on intercollegiate surgical curric-

ulum programme (ISCP) website.4 Trainees have assigned

educational supervisors and training is closely monitored at

each level. Formal work-place based assessment tools are at

the heart of structured training and make one of the most

significant differences compared with the old system of

training. A trainee’s progression is assessed by documented

acquisition of competencies through work-place based

assessments throughout the training period and formally

reviewed at annual review of competence progression (ARCP)

meeting, in common with other specilaties.3,4 Current model

Abbreviations: AES – assigned educational superassessments, CBD – case based discussion, CEX directly observed procedural skills, PBA – procedassessment tool, ISCP – Intercollegiate Surgical Cprofessional development

WBA (CBD, DOPS, CEX, PBA, PAT)

AES to monitor individualtraining /

address learning needs

Meetings with AES: Learning agreement and

AES’ report Annual rof compe

progres(ARC

Surgiccurricu

Traincentrtraini

Fig. 1 e Current model of MM

of surgical training incorporating MMC reforms is shown

in Fig. 1.

The implementation of the surgical training reforms was

part of a larger process of implementation of MMC pro-

gramme at national level encompassing the foundation and

specialty training across all specialties. Quite understandably,

such a radical change of reforming the training programmes

and the recruitment system required a robust implementation

strategy by adopting a staged approach. Unfortunately,

implementation of these reforms at national level saw most

unprecedented failure of the central web-based recruitment

system.5 This prompted initiation of an inquiry into the MMC

reforms and their implementation process led by Sir John

Tooke.6 The report of this inquiry, Tooke report, proposed

several recommendations to salvage the MMC programme.7 It

recommended that the structure of postgraduate training,

including the relevant selection and assessment processes,

should provide a broad based platform for subsequent higher

specialist training. The most significant development in

surgical training, as recommended by Tooke report, was un-

visor, WBA – workplace based – clinical evaluation exercise, DOPS – ure based assessment, PAT – peer urriculum Programme, CPD – continuous

eview tence sionP)

Collegeexamination (MRCS)

CPD, teaching, research, audit

Record of operative

experience(ISCP logbook)

allum

eeedng

C based surgical training.

Table 1 e Basic demographic data of respondents, theirhospital base and grade.a

Number of respondents 138

Gender

Male 113 (82)

Female 25 (18)

Age, years, Mean (SD) 35.3 (6.1)

Hospital base

University 76 (55)

DGHb 62 (45)

Grade of respondents

STc: 1e2 or equivalent 13 (9)

t h e s u r g e on 1 0 ( 2 0 1 2 ) 9e1 5 11

coupling of core training from higher surgical training, i.e.

a split in the run-through training. Tooke report promoted

MMC’s key features of providing structure to training in the

form of competency-based assessment, educational supervi-

sion and promoting excellence.7

Surgical training continues to evolve in its structure in the

light of Tooke report in an era of reduced working hours. The

aim of this questionnaire survey was to establish the insight

of surgical trainers and trainees about these surgical training

reforms and to record their views about the resultant quality

of surgical training.

ST: 3e8 or SpRd 87 (63)

SASGe 7 (5)

Consultant 31 (23)

a Data are presented as number (percentage) unless otherwise

indicated.

b District General Hospital.

c Specialty Trainee.

d Specialist Registrar.

e Staff Grade & Associate Specialist.

Methods

A web-based questionnaire survey was undertaken. The

survey questionnaire comprised of 12 questions, four per-

taining to demographic details of the participants and eight

structured questions related to the key features of training

reforms as published on ISCP and MMC websites.3,4 Each

structured question contained four options with one best or

correct response. Participant could only select one response.

There were no open-ended questions.

Surgical trainers and trainees were invited to participate in

the survey via a web-based link placed on the Association of

Surgeons in Training (ASiT) website. All trainers and trainees

from any surgical specialty were eligible to participate.

Consultant surgeons, regardless of whether in clinical super-

visor, educational supervisor or no supervisory role, were

defined as trainers. Doctors working in grades of specialty

training (ST) 1, 2 or equivalent, ST3 to ST8, and specialist

registrar (SpR) were defined as trainees. Doctors in staff grade

and associate specialist (SASG) grade were also eligible to

participate and considered equivalent to trainees in the SpR

tier due to their potential eligibility for certificate of comple-

tion of training (CCT) via article 14 route provision.8

Reminder emails were sent twice to maximise the

response rate. Database was maintained and analysed in

Microsoft Excel. Responses were tabulated and reported as

percentages. Responses from trainees and trainers regarding

their views about standard of MMC based surgical training

were compared using SPSS software (V.17 for Windows; SPSS

Inc, Chicago, IL). Chi-square test was used to compare cate-

gorical variables between the two groups. A p-value of <0.05

was considered statistically significant.

Fig. 2 e Surgical training reforms aim to make training.

Results

A total of 138 responses were received. Of those who respon-

ded, 77% (n ¼ 107) were trainees. Main groups of respondents

included: Specialist registrars/ST3-8 63% (n ¼ 87), consultants

23% (n ¼ 31), ST1-2/SHO 9% (n ¼ 13) and associate specialist/

staff grade 5% (n ¼ 7). Fifty-five per cent of respondents

belonged to university hospitals. Demographic details of the

respondents are given in Table 1. Of those who responded,

there were 113 (82%) males and the mean age was 31 years at

the time of completion of the survey.

Figure 2 shows understanding of the respondents about

the aim of the MMC surgical training reforms. Ninety-two per

cent (n ¼ 127) of respondents understood that the purpose of

MMC based training reforms was to provide structured

training. Fig. 3 pertains to the question asked about the main

finding of English chief medical officer’s report, Unfinished

Business.2 Consistent with his report, a great majority of

respondents (98%, n ¼ 135) agreed traditional SHO training

was poorly structuredwith no limit on time spent in the grade

and thus described as ‘lost tribe’. When asked about their

knowledge of the duration of MMC based surgical training,

some two-thirds of the respondents (67%, n¼ 92) believed that

surgical training reforms under MMC will shorten the total

duration of surgical training compared with old system

(Fig. 4). Nearly half the respondents (46%, n ¼ 64) correctly

recognised that the term specialty registrar (StR), rather than

senior house officer, applies to doctors in initial years of

training in the new nomenclature (Fig. 5).

Next three questions highlight the salient features of

assessment and monitoring in MMC based surgical training

which distinguish it from the traditional training. Eighty-two

per cent (n¼ 113) recognisedwork-place based assessments as

the competency assessment tool in MMC (Fig. 6) and a similar

proportion (82%, n ¼ 113) were aware that an educational

Fig. 5 e Nomenclature of doctors in initial years of training.Fig. 3 e Grade needing reforms, described as ‘lost tribe’.

t h e s u r g e on 1 0 ( 2 0 1 2 ) 9e1 512

supervisor is assigned to monitor individual training at each

level (Fig. 7). Moreover, 70% (n¼ 96) understood that training is

a shared responsibility between trainee, educational super-

visor and supervising consultants (Fig. 8).

When asked for their views about quality of surgical

training as a result of the reforms, interesting results were

received (Fig. 9). Two-third (69%,n¼ 95) of surgical trainees and

trainers believed the standards of surgical training will dete-

riorate, whereas 18% (n ¼ 25) anticipated no difference. Eight

per cent (n¼ 11) passedno commentsabout thequality ofMMC

based surgical training and a mere 5% (n ¼ 7) perceived any

improvement. A comparison of the responses from trainees

and trainers was made and no significant differences in

responses were found (Table 2).

Discussion

The results of this survey indicate the understanding of the

surgical trainees and trainers about training reforms and their

impact on the quality of training. It is evident that surgical

trainees and trainers have good insight into the new changes

brought into the structure, delivery and assessment of

surgical training. Surgeons demonstrated their knowledge

about the problems with previous training system that led up

to the introduction of these reforms. A majority of them are

Fig. 4 e Duration of MMC based surgical training.

aware that training is better-structured, competency-based,

supervised and closely monitored.

However, our survey found that a majority of surgeons

believe the training standards will be compromised following

MMC reforms. There are several possible explanations for this

perception. The core feature of streamlined training in MMC

leads to substantial reduction in the total number of hours

available for training.9 Similar concerns were being echoed

around the time of implementation of these reforms.9,10 The

common denominator remains the inherent feature of

shortened training period.9 However, the Academy of Medi-

cal Royal Colleges dismissed these concerns stressing upon

appropriate utilisation of training time. Colleges promoted the

concept of training delivery in a more focused manner with

explicit use of trainee-trainer contact time.11 Surgeons’ poor

confidence into requesting quality of MMC based training,

reflects the fear that a new systemmay struggle to deliver the

quality of training it promises. Whereas the training delivery

with close traineeetrainer relationship was envisaged to be

an effective training model, it may not be accepted as

a compensatory measure for a shortened training period.

Training opportunities are further hampered, as some degree

of training time is certainly lost to service provision. Other

factors affecting the trainees’ and trainers’ confidence in the

new systemmay include: un-availability of training lists, mal-

distribution of trainees in sub-specialties/hospitals, validity/

Fig. 6 e Competency assessment tool in MMC based

surgical training.

Fig. 9 e Standard of MMC based surgical training.

Fig. 7 e Person assigned to monitor a trainee’s training.

t h e s u r g e on 1 0 ( 2 0 1 2 ) 9e1 5 13

application of in-training assessment and, understanding and

engagement of trainees, trainers, and trusts.12

It must be acknowledged that the MMC programme

brought several positive changes in training delivery and

assessment. The fundamental principles of MMC govern the

provision of structured, curriculum-based, competency-

assessed and well supervised training.3 Arguably, MMC came

as ananswer to concerns surrounding traditional SHO training

with no defined educational goals. MMC redefined the training

structure of the lost tribe of SHOs. Clearly, the foundation of

current day structured surgical training was laid by MMC

reforms. The principles of MMC system still apply and form

the core principles of training delivery and assessment.

The shortened training period in MMC is, in part, linked to

the European working time directive (EWTD) posing a direct

threat to quality of surgical training. In parallel with early days

ofMMC, awealth of evidence accumulated about the impact of

reduced working hours of EWTD on surgical training.13e17 The

resultant reducedexposure to case-load forced some to believe

surgeons at the time of completion of training would not be

ready for a consultant role.13,18 Surgery is a craft speciality in

which training thrives on the amount of operative experience

gained, in its simplicity. Reduced time in training is perceived

to have direct bearing on this experience, clearly detrimental

to acquisition of sound surgical skills and competence to deal

with operative complications. In addition to directly affecting

Fig. 8 e Responsibility of training is shared with.

training time, EWTD further impacts on training as operating

time is lost to service provision.18 The negative impact of

EWTD has been consistently shown to hamper training

opportunities, competence development and trainee satis-

faction across the surgical specialties.13e17 Moreover, it has

been found to adversely affect the continuity of care.15

Surgeons are left with no choice but to keep a realistic

approach. EWTD has become an obligatory regulation since

August 2009. The un-avoidable fact of a shortened training

periodneeds tobeacceptedandappropriately tackled. Surely, it

providesa strong drive to improve theway training is delivered.

Amore recent comprehensive review of EWTD by Professor Sir

John Temple suggested a number of fundamental changes

to deliver effective training within the constraints of redu-

ced training time.19The recommendationsof theTemple report

include: Re-configuration of a consultant delivered service

explicitly supporting training, training delivered in a service

environmentwith appropriate consultant supervision, training

planned and focused for trainee’s needs, maximising every

possible training opportunity, supervised handover practice,

integrated use of technology and simulation, recognising,

developing and rewarding trainers, and recognising educa-

tional governance on every trust board to ensure excellence in

training.19 Indeed, training delivered in such a way will ensure

competency development in a relatively short period.

There is an obvious need for a multifaceted approach to

deliver training in a shortened period. Attitude towards

surgical skills teaching and learning will inevitably change.

Various skills development and assessmentmodels have been

developed. Most of those rely on developing surgical skills in

a non-clinical setting before transferring to the clinical envi-

ronment. An objective surgical training tool, with an ability to

teach generic skills at six progressive levels of competence, is

one of the tested models. In this novel model, surgical skills

exercises with increasing levels of competence, dedicated

trainer-trainee contact, immediate feedback and opportunity

to practise at home ensure rapid acquisition of skills.20 More-

over, encouraging results can be achieved when surgical skills

teaching is contemplated at an early stage in career, possibly at

undergraduate level.21 Surgical simulation has a well defined

role in surgical skills teaching. In addition, training in the

simulated environment does not carry clinical consequen-

ces in case a technical error occurs.22,23 Simulated training

on virtual reality devices has the potential to supplement

Table 2 e Views of trainees and trainers about the standard of MMC based surgical training.a

Standard of MMC basedsurgical training

Trainees þ trainers (n ¼ 138) Trainees (n ¼ 107) Trainers (n ¼ 31) P valueb

Improved 7 (5) 4 (4) 3 (10) 0.18

Worse 95 (69) 75 (70) 20 (65) 0.55

No difference 25 (18) 19 (18) 6 (19) 0.83

No comments 11 (8) 9 (8) 2 (6) 0.72

a Data are presented as number (percentage).

b Chi-square test.

t h e s u r g e on 1 0 ( 2 0 1 2 ) 9e1 514

standard training and can be a useful tool to develop surgical

skills to be applied in real environment.24 Similarly, practising

on animal models in wet lab has been shown to be effective

method of acquiring surgical skills.25

Strategies to maximise operative exposure have been re-

commended. Taking time out of training to gain experience at

overseas centres has been shown to enhance the exposure

and skills substantially, especially in emergency surgery.26 To

substantiate surgical skills in clinical environment, training in

dedicated training theatre lists has been suggested.27 Re-

configuration of services will increasingly allow provision of

such theatre lists. For trainees struggling to demonstrate

competence achievement at the end of training or aspiring to

further their skills in a sub-specialty area of interest, a period

of post-CCT fellowship has been recommended.28

Despite thewidespread concerns surrounding the quality of

MMC based surgical training, these reforms were inevitable

given the problems with traditional training. Traditional

apprenticeship model of surgical training now appears to

be outdated.29 Structured, curriculum-based, competency-

assessed and well supervised training with defined learning

goals at each level of training is the way forward.11,29 Having

already embarked on such a training model, we should now

look to improve the standards, learn from experience and seek

to improve as necessary. It is now time to accept the limita-

tions like EWTD, and implement the strategies to maximise

training.19Goodunderstandingof surgical traineesand trainers

about the new training system means they can be effectively

engaged into implementing all such strategies to promote the

education and training of future surgeons.

Conclusions

This study confirms a generally good level of insight amongst

trainers and trainees into the aims and structure of surgical

MMCtraining.However, themajoritybelieve thatultimately the

standard of surgical training is set to fall in a shortened training

period.We recommend surgeonsmust implement strategies to

maximise skills developmentwithin the constraints of reduced

training times tomaintain thecurrenthigh level ofcompetence.

Disclaimer

Presented to international congress of the Association of

Surgeons of Great Britain & Ireland (ASGBI), Glasgow, May

2009 and published in abstract form in British Journal of

Surgery cited as Br J Surg 2009; 96(S4): 82e180.

Conflict of interest statement

Authors declare no conflict of interest.

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