ORTHOPAEDICS
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
Prof W Angus Wallace is chair of the
Specialty Advisory Committee (Training
Committee) in Trauma and Orthopaedics
Miss Clare Marx is president of the British
Orthopaedic Association
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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.
Background
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
Sep/Oct 09

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.
The consequence of this is that
ST1, ST2 and ST3 T&O doctors
have been allocated to effectively
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.
How are these changes
affecting early years T&O
training?
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.
In order to fulfil the increasing
administrative demands, the
team is now usually two to four
consultants with one to two
trainees of any level and with
less opportunity for the trainee
to work as an apprentice to their
consultants.
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
Sep/Oct 09
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
recommendations:-
1. The level of concern about
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
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.
The impact of this process needs
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.
2. The risks associated with the
current use of surgical trainees
in emergency and trauma
surgery need particularly urgent
attention.
3. The training that does occur
is less effective than previously
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
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
work as devoid of learning,
while trainers argue that most
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
of surgical eLogbooks for early
years surgical trainees
At the British Orthopaedic
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
and those from ST3 onwards
develop their training in elective
orthopaedics – hip and knee
replacement etc. The analysis
of their eLogbooks showed the
following:-
1. Early years trainees (ST1 and
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
COMPANY NEWS
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.
Conclusions
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.
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
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