Article Text

Military surgery in the new curriculum: whither general surgery training in uniform?
  1. Neil Shastri-Hurst1,
  2. D N Naumann1,
  3. D M Bowley1,2 and
  4. T Whitbread2
  1. 1Department of General Surgery, Heart of England NHS Foundation Trust, Birmingham, UK
  2. 2Joint Medical Command, Lichfield, UK
  1. Correspondence to Gp Capt Tim Whitbread, HQ JMC, Coltman House, DMS Whittington, Lichfield, UK. WS14 9PY; SGJMCMEDD-DCASurg{at}mod.uk

Abstract

Background The nature of general surgical training within the UK has undergone significant changes recently, including the evolution of the Intercollegiate Surgical Curriculum Programme (ISCP). In 2013, new task-specific goals tailored towards military surgery were incorporated into the general surgery curriculum. In order to meet the demands of training the next generation of military general surgeons, a new compendium of workplace-based assessments (WBAs) is now required.

Addressing the need In 2013, the ISCP general surgery curriculum was revised to include new, military-specific WBAs to allow formative assessment of a trainees’ experience and preparedness for their future deployed role. Index procedures considered mandatory for a deployed military general surgeon to be effective in the field are now included in the general surgery curriculum. These will permit formative assessment of trainees and also permit revalidation of deployed skills among the consultant cadre.

Conclusions General surgical training in the UK is in a transitional period, and the move towards increased sub-specialisation appears inexorable as evidenced by the split of Vascular Surgery into a separate specialty, along with its own training pathway and curriculum. With the ‘generalist’ demands on deployed surgeons in the Defence Medical Services, the task of training towards broader surgical competencies may appear daunting. Inclusion of defined military WBAs into the curriculum should help focus trainees and their trainers to identify the deployed general surgical skill set, identify the appropriate learning opportunities/placements required to enable the acquisition of relevant competencies and document their attainment and later retention.

  • Military Surgery
  • Medical Education & Training
  • Curriculum

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Key messages

  • Surgical training is undergoing a period of flux.

  • The DMS requires broad surgical competencies in order to fulfill operational demands.

  • Through a combination of military specific PBAs, operational experience, and simulated training it is hoped that the future development needs of military surgeons are met.

Background

In the past decade, surgical training in the UK has undergone major changes. In 2008, the publication of Modernising Medical Careers led directly to the introduction of the Intercollegiate Surgical Curriculum Programme (ISCP).1 The ISCP provides the approved training programme from the start of Specialty/Core Training through to the Certificate of Completion of Training (CCT). The curriculum is competence-based and focuses on the trainee's’ ability to demonstrate the knowledge, skills and professional behaviours acquired in their training through direct observation, discussion and reflection. Procedural-based assessments (PBAs) have been adopted to act as the principle method by which surgical trainees may receive assessment of their progression in specific procedural skills. PBAs are formative, not summative (ie, they are assessments of progression, filled out contemporaneously, not ‘signed-off’ after the skill has been achieved).

The era of the ‘true’ general surgeon in the NHS has passed.2 ,3 Sub-speciality focus in training now takes place at a much earlier stage of a surgeon's career. General surgical trauma experience within the NHS setting is limited; in 2002, in a questionnaire study aimed at UK consultants and trainees, just under a half of Specialty Registrars declared no experience in packing a liver for trauma, a third having not repaired a peripheral vascular injury and a fifth having not performed a splenectomy in the trauma setting. In addition, only 30% of consultant general surgeons felt they had the adequate skill set to manage acute cardiothoracic injuries.4 To compound matters, the introduction of the European Working Time Directive and later European Working Time Regulation have reduced the available time for surgical training opportunities, prolonging the years taken to achieve competency in independent operating.5 ,6

From August 2013, a further significant change has occurred in general surgical training, with the separation of Vascular Surgery from the specialty of General Surgery. It was now even harder than previously to train someone in the generality of surgery required on deployment within the training programmes principally developed to provide for the needs of the NHS. As a result, when the General Surgery Curriculum was revised in 2013, it was developed to include Advanced Trauma/Military Surgery as a defined area of that curriculum.7 These changes have mandated the introduction of WBAs, beginning with PBAs required to evaluate the adequacy of training of military surgeons within the Defence Medical Services (DMS), to ensure that they are able to deliver the necessary level of care on operations after CCT.

Training structure

The start of Specialty Training in general surgery in the UK begins with competitive selection into Specialty Training Year 3 (ST3). This follows a 2-year generic Core Surgical Training (CST) programme, encompassing at least 12 months of general surgical experience. As a result of the condensed nature of CST, the specialty trainee in general surgery may have limited experience in allied surgical specialties at the outset.8

Specialty Training itself is sub-divided into two stages; Intermediate and Final. The Intermediate stage covers the ST3–4 training period, while the Final stage (itself sub-divided into Final I and Final II) covers the ST5–8 years of training. The details of these stages are summarised in Table 1.

Table 1

Summary of the structure of HST

Progression through training is assessed via the Annual Review of Clinical Progression (ARCP). Trainees are awarded their CCT upon successful completion of all stages of training, having achieved the competences as outlined in the ISCP syllabus as evidenced by their Training Programme Director at successive ARCPs. Trainees must also pass the Intercollegiate Fellowship of the Royal Colleges of Surgeons examination.

Procedural-based assessments

PBAs are now the recognised modality of conducting on-going formative assessments of surgical trainees' operative skills. These assess core competences in terms of clearly defined, measurable characteristics and incorporate a continuum of management from the pre-operative stage through to the post-operative period.9 ,10 The ISCP curriculum has identified a number of index procedures in which competence must be achieved during training. Assessment is based on a scoring system of 1–4. The criteria for each of these components of the scoring system, as outlined by ISCP, are summarised in Table 2.7

Table 2

Description of competency levels

Workplace-based assessments encompass many different modalities of which PBAs form just a part. In terms of assessing competences that may be required in deploying military surgeons, it is rational to start with PBAs covering operative/procedural skills that are outwith the scope of the majority of civilian general surgical practices. Once that foundation is laid, the system can be reinforced by development of other assessment modalities such as case-based discussions to look at decision-making processes, underpinning basic science knowledge and so on.

Training the military general surgeon

Military general surgeons are required to provide non-orthopaedic trauma care on deployment, whether it is during war or ‘operations other than war’. In addition to their role in the management of trauma they must be able to provide a general surgical service to deployed allied personnel and civilian contractors along with displaced civilians, prisoners of war and even local nation servicemen in the later stages of rebuilding. It is therefore essential that the surgeon demonstrate a broad spectrum of general surgical skills, as well as competency in managing non-orthopaedic trauma. These skills may not all be readily gained in a standard UK surgical training programme, and relevant trauma experience must be developed and maintained in parallel throughout the career of the military surgeon. It is not acceptable practice to develop these skills while on operations; rather they should be fostered as a trainee under the guidance of skilled and experienced practitioners8 ,11 and then maintained throughout a consultant career that will be based within the NHS.

The fundamental deployed UK surgical team consists of a general and an orthopaedic surgeon. Given the nature and number of injuries encountered on recent operations, the inclusion of a third surgeon in the basic deployed unit will increase the personnel and available operative skills to the team.11 Between all of the deployed surgeons, there needs to be a set of competences that must be collectively held in order to achieve operational effectiveness.12 Furthermore, given that paediatric casualties have represented a significant workload (2%–33%) in recent conflicts, the ability to manage injured children effectively is a vital requirement.10 ,13–16

As a result of experience on operations in Iraq and Afghanistan, a new approach has been undertaken to the training and development of military surgical trainees. Trainees have been able to join their Consultant colleagues on deployments in order to augment their trauma experience, as well as providing a useful service during periods of heavy workload.17 In a scheme supported by the Surgical Royal Colleges, through the Joint Committee on Surgical Training and General Surgical Speciality Advisory Committee, 6- to 8-week deployments have been undertaken, providing a unique opportunity for training in a conflict setting. Some have compared the experience gained from this short-duration trauma exposure with a UK experience of 3 years.8

In addition to the ‘real time’ training experiences gained on operational duties, the Academic Department of Military Surgery and Trauma (ADMST) has identified and addressed the need for ongoing continuing professional development. Key initiatives in this regard have been ADMST's active involvement with the MSc in Trauma Surgery (Military), delivered by the University of Swansea and the Military Operational Surgical Training, hosted by the Royal College of Surgeons of England.18 ,19 These courses enable students to develop their operative skills and enhance their non-technical skills in military/trauma surgery, as well as their understanding of UK protocols and doctrine.

The ISCP curriculum, updated in 2013, has now incorporated specific objectives to be achieved by the military general surgical trainee.7 The acquisition of technical skills in Damage Control Surgery is vital to ensure the military consultant surgeon on deployment possesses the ability to perform life-, sight- and limb-saving procedures in arduous conditions, thereby stabilising the patient for evacuation less than 48 h from point of wounding. In order to achieve this aim, the development of new military task-specific PBAs was required.

Addressing the need

The new ISCP curriculum dictated a need for a new assembly of PBAs to enhance the trainee's’ experience and preparedness for their deployed role. Index procedures considered mandatory for future military general surgeons to be effective in the field have been included in the curriculum. The structure of the newly developed PBAs was based on the existing ISCP system.7 They are sub-divided into six distinct parts: (i) consent; (ii) pre-operative planning; (iii) pre-operative preparation; (iv) access and closure; (v) procedural technique; and (vi) post-operative management.

From these elements, key areas of variation and specific interest to the military surgeon are: consent, access and closure, and procedural technique. The legislature regarding consent as practiced in the UK cannot easily be directly translated to the war-footing setting;20 communication may also prove a barrier to informed consent and the ability to adapt to these circumstances must be evaluated. The ability to recognise futility of care and to understand how to operate within resource constraints is a key skill for military practitioners.21 These competences demonstrate the need to develop WBAs to assess areas other than operative skills. Access and closure along with procedural technique are inevitably task-specific, and while some may be outside the ‘comfort zone’ of most general surgical trainees, they must be embraced by the military trainee.

The current index military general surgical procedures are:

  • Median sternotomy

  • Trauma thoracotomy (anterolateral) and pulmonary tractotomy

  • Emergency thoracotomy (Clam Shell technique)

  • Tracheostomy

  • Femoral artery repair

  • Arterial shunting

  • Lower limb fasciotomy

  • Emergency Caesarean section

  • Craniotomy and evacuation of extra-dural haematoma

  • Craniotomy and evacuation of sub-dural haematoma.

The concept of procedural technique, using the Military Surgery PBA: Vascular trauma—Arterial shunt for Common Femoral Artery injury as an example, can be appreciated in Table 3. Further exemplars of these, in their entirety, are illustrated in the online supplementary appendices A–C.

Table 3

Military surgery procedural-based assessments: Vascular trauma—Arterial shunt for Common Femoral Artery injury; Sub-section (V) Procedural technique

While the formal development of a military sub-specialisation within the general surgery curriculum is to be supported, it is important to assess whether its current format goes far enough in identifying the needs of the military trainee, the DMS and the casualties they care for. A number of papers from a variety of coalition partners with experience in Afghanistan have sought to classify a surgical team skill set required in the combat setting.8 ,11 ,22–25 While a degree of variation exists between them, the consensus is firmly behind the ability to provide high quality surgical management of emergency abdominal, vascular, thoracic, orthopaedic and neurosurgical injuries. The most extensive of these, from the German model of ‘Einsatzchirurg’ (‘Surgeon to use’), are summarised in Table 4.23 While achievement of all of these skills by a single surgeon is challenging, the collective ability of the deployed surgical team to effectively manage these emergencies is essential for operational effectiveness. In the UK, such ‘collective training’ is delivered within the Military Operational Surgical Training course and, immediately before deployment in Hospital Exercises which allow the trainees to familiarise themselves with both their colleagues and the systems in place on operational deployment.

Table 4

A proposed skill set for the military surgeon23

As it presently stands, the new ISCP curriculum provides a rudimentary baseline for the core skills of the modern military surgeon. In its present format, it must be considered a work in progress. It remains some way distant from the aspirations expressed by an array of military surgeons with recent experience during times of conflict,8 ,11 ,22–25 and further development is still required. Given the high demands for medical support to the indigenous population during recent conflicts in Iraq and Afghanistan, this is particularly true with regard to the management of paediatric and emergency obstetric and gynaecological procedures.16 ,23

Ways and means

The challenges of obtaining competencies in these fields have been discussed at length. They are, by their very nature, a skill set specific to the military or humanitarian general surgeon and training opportunities within the NHS are limited. A balance must be struck between acquiring these skills prior to deployment and having ready exposure in the trainee's surgical training. As mentioned, the opportunity to undertake deployments as a trainee, under the guidance of an experienced consultant, is invaluable. However, this opportunity will be lost at the cessation of operations in Afghanistan.

The role of fellowships in surgical training has traditionally been in developing the trainee's area of specialist interest. High quality trauma experience outside deployments may require a period of time outside the UK, a prospect that has financial implications for the individual and DMS. The current fiscal constraints placed upon the DMS means justification for these fellowships must be robust and based on a sound business case.6 An extra training year(s) may even need to be bolstered onto the final stages of the CST programme for military trainees wishing to pursue a career in general surgery.

A more radical and innovative approach has been proposed by Willy et al in the form of ‘DUOplus.23 Within this model, the military surgeon attains a second specialisation alongside general surgery. This could either be in visceral surgery or trauma and orthopaedics. In order to achieve this, a further period of training is incorporated and a certificate of completion is required. The aim of this system is to ensure military surgeons are competent in the management of emergencies involving the viscera, vasculature and thorax. In addition, specific courses have been established to ensure the surgeon in training has a knowledge base to manage emergency neurosurgery, maxillofacial and gynaecological caseloads. Upon successful completion of these criteria, individuals are appointed for a period of 5 years, after which revalidation is required to ensure they remain combat fit.

For the more than the past decade, the Centre for the Sustainment of Trauma and Readiness Skills (C-STARS) programme has been providing didactic, simulation and real time trauma experience to personnel due to be deployed on operations.26 Under the central command of the Air Force Expeditionary Medical Skills Institute, the three C-STARS institutions use both civilian and military experiences of trauma care in order to evolve and develop the specialty and endeavour to keep the individual's skill sets up to date, whether as a trainee or fully accredited. The use of such a model in the UK may prove challenging due to the potential sparsity of the available workload but warrants further investigation and thought.

The future

The ‘Shape of Training’ review carried out by Professor Greenway and published in October 2013 provides much food for thought.27 The overarching objective of the review process was to ensure the delivery of highly qualified doctors who meet the changing demands of the modern health service. ‘Shape of Training’ focused on five key themes in its report, namely:

  1. Patient needs drive how we must train doctors in the future

  2. Changing the balance between specialists and generalists

  3. A broader approach to postgraduate training

  4. Tension between service and training

  5. More flexibility in training.

Among the 19 primary recommendations were a need for broad based training, with a more generalist skill set to adapt to the changing demands of health provision, a greater degree of flexibility in training pathways, and the return to a more traditional apprenticeship-based model of training, limited to a small number of designated units. It will be interesting to see how well these recommendations are received and acted upon.

General surgical training is in a transitional period in the UK. Its nature is changing, and the ability of both trainee and trainer alike to adjust to this is vital. For the military surgeon in the advent of DMS 20, the combination of ongoing operational duties as well as both military and civilian training requirements can feel daunting.28 It is hoped, however, that the integration and further development of these new PBAs, combined with operational and simulated experiences, may provide the trainee with the skill set necessary to provide effective clinical care in future deployments, wherever they may be.

References

Supplementary materials

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Footnotes

  • Contributors The original concept of the article was from DMB. NS-H was the primary author with advice and guiding contributions from DNN, DMB and TW.

  • Competing interests None.

  • Funding None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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