Final
Final and Special Interest Stage
Plastic Surgery trainees who enter ST7 from August 2013 onwards must follow the 2013 curriculum. Trainees entering ST8 should also use the 2013 version (in which the final stage syllabus is identical to 2012. Note that downloading 2013 syllabus topics in the learning agreement will automatically transfer progress recorded against 2012 syllabus topics). Trainees entering ST8 who were using an older version do not need to transfer in the final year.
Overview of model
The Final Years Plastic Surgery syllabus provides a detailed description of the range of practice within our specialty. The skill sets required of the competent consultant have been defined and mapped back into the Final Years. We think this is the logical way to proceed as these curricula were originally written from the early years forwards rather than from the consultant years going back. The Curriculum Development Group of the SAC in Plastic Surgery have sought to ensure there is no skills gap at the time of consultant appointment so that all may continue to have confidence in the value of our CCT.
We have introduced a modular structure of study that encompasses the areas of special interest and delivers the acquisition of competency based on Knowledge, Clinical Skills and Technical Skills. The subject matter of each module is presented in a hierarchical manner; namely Basic, Intermediate or Advanced Levels of complexity. Workplace Based Assessments are mapped to the Modules and to the Basic, Intermediate and Advanced Levels.
Basic level competencies have normally been achieved in the Early and Intermediate Years. At least part of the Intermediate Level has been covered in ST3-6 and the Final Years programme builds on this. Trainees are not expected to acquire all the Advanced Level skills in a particular syllabus but will choose specific modules to pursue at Advanced Level according to interest, opportunity and service need in consultation with the trainee's Programme Director.
Plastic Surgery encompasses Aesthetic*, Burns, Cleft*, Complex Wound, Craniofacial. Ear Reconstruction, Genitourinary Reconstruction, Hand*, Head & Neck*, Lower Limb, Oncoplastic Breast*, Skin, (*Indicates an existing Training Interface Fellowship arrangement with other specialties). For each special interest area we have specified a series of topic Modules that detail the pertinent Learning Objectives, Knowledge, Clinical Skills and Technical and Practical Skills.
The special interest areas together represent a total expression of our specialty and it is important for non-plastic surgeons reading this document to appreciate that there is no area of more general plastic surgery practice that is not otherwise covered under one of the syllabus areas. Aesthetic surgery, Cleft surgery, Hand surgery, Head & Neck surgery and Oncoplastic Breast surgery represent areas of practice that we share with surgical partners in other disciplines. Training Interface Groups (TIGs) exist for these special interest areas with opportunity for trainees from Plastic Surgery to work alongside other surgical groups. Although the Final Years syllabus, as written, is stated for Plastic Surgery there is also a clear need for TIG fellows from different specialties to have a common curriculum. We offer our own proposal for further consideration by other specialties. It is accepted in proposing solutions for our own specialty that we cannot expect an instantaneous and complete convergence of curriculum models with other surgical partners. It is reasonable to seek measures of agreement in shared areas of content and for other specialties to determine their own structures or models for training. We hold that the modular structure has much to commend it having utility, efficacy and flexibility at its core.
Vivien Lees, SAC Chair Plastic Surgery
on behalf of the Curriculum Development Group April 2012
For more information click on the following links:
Competency levels within each module
Assessment of the final years
PBA Blueprint
Training Pathways
Entry criteria
Exit criteria
Key features of model
JCST Quality Indicators
Glossary of terms
The overarching intercollegiate curriculum describes Levels 1- 4 competencies. The Final Years syllabus varies this by recognising that some parts of practice are inherently more difficult than others and that some more complex procedures are mastered from simpler competencies in a hierarchical manner (named as Basic, Intermediate and Advanced). Within the context of the Final Years curriculum competency is defined as Level 4.
A. Basic level competencies
Within each module there are elemental topics that are designed to act as building blocks from which more complex competencies can be achieved. Basic level competencies need to be achieved in all selected modules irrespective of which of the three career pathways is followed.
B. Intermediate level competencies
These include a list of the more common topics within each module and many of these competencies will already have been achieved within Intermediate Years prior to entry into the Final Years programme.
C. Advanced level competencies
This third tier of topics includes the most complex topics in each module and trainees will be expected to demonstrate a range of competencies from their selected modules.
The assessment of the curriculum will be by workplace-based assessments (WBA), including MSF, PBA and CBD, including a new format reflective CBD. The only formal test of knowledge in the Final Years is through the Intercollegiate Specialty Examination in Plastic Surgery. JCST Quality Indicators specify that the training post should be able to offer a minimum of 40 WBAs per year as outlined in the Final Years Assessment Blueprint. Evidence from these assessments will be used to inform the ARCP that will form the summative assessment of trainees.
Workplace Based Assessments
Module Specific PBAs
For each module there will be specific PBAs or DOPS for Basic Level, PBAs for Intermediate Level and PBAs for Advanced Level. DOPS and PBAs already exist on ISCP and some will have already been completed prior to commencement on the Final Years programme. Thus any competencies gained earlier in the programme can be migrated into and acknowledged in respect of the Final Years skill set. Mapping of logbook activity by special interest areas and by modules will be made available shortly through the Plastic Surgery E-logbook portal allowing easy overview of achievement and progression.
Multisource Feedback (MSF)
The MSF is one of the forms of WBA and it is specified that there will be one such feedback exercise each year. This is in line with what is likely to be required of consultants under revalidation.
Case-based Discussion (CBD)
These would be conducted in the format with which we are already familiar. Topics appropriate to the level of the trainee would continue to be selected as now and the discussion focussed to the appropriate level of training. It would be helpful to include emergency scenarios within the cases. It is further recommended that the CBDs be used for discussion around complex management planning particularly in the context of the multidisciplinary teams that are increasingly a feature of much plastic surgery activity.
Reflective CBD
A reflective CBD has been introduced as a new format CBD. One reflective learning episode would count as equivalent to a single WBA with the aim of achieving about 8-10 of these per year.
The reflective CBD represents a higher order learning tool seeking to inform and develop the senior trainee in preparation for consultant practice. The objective is to encourage trainees to think more like the consultant they are about to become. Senior trainees have accumulated a considerable store of professional and personal experience and this makes it easier for them to reflect on events. This is in contrast to junior trainees who may have a limited foundation of relevant experience and may lack insight into the subtleties of complex surgical decision-making. The ability to reflect is strongly correlated with star performers and therefore rightly associated with the higher order skills expected of trainees about to become consultants.
The trainee and trainer should agree the topic to be addressed prior to the discussion. The reflection can be conducted as a face to face discussion with the trainer or may be submitted in advance in written format for subsequent discussion. These reflective exercises will be conducted as Supervised Learning Events (SLEs), written reflections will not be uploaded onto ISCP but comment on the discussions held will be recorded in the usual way.
The specific areas that we would be interested in would map to the domains of Good Medical Practice[1]; namely:
- Knowledge, Skills and Performance
- Safety and Quality
- Communication, Partnership and Teamwork
- Maintaining Trust
Examples of suitable exercises could include:
Knowledge, Skills and Performance
- Reflection on operations undertaken or observed
- Clinical cases either from ward or clinic
- Scientific conference reports
- Journal Club reports
Safety and Quality
- Patient experience during a course of treatment
- Issues arising from audit
- Process and safety issues
- Ethics
Communication, Partnership and Teamwork
- Learning from Multidisciplinary Clinics (particularly important for plastic surgeons who participate in a number of these)
- Interpersonal communications and workplace issues
- Patient consent issues
Maintaining Trust
- Dealing with patient or colleague complaint
- Reflection on recruitment of patient to a clinical research trial
- Construct a hypothetical reference for another colleague
[1] Revalidation_way_ahead_annex1.pdf (GMC)
A PBA Blueprint shows for each special interest area the PBAs corresponding to the module and to the level of attainment within that module. There are hyperlinks to the PBAs and DOPS that exist on ISCP. Those that will be written are indicated in red text. Some existing PBAs have been taken from other specialties on ISCP for the relevant interface areas. The individual PBA blueprints appear in alphabetical order:
- Aesthetics (TIG)
- Burns
- Cleft (TIG)
- Craniofacial
- Complex wound
- Ear reconstruction
- Genitourinary reconstruction
- Hand (TIG)
- Head & Neck (TIG)
- Lower Limb Trauma
- Oncoplastic Breast (TIG)
- Skin
The Final Years trainee has several options in respect of developing further expertise in an area of special interest (see also Appendix A for a fuller description of Training Pathways).
Plastic Surgeon with Special Interest:
Either
- Training Interface Group Fellowship (pre-CCT, typically 1 year fellowship also open to trainees from related surgical disciplines).
It is envisaged that trainees undertaking a training interface group fellowship will achieve:
- Basic competencies in all modules
- Intermediate competencies in all modules
- Advanced competencies in up to 4 modules.
Interface Route Diagram
Or
Plastic Surgeon in General:
The trainee wishing to maintain a more general practice may do so and develop their competencies through selection of 6 modules from the wider syllabus.
- Basic competencies in all modules
- Intermediate Competencies in all modules
- Advanced competencies in 3 modules (one in each of the three sections)
Plastic Surgeon in General Route Diagram
Entry criteria: All trainees
In order to enter final years training the trainee must have completed a successful ARCP at the end of ST6. They must show evidence of achievement of competencies as specified under the existing Intermediate Years syllabus, supported by evidence from workplace-based assessments of clinical performance (DOPS, PBA, CEX, CBD, MSF). The trainee's portfolio must demonstrate the ability to present management plans for all the common conditions encountered in elective practice including:
- Should demonstrate competence in management of common elective hand conditions.
- Should be able to demonstrate competencies in breast surgery including reconstruction. This includes flap reconstruction.
- Should demonstrate competencies in reconstructive procedures required after excision of major defects or after major trauma. This includes flap reconstruction including developing competence in microsurgical reconstructive techniques.
- Should demonstrate competencies in the management of skin malignancy and other soft tissue tumours.
- Should have demonstrated competencies in common areas of paediatric plastic surgical practice. Will have had exposure to cases of cleft lip and palate and hypospadias and will have demonstrated competencies relating to knowledge of and operative skills relating to these cases.
- Should have gained competencies in the areas of aesthetic surgery including preoperative assessment of these cases as well as operative skills.
The trainee's portfolio must demonstrate the ability to present management plans for all the common conditions encountered in emergency practice. The trainee should be competent in the emergency management of trauma to include assessment, operative management and aftercare.
- Ability to manage the breadth of cases of hand and upper limb trauma
- Ability to formulate management plans for most cases of lower limb injury
- Ability to formulate management plans for most cases of burns in adults in children and be able to adjust as appropriate resuscitation regimens in those cases where management is not straightforward. The trainee should also be able to carry out early excision and grafting in suitable cases of burns or scalds. By this stage he/she should have a clear understanding of the role of psychology in burn care, the importance of rehabilitation in burn care.
Entry into Final Years Training is specifically NOT linked to obtaining FRCS(Plast) but this remains a requirement for CCT.
Entry criteria: Training Interface Fellowships
The Training Interface Fellowship posts are cross-specialty and most specify that the trainee will be in possession of FRCS(Plast) at the time of taking up the post (with the exception of Reconstructive Cosmetic TIG fellowship which is currently only 3 months duration). This requirement is in addition to the requirements otherwise listed for all trainees in the specialty. (This is part of the existing cross-specialty agreement for these posts).
Exit criteria: All trainees
At the end of training the trainee will have a number of satisfactory ARCPs which will demonstrate that the level of training required to work as an independent consultant surgeon has been reached. In order to satisfy the ARCP process the trainee's portfolio must contain a number of mandatory elements:
- FRCS(Plast)
- WPBAs showing that a satisfactory standard has been reached
- Learning Agreements and AES Reports signed off by the AES
- E-logbook containing an appropriate range and number of operations and involvement at satisfactory level
- Current ATLS certificate or equivalent
- Evidence of publications, presentations, audits, research and relevant courses
- Legal documents
At CCT the Plastic Surgeon should be emergency competent in the generality of plastics: (hands, lower limb soft tissue, major wounds and burns). In addition, the trainee should be able to manage psychosocial issues caused by trauma, disease and surgery including anxiety, depression, altered body image, bullying, social prejudice and even discrimination.
The trainee will have completed one of the specified Final Years pathways: Plastic Surgeon in General, Plastic Surgeon with Special Interest (TIG or monospecialty route). The trainee will demonstrate the competencies laid out on that particular pathway.
Exit criteria: Plastic Surgeon in General
6 modules (basic and intermediate competencies in all modules, advanced competencies in 3 modules corresponding to the different interest areas) demonstrating competencies as laid out in the syllabus:
- Trauma (Hand or Burns or Lower Limb)
- Oncology (Oncoplastic Breast or Skin Oncology)
- Aesthetics / Complex Wound / Ear Reconstruction / Genitourinary Reconstruction / Oncology
Exit criteria: Plastic Surgeon with Special Interest (TIG route)
6 modules in one of the special interest areas listed below (basic and intermediate competencies all modules, advanced competencies in 4 modules) demonstrating competencies as laid out in the syllabus:
- Cleft
- Hand
- Head and Neck
- Oncoplastic Breast
Exit criteria: Plastic Surgeon with a Special Interest (Monospecialty route)
6 modules in one of the special interest areas listed below (basic and intermediate competencies, in all modules, advanced competencies in 3 modules) demonstrating competencies as laid out in the syllabus:
- Burns*
- Craniofacial
- Ear Reconstruction**
- Genitourinary Reconstruction**
- Hand
- Head and Neck
- Lower Limb*
- Oncoplastic Breast
- Skin Oncology
* Must be modules 1-3
** Need to add Trauma and/or Oncology from the Plastic Surgeon in General list to make up a 6 module programme.
Exit criteria: Aesthetic
At CCT the trainee will have acquired and demonstrated skills needed to manage patients or practice in the following areas:
- aesthetic breast surgery including developmental and acquired anomalies
- aesthetic surgery for reversal of physiological aging of the face, brow, neck and orbits
- aesthetic nasal and ear surgery
- restoration of body contour including post-massive weight loss, lipomodelling and fat grafting
- non-surgical rejuvenation techniques
- psychological assessment of patients presenting for aesthetic surgery
Exit criteria: Burns
At CCT the trainee will have acquired and demonstrated skills needed to manage patients or practice in the following areas:
- primary management of burn patient and transfer to appropriate burns facility/unit/centre
- resuscitation of the burn patient and ongoing critical care
- early surgery for burns
- later burns management including reconstructive surgery
- burn infections and other complications
- paediatric burns including integration of multidisciplinary management
Exit criteria: Cleft
At CCT the trainee will have acquired and demonstrated skills needed to manage patients or practice in the following areas:
- primary management of cleft lip and nose
- secondary repair of cleft lip and nose
- primary management of cleft palate
- speech disorders associated with cleft palate and related disorders
- alveolar defects associated with cleft lip and palate
- residual cleft deformity in adults including principles of orthognathics and related assessment / investigation
- participation in the Cleft MDT, including working with allied disciplines as a team member and team leader
Exit criteria: Complex Wound
At CCT the trainee will have acquired and demonstrated skills needed to manage patients or practice in the following area:
- complex wound excluding burn injury
Exit criteria: Craniofacial
At CCT the trainee will have acquired and demonstrated skills needed to manage patients or practice in the following areas:
- general principles of management including assessment, integration with MDT, imaging and cephalometrics, surgical approaches and techniques, implants, trauma and emergency procedures
- craniosynostosis including single suture craniosynostosis and syndromic craniofacial dysostosis
- craniofacial tumours in adults and children
- craniofacial syndromes of tissue deficiency
- craniofacial overgrowth syndromes
- orbital surgery
Exit criteria: Ear Reconstruction
At CCT the trainee will have acquired and demonstrated skills needed to manage patients or practice in the following areas:
- ear deformities and ear reconstruction
Exit criteria: Genitourinary Reconstruction
At CCT the trainee will have acquired and demonstrated skills needed to manage patients or practice in the following areas:
- hypospadias and allied conditions.
- epispadias, anomalies of female genitalia, ambiguous genitalia and acquired perineal defects.
- genital reassignment.
Exit criteria: Hand
At CCT the trainee will have acquired and demonstrated skills needed to manage patients or practice in the following areas:
- soft tissue problems around the hand and upper limb including traumatic loss and microsurgical reconstruction
- Dupuytren's disease
- fractures and joint injuries of the hand and wrist including instability
- Osteoarthritis and inflammatory arthritides of the hand and wrist
- tendon injuries including reconstruction and rehabilitation regimens
- nerve-related disorders including nerve compression, nerve palsy and nerve injuries along with associated reconstructive techniques and rehabilitation regimens for the same.
- children's hand problems with emphasis on congenital hand conditions.
- vascular disorders and neoplastic conditions of the upper limb in both children and adults.
Exit criteria: Head and Neck
At CCT the trainee will have acquired and demonstrated skills needed to manage patients or practice in the following areas:
- head and neck assessment including examination, investigations, specialist imaging and biopsy techniques (including applied basic sciences).
- all types of skin related cancer of the head and neck.
- all types of non-skin related cancer of the head and neck.
- soft tissue reconstruction of head and neck defects.
- specific reconstructions for head and neck sub-units including eyelids, nose, lips, ears and scalp.
- facial re-animation for nerve palsy including surgical options of both static and dynamic procedures as well as non-surgical treatments.
Exit criteria: Lower Limb
At CCT the trainee will have acquired and demonstrated skills needed to manage patients or practice in the following areas:
- primary management of lower limb injury with open fractures.
- subsequent management of lower limb injury including compartment syndrome, debridement, stabilisation.
- soft tissue coverage of open tibial fractures
- vascular injuries to the lower limb.
- early and delayed lower limb amputations
- bony and soft tissue complications
- children with lower limb injuries
- outcome measures used to determine efficacy of treatment following lower limb trauma.
Exit criteria: Oncoplastic Breast
At CCT the trainee will have acquired and demonstrated skills needed to manage patients or practice in the following areas:
- breast assessment including clinical assessment, investigations, imaging and biopsy techniques (including applied basic sciences)
- all types of breast cancer including premalignant conditions and screening for breast cancer.
- benign breast conditions.
- implant based reconstruction
- autologous tissue based breast reconstruction
- aesthetic breast surgery including developmental and acquired anomalies
Exit criteria: Skin
At CCT the trainee will have acquired and demonstrated skills needed to manage patients or practice in the following areas:
- skin assessment including clinical assessment, investigations, imaging and biopsy techniques for suspicious skin lesions (including applied basic sciences)
- primary skin-related neoplasia.
- recurrent and metastatic skin cancers.
- soft tissue reconstruction for skin defects.
- scar management, chronic wounds, lymphoedema, longer term management of benign and malignant skin conditions
- multidisciplinary team working, outcome assessment, NICE Improving outcomes guidance and Peer review.
- research and audit in local, national and international settings
- Final Years training is not linked to success in FRCS(Plast) so that all trainees will have a full two years in which to develop their areas of clinical interest.
- Entry to Final Years training (ST7) is determined by successful ARCP outcome and is at the recommendation of the Training Programme Director.
- Everybody does not do everything - there will be choices within specific parts of the syllabus to allow senior professional development according to interest and opportunity. There is nothing to stop the use of the curriculum in further development in areas of particular interest post-CCT.
- Senior trainees will have the alternative of a properly targeted Final Years training programme without the need to depend on overseas placements to develop their expertise.
- The indicative duration of each module on each syllabus will be about 4 months where the subject is studied for the first time. For plastic surgery trainees there has already been extensive experience in most of the content at Basic Level and substantial experience at Intermediate Level. For this reason, and bearing in mind this is a competency-based programme, there are no hard and fast time limits on the duration for each module. The TIG fellowships are also of varying duration form 3 months up to 2 years.
- Some trainees may be able to complete more than 6 modules within the indicative 2 year period according to interest and opportunity.
- Modular construct represents an integrated training solution facilitating linkage with other educational projects; notably, Professional Association Instructional Courses, current JCST, simulation mapping exercise, E-Learning for Health, linkage to Oxford University Textbook of Surgery (Plastic Surgery section).
- Facilitates sharing of those parts of the curriculum held in common with other specialties and facilitates in return the acquisition of new skills sets by our senior trainees working in areas of special interest. This will help the specialty to continue to develop and take on new areas of interest - this being key to the future of our specialty that depends on innovation and adoption of new techniques.
- Adds value to trainees Final Years experience with priority on rotation placements to underpin acquisition of Advanced Level skills relevant to their chosen areas of interest.