Trauma and Orthopaedic Surgery (2015)

Intermediate

Intermediate Stage ST3 – 6 Overview

This phase of training provides the fundamental basis to training in the generality of T&O. During this phase trainees will develop knowledge, skills, judgement and professionalism in all areas of T&O with an equal weighting being given to trauma and orthopaedics. Trainees must be allocated to posts in the major specialty interest areas – hand surgery, spinal surgery and children’s T&O during this period. The trainees must gather evidence supporting their achievements, including WBAs, audit, research and attendance at courses and meetings. This phase represents 4 indicative years of training. Training Programme Directors should discourage trainees from undertaking the intercollegiate examination during ST3-6 as they are unlikely to be suitably prepared.

During this stage the trainee obtains many of the clinical competencies. They will also acquire both in and outpatient diagnostic and management skills and will supervise the day to day ward work of the foundation and core trainee doctors.

The intermediate phase includes further training in trauma and the introduction of specialty modules for example ankle and foot, hand, shoulder and elbow, hip, knee, spine and children’s surgery. The precise shaping of the modules will differ in different training programmes. Most training posts will be attachments to one or at most two trainers. Trainees should not have to “compete” with others seeking training, such as fellows, when attached to a particular trainer. Training posts should have a job plan that maximises contact between the trainer and trainee, has combination of trauma and elective orthopaedics and must include time for personal study, attendance at regional training programme teaching and time for audit and research.

The majority of posts include trauma on call according to a rota which would normally be supervised by a number of different trainers during an attachment. This provides an opportunity to receive feedback from more than one source, during a training interval, which is to be encouraged. Occasionally posts will include no trauma commitment, but this is unusual. Overall, approximately 50% of training experience should be allocated to the specialist subjects and 50% to trauma.

Over the intermediate training interval the majority of the examples of modular training outlined above should be covered.

APPLIED CLINICAL KNOWLEDGE

This component contains that which underpins training in T&O and is essential both to contextualise skills and attitudes acquired in training and in order to practice as a T&O surgeon.

The knowledge level expected is indicated on the following four point scale:

1. knows of
2. knows basic concepts
3. knows generally
4. knows specifically and broadly

These are difficult terms to define precisely (see T&O syllabus overview: Specific knowledge/skill requirements) for an example of the levels of knowledge) but it will be expected that a practicing surgeon (level 4) will not only be able to apply specific, detailed knowledge of a given condition or technique but also utilise a broad knowledge of orthopaedics and medicine to view any patient’s situation holistically. Most crucially, trainees must demonstrate an appreciation that knowledge changes as research progresses, and so they must also possess and apply the relevant skills to keep themselves up to date. These skills are defined in the Professional Behaviour & Leadership Skills syllabus.

In the early years of training trainees must acquire core technical skills expected of a surgeon in any discipline (e.g. suturing, soft tissue handling, sterile practice). Moreover, they must acquire the skills relevant to entering higher training in T&O as defined in the Core Surgical Training syllabus and required in the person specification for selection into T&O.

A collection of core competencies have been identified through OCAP. These now form part of the Applied Clinical Skills syllabus (and form the basis for assessment through the primary WBAs). The trainee must demonstrate the same competency and skill in all procedures they eventually perform as a consultant.

The Applied Clinical Skills syllabus is a reflection of the procedures that have been recorded in the T&O logbook and therefore encountered in routine and specialist T&O practice. In all training programmes trainees should have the opportunity to be exposed to a large selection of the procedures.

Assessment of competency in procedures is dealt with in depth in this curriculum (see T&O syllabus overview: Assessment & Feedback). In order to facilitate workplace based assessment (WBA) a number of key (indicative) procedures have been identified. These will be assessed in depth in the Procedure Based Assessment workplace assessment instrument. It is essential to realise that these key procedures do not encompass the whole practice of the discipline but do indicate the whole range of skills to be acquired by a competent T&O surgeon. Assessment (PBA) in the key procedures gives evidence as to the quality of a trainee’s performance, their overall competence is assessed from this evidence set in the context of their entire logbook (quantity) of procedures. Trainees must make every effort (with the support of their local programme) to experience the scope of the whole procedures list in as much depth as is practicably possible. Trainees and trainers should aspire to a level of mastery and not just core competence.

The skills and procedures have 6 defined levels:

0 No experience expected
1 Has observed or knows of
2 Can manage with assistance
3 Can manage whole but may need assistance
4 Able to manage without assistance including common potential complications

The “0” level has been included as is applicable to core trainees only. All key procedures assessed by primary PBAs must be mastered to level 4 and the remainder at a level as indicated in the syllabus depending upon the level of training and specialisation.

This syllabus can be found as a generic syllabus on ISCP for all surgical specialties. This syllabus / section incorporates clinical skills alongside general aspects of behaviour as a high grade professional. The two are deliberately integrated to reflect their essential and inseparable nature in day to day practice. They map to Good Medical Practice and the Academy of Medical Royal Colleges’ Leadership syllabus. It cannot be over emphasised how important it is for a T&O surgeon to behave in an all round manner which is nothing less than exemplary at all times.