Trauma and Orthopaedic Surgery (2015)

Special Interest

The final phase is assumed to occur in the last one to two indicative years of the programme, assuming that by then all the necessary competencies outlined in the curriculum have been acquired. During this period trainees have a number of choices.

The purpose of this phase is for the trainee to consolidate their skills in the generality of T&O surgery and practice and to extend their expertise in one or more of their areas of special interest. This period enables the trainee to further develop their decision making skills under guidance based on the solid grounding of knowledge, skills, judgement and professionalism obtained in the earlier phases. It prepares the trainee for entry onto the Specialist Register and for the role of team leader required as a consultant in the NHS.

The most likely choice of training posts may be a combination of one of the following:-

• A reprise in one of the modular components revisiting existing training places on your rotation to study in more depth. For example, ankle and foot, hand, shoulder and elbow, hip, knee, spine and paediatric.
• Visits to another specialist in the trainees declared field of interest in the existing programme. This is only likely to apply in larger programmes
• Fellowships within other UK programmes or in national training accredited posts for specialist training these are well recognised in particular disciplines particularly hand surgery, children's orthopaedics and spinal surgery. Standalone fellowships, either in the UK or overseas may also provide the training required by a trainee. All fellowships must have prospective approval from GMC prior to commencement. The SAC liaison member for training programme is required to consider a post for approval and will review the experience once the post has been completed. Approval that the post will contribute to overall training will be given only if evidence is provided demonstrating the acquired competencies.
• A period in research. If a trainee has already spent a period in research and sought to have it approved for training, a second period is unlikely to be recognised unless it has a substantial clinical element. It is vital that the trainee checks with the SAC if such a proposal is to be considered. The SAC wishes to support academic development but within the context of training.
• The trainee is required to successfully complete the Intercollegiate Specialty Examination in Trauma and Orthopaedics (FRCS (T&O)) during this last phase of training. A CCT will not be awarded without passing the examination.

During this phase of training, trainees may have the opportunity of developing a specialty interest. However, in ST7-8 this will serve as an introduction to such an interest and the trainee must expect to continue developing their specialist skills in the initial post-CCT years, either by undertaking a specialist fellowship or by working closely with a senior colleague. For some trainees and indeed in some training programmes, specialty interest fellowship may not be possible until after acquisition of CCT.

Further, trainees must maintain their skills in the generality of trauma during ST7/8 so they can provide a general trauma service from day 1 on appointment as a consultant. The trainees must have an up-to-date ATLS provider certificate or an equivalent assessment.

Trainees will be able to demonstrate the following evidence in support of their application for a CCT and entry into the Specialist Register:

• Completion of 8 indicative years of training 2 at core level and 6 at higher level.
• Successful completion of the intercollegiate specialty examination in Trauma and Orthopaedics.
• A comprehensive portfolio showing training in the generality of T&O and evidence of specialty interest advanced training.
• Consolidation sheets from an e-logbook that demonstrate the breadth of exposure and performance of procedures progressing from supervised with the trainer scrubbed to more independent operating.
• Completion of all the primary PBAs to level 4; completion of the CBDs for critical conditions; completion of such additional PBAs to demonstrate wider competency in T&O surgery.
• Completion of quality improvement projects including the completion of 2 full audit loops in ST3-ST8.
• Completion, presentation and publication of appropriate research work.
• Maintenance of ATLS provider status or an equivalent status in the acute management of the injured.
• Completion of an appropriate teaching course such asTraining the Trainers as a minimum requirement.
• Completion of a course on management in the NHS.
• Completion of training in equality and diversity and assessment and appraisal.

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 College's 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.