Core Surgical Training Curriculum

2 Purpose

The purpose of the curriculum for Core Surgical Training is to act as a unifying document to govern the first two years of all UK surgical training (with the exception of neurosurgery which combines only the common content component of the core curriculum with Neurosurgery, Neuroradiology, Neurology and Neuro-intensive Care). This is phase 1 of surgical training. Successful completion of the Core Surgical Training curriculum does not confer certification but means that a candidate will have reached the minimum required level of competence for application into one or more of the higher specialised surgical training programmes. Many trainees who make satisfactory progress in core surgical training may also elect to pursue valuable careers in other branches of medical practice and, in recognition of this, the JCST is committed to working through the Academy of Medical Royal Colleges to identify competencies within this curriculum which are transferable to other postgraduate medical training curricula.

The curriculum provides surgical trainees with the generic professional and specialty-specific capabilities needed to be entrusted to undertake the role of core trainee in surgery whilst following this curriculum and prepares trainees to undertake the role of Specialty Registrar (StR) in their subsequent training. These capabilities will include those required of trainees, working under appropriate levels of supervision, to contribute to keeping patients safe in the emergency department, ward and theatre environment, to perform parts initially and, as specialty training progresses, all of increasingly complex surgical procedures, and to be familiar with the management of acute and elective conditions in the generality of their chosen special interest. Trainees will be qualified, after satisfactory completion of this curriculum, to apply for training posts in one or more surgical specialties in the UK or Republic of Ireland.

Patient safety and competent practice are both essential and the curriculum has been designed so that the learning experience itself should not affect patient safety. Patient safety is the first priority of training demonstrated through safety-critical content, expected levels of performance, required breadth of experience and levels of trainer supervision needed for safe and professional practice. Upon satisfactory completion of training programmes, we expect trainees to be able to work safely and competently in the defined area of practice and to be able to manage or mitigate relevant risks effectively. A feature of the curriculum is that it promotes and encourages excellence through the setting of high-level outcomes, supervision levels for excellence, and tailored assessment and feedback, allowing trainees to progress at their own rate.

This purpose statement has been endorsed by the GMC’s Curriculum Oversight Group (COG) and confirmed as meeting the needs of the health services of the countries of the UK.

There is a gap between the product of UK Foundation training and the entry requirements for specialty training in the surgical specialties. It contains much common ground; the basic sciences of anatomy, physiology and pathology, the principles of managing patients affected by trauma, infection and cancer, basic surgical skills and the resuscitation of critically ill patients, all within the generic professional framework of medical practice.

The route across the gap from Foundation to surgical specialty training is diverse including both run-through and uncoupled appointment and generic and themed, academic and clinical programmes, with distinct target criteria for appointment or run-through to specialty surgical training. To fulfil this need for diversity, the 2017 Core Surgical Training curriculum took a modular approach around a heart of common content and although accepted, concern was generated amongst employer groups regarding mechanisms for matching trainees to specialty according to workforce requirement. In addition, the GMC in their approval letter required the JCST to work towards a more common core curriculum.

In rising to the challenge of producing a new curriculum to meet the requirements of Shape of Training1 review and Excellence by Design: standards for postgraduate curricula2, the Core Surgical Training Advisory Committee has taken a blank canvas and considered a wide range of options to fill this training gap including a move towards exclusive run-though training, a single year of common content and various hybrid models. Ideas developed internally have been discussed within the Improving Surgical Training (IST) project, the Confederation of Postgraduate Schools of Surgery (CoPSS), the wider JCST and its curriculum development days in October 2017 and June 2018, and at the General Surgery in Scotland workshop in May 2018. An options appraisal, fully exploring the benefits, necessary mitigations and risks of five identified options was presented to the GMC’s COG in March 2019. There was agreement that there remains some common ground to surgical training. This is represented in the common content module of the 2017 curriculum and specifies material for learning sufficient to fill an indicative year of training. There were felt to be major logistical difficulties with recruitment to specialty training after just a single year of core surgical training and further concerns about a more generalised training that would mean less experienced trainees entering their specialty training without skills at the level required to participate in the middle grade rota. With the footprint of surgery in both undergraduate medical curricula and the Foundation curriculum reduced over the last ten years, and the existence of undecided surgeons (early years trainees with a career interest in surgery in general, with specialty undecided), it was felt there is still a need for generic core surgical training as a space for career exploration within training. This would exist alongside specialty-specific run-through and themed uncoupled training in what has been referred to as a ‘mixed economy’.

There remains therefore a need for a Core Surgical Training curriculum, lasting an indicative two years, as a bridge from completion of Foundation training to the beginning of surgical specialty training. This curriculum specifies those areas of knowledge and skill shared by all surgeons through its common content, describes the additional elements of learning for all core trainees attached to specific surgical teams and facilitates the development by trainees of the requirements for competitive entry by national recruitment, or run-through into, at least one of the specialty programmes in the nine surgical specialties excluding Neurosurgery at ST3 level.

This curriculum takes as its high-level learning outcomes the GMC’s framework of Generic Professional Capabilities3 (GPCs) common to all medical specialties and the five Capabilities in Practice (CiPs) common to all ten surgical specialty curricula. Those following this curriculum will, therefore, begin to develop the generic professional and specialty-specific capabilities needed by surgeons of any specialty, and by completion of the curriculum trainees will be capable of being entrusted to undertake the role of the general (StR) during their subsequent training. The GPCs provide the blueprint for surgical trainees to develop the patterns of professional behaviour which will contribute to functional surgical teams and the delivery of high quality, safe care. By also adopting the CiPs shared across surgical training, this curriculum provides a new unifying structure to generate a more common core curriculum, underpinned by a modular syllabus to reflect the ongoing need for subject-specific diversity. These capabilities will include those required of trainees, working under appropriate levels of supervision, to contribute to keeping patients safe in the emergency department, ward and theatre environment, to perform parts initially and as specialty training progresses, all of increasingly complex surgical procedures, and to be familiar with the management of acute and elective conditions in the generality of their chosen specialty.

2.3.1 Recruitment

Trainees will follow this Core Surgical Training curriculum after entry into a surgical programme through a variety of routes. Core Surgical Training national recruitment offers uncoupled programmes at CT1 level (87%4, table 1), either themed to a specific surgical specialty, or generic (19% of uncoupled). Themed programmes provide a rotation through placements specifically chosen to suit the development of an individual who already knows in which surgical specialty they wish to train. Generic programmes provide the opportunity to complete the Core Surgical Training curriculum in a rotation through a wide variety of surgical specialties and may be ideal for a trainee who, although committed to surgery, has yet to decide in which of the nine specialties they wish to undertake higher surgical training. Post-specific preferencing for themed programmes, embedded within the Core Surgical Training national recruitment process, and competitive regional processes for the allocation of placements in generic programmes, both match the number of opportunities to specified ST3 destinations to specialty volume and represent mechanisms for fairly matching trainees to specialty-specific content according to workforce requirements. The GMC National Training Survey (NTS) data suggests that ST3 specialty destination is well balanced to specialty workforce volume.

Core Surgical Training national recruitment also serves to recruit at ST1 level into pilot run-through programmes in Trauma and Orthopaedic Surgery (T&O) and Paediatric Surgery; and into run-through programmes in General Surgery, Otolaryngology, Urology and Vascular Surgery. Specialty-specific national recruitment manages appointment to run-through training at ST1 level in Oral and Maxillofacial Surgery (OMFS) and Cardiothoracic Surgery. Neurosurgery national recruitment manages entry to training in that specialty and those recruited at ST1 level in Neurosurgery follow only the common content of this curriculum.

The National Institute for Health Research (NIHR) and locally funded Academic Clinical Fellowships (ACFs) (3%) appointed at ST1 level also follow this curriculum. They are appointed locally but must in addition benchmark by gaining an appointable score at the appropriate national recruitment process for their level of entry into training.

Table 1 – representation of the numbers and proportions of the 2018 Core Surgical Training cohort, as reflected in the GMC NTS, in various trainee groups
trainee type number in 2018 NTS cohort; n=1171 percentage of cohort
uncoupled - themed 833 71
uncoupled - generic 190 16
run-through - clinical only 109 10
run-through - ACF 39 3

2.3.2 Progression and completion

Trainees in Core Surgical Training rotate through a number of specialty posts, typically of between four and twelve months each. The Core Surgical Training curriculum is outcome-based rather than time-based. However, it will normally be completed in an indicative time of two years. There will be options for those trainees who demonstrate exceptionally rapid progression and acquisition of capabilities to complete training more rapidly than the current indicative time of two years. There may also be a small number of trainees who develop more slowly and will require an extension of training in line with A Reference Guide for Postgraduate Foundation and Specialty Training in the UK (the Gold Guide5).

Completing Core Surgical Training satisfactorily as laid out in this curriculum will not lead on directly to certification, but an outcome 6 in the Annual Review of Competence Progression (ARCP) at the end of the CT2 year, which will allow a successful applicant from an uncoupled core programme to enter a higher surgical training programme to take up their ST3 post. An ARCP outcome 1 at the end of ST2 in a run-through programme will allow a trainee to progress to the next phase of their specialty training. There is no other critical progression point.

Trainees who successfully apply to pursue less than full time training (LTFT), will have the indicative training time extended pro-rata in accordance with the Gold Guide. LTFT trainees will perform both elective and out of hours duties pro-rata throughout the time of LTFT.

Those trainees who complete this curriculum and continue to pursue surgical specialty training as described will enter phase 2 of the appropriate specialty curriculum before, success in attaining the relevant critical progression point criteria permitting, entering phase 3 and completing their training by satisfying the criteria for certification. This Core Surgical Training curriculum does not describe these subsequent stages of training, but they are available to view via each surgical specialty’s curriculum on the ISCP website6.

2.3.3 Flexibility

In the early years of surgical training it is possible that a trainee who has started to develop a portfolio consistent with a particular surgical specialty might wish to move to another. The combination of the flexibility of a modular curriculum and the unifying GPC/CiP framework across surgical training should make it possible until well into the CT2 year, for a trainee to change their career intention and adopt a different ST3 preparation module from that of their original intent. It will, therefore, be possible for trainees to transfer knowledge, clinical and surgical skills to another surgical specialty without restarting at CT1/ST1 level. Clearly this would be contingent on local post availability, workforce requirements and notice periods in discussion with the local School of Surgery. This sort of move would be conditional on a trainee achieving the educational milestones so far agreed for them. Moving from one intended specialty to another because of the need to remediate would not normally be permitted. It is unlikely that a change in career intention alone would be a valid reason for an extension of Core Surgical Training beyond two years. This flexible approach with acquisition of transferable capabilities will allow training in Core Surgical Training to adapt to current and future patient and workforce needs as well as to changes in surgery with the advent of new treatments and technologies.

Regarding the transfer of capabilities learned within Core Surgical Training to non-surgical specialties, a trainee who has decided to change career direction would first need to be appointed to their new specialty of choice through the appropriate national recruitment process. The commonality of the GPCs to all medical curricula after August 2021, should facilitate the transfer of learning across all other related specialties and disciplines. As an example, prior learning of history-taking, physical examination, health promotion, medical record keeping, team-working and empathy, compassion and respect for patients should allow accelerated learning in the trainee’s new specialty. Progress made against those aspects of the surgical CiPs situated out with the operating theatre may be similarly transferable while those focused on procedural surgery itself may still be relevant to other procedurally based specialties such as Obstetrics and Gynaecology, Interventional Radiology and some other specialties with significant interventional procedure components such as Cardiology and Gastroenterology. Thus, trainees who choose a different career route may be able to have a shorter than usual training pathway in their new training programme, in recognition of learning already gained.

1 Shape of training: Securing the future of excellent patient care

2 Excellence by design: standards for postgraduate curricula

3 Generic professional capabilities framework

4 data from 1171 out of 1175 Core Surgical Training trainees responding to the 2019 GMC NTS indicating the proportion of trainees taking these various routes through training

5 Gold Guide 8th edition