Core Surgical Training Curriculum

3 Programme of Learning

This section covers the expected learning outcomes, learning methods, breadth of experience and levels of performance in the training programme and the levels of performance expected of those completing the Core Surgical Training curriculum.

The practice of surgery requires the generic and specialty knowledge, clinical and technical skills and behaviours to manage patients presenting with a wide range of emergency and elective conditions. It includes the development of competence in diagnostic reasoning, managing uncertainty, dealing with co-morbidities, and recognising when another specialty opinion or care is required. The main areas for learning are described by the GPCs and the five CiPs shared with the ten surgical specialty curricula, which are the high-level learning outcomes for training in surgery. The CiPs are described below and shown in full in appendix 1. In addition, a syllabus, shown in appendix 2, provides a guide to the specific areas of knowledge and skill to be learnt by all using this curriculum (in the common content module), by all attached to clinical teams from each of the surgical specialties and critical care (in the core specialty modules) and by trainees preparing for progression or recruitment to ST3 training in their chosen surgical specialty (in the ST3 preparation modules).

The entirety of surgical training is designed to produce a person capable of safely and effectively performing the role of a first day consultant surgeon. The role of a consultant surgeon can be thought of as a sum of all the various tasks which need to be performed through a working week. These tasks are the high-level outcomes of the curriculum and grouping these together describe the role of a consultant surgeon. To perform a high-level clinical task as a consultant surgeon requires trainees to be able to integrate areas of learning from all parts of the syllabus, including knowledge, clinical skills, professional skills and technical skills. In addition, a surgeon will need to have acquired the generic skills, behaviours and values shared by all doctors in order to perform this task safely and well. A capability is a set of skills that can be developed through training from novice to expert and, therefore, these high-level clinical outcomes are known as Capabilities in Practice. They are common across all surgical specialties and are delivered within the context of the GPCs and the specialty syllabus.

Because surgical specialty trainees train against curricula built on the high-level outcomes which together describe the role of the consultant surgeon, those same outcomes describe the role of the specialty trainee. This Core Surgical Training curriculum, whose product is the first day phase 2 trainee, therefore, uses those same high-level learning outcomes. Each is supposed to deliver to a correspondingly lower level of capability or under a greater level of supervision, than would be expected of a first day consultant.

The five CiPs which are shared between all surgical specialties are:

  1. Manages an out-patient clinic
  2. Manages the unselected emergency take
  3. Manages ward rounds and the on-going care of in-patients
  4. Manages an operating list
  5. Manages multi-disciplinary working

The generic knowledge, skills, behaviours and values shared by all doctors are described in the GPC framework. The GPCs are essential components and have equal weight to the CiPs in the training and assessment of clinical capabilities and responsibilities in the training programme.

The GPC framework has nine domains:

Domain 1: Professional values and behaviours

Domain 2: Professional skills

Practical skills
Communication and interpersonal skills
Dealing with complexity and uncertainty
Clinical skills

Domain 3: Professional knowledge

Professional requirements
National legislative requirements
The health service and healthcare system in the four countries

Domain 4: Capabilities in health promotion and illness prevention

Domain 5: Capabilities in leadership and team working

Domain 6: Capabilities in patient safety and quality improvement

Patient safety
Quality improvement

Domain 7: Capabilities in safeguarding vulnerable groups

Domain 8: Capabilities in education and training

Domain 9: Capabilities in research and scholarship

Simply put, the CiPs and GPCs are the constituent parts of the role of a consultant surgeon. Each part is as important as the next and doctors are required to be capable in all parts of the role in order to be able to practice independently. Each part is also important to developing the capability to perform as a phase 2 trainee, although independence is far from being required in any of them at this stage. In order to complete training and become a phase 2 surgical trainee, the doctor must demonstrate that they are capable of practice in all CiPs at the supervision levels laid out in section 3.4 below, and that they demonstrate all the GPCs.

The supervision level required for each trainee in each CiP should be made with reference to the syllabus for the common content module, the core specialty module content and the ST3 preparation module content the trainee is undertaking. For example, managing an unselected emergency take (CiP 2) requires the integration of knowledge, clinical and diagnostic skills, and technical skills described in the syllabus, as well as communication and interpersonal skills, time management skills and many other generic skills described in the GPCs in order to be delivered safely, professionally and effectively. This will be assessed using the multiple consultant report (MCR) as described below. The full content of the five CiPs can be found in appendix 1.

The Interrelationship between GPCs, CiPs and MCRS

Figure 1 - The interrelationship of the GPCs, the syllabus, the CiPs and their descriptors to the role of a phase 2 trainee, and subsequently to the role of a consultant surgeon. Items from the syllabus are combined with items taken from the GPC framework to form the small tasks which are the CiP descriptors. When the small tasks of the descriptors are integrated, they comprise the constituent parts of the role of a phase 2 trainee/consultant surgeon (the CiPs). When the CiPs are taken together, along with the GPCs, the role of a phase 2 trainee/consultant surgeon (the overall outcome of the curriculum), is described. Each of these CiPs will be developed through training in this and subsequent curricula, until the level required of a day-one consultant is reached. Assessment in an outcome-based curriculum through the MCR examines the trainee from the perspective of the outcome (phase 2 trainee) and compares performance in each CiP and in the GPCs to that level. If the outcome level is not reached, then targeted feedback and development plans can be made with reference to the CiP descriptors and beyond to the syllabus items and GPC items that combine to form the descriptors.

The five CiPs taken together with the GPCs describe the role of a phase 2 surgical trainee but more detail is needed to help core trainees develop each capability through training via detailed feedback and focused development goals.

We can break the CiPs down into smaller tasks. Each of these smaller tasks is a CiP descriptor. For example, managing the unselected emergency take (CiP 2), includes the need to promptly assess acutely unwell and deteriorating patients and deliver resuscitative treatment and initial management and ensure sepsis is recognised and treated in compliance with protocol (see appendix 1). If a trainee has not yet reached the level required of a phase 2 surgical trainee in a CiP, then the descriptors can be used to describe in standard language what needs to be improved through learning and training to allow the trainee to get closer towards the outcome of this curriculum. By describing the component parts of a CiP, descriptors also aid decisions on assessment of the level of supervision required by a trainee at the time of that assessment, providing prompts for feedback of performance by allowing identification of areas of excellence or specific detail on areas for development, including in behavioural and professional domains. Descriptors can, therefore, help trainees identify where to focus their efforts. More detail about assessment and feedback is given in section 5, Programme of Assessment.

Each CiP is judged against a scale that describes the level of supervision required to perform the CiP to the standard required for completion of this curriculum. The level of supervision changes in line with the trainee’s progression, consistent with safe and effective care for the patient. Typically, there should be a gradual reduction in the level of supervision required and an increase in the complexity of cases managed as training progresses. The ten surgical specialty curricula specify training until the level of competence for independent practice is acquired at which point little or no supervision is required. In phase 1 of training much closer levels of supervision are needed. In order to allow more scope for the demonstration of progress and excellence by trainees following this core curriculum, the lowest two supervision levels are expanded, compared to those in use in the specialty curricula for phase 2 and phase 3. The supervision levels indicating consultant level practice and beyond, present in the ten surgical specialty curricula, are not reproduced here to avoid unrealistic expectations of core trainees.

The supervision levels are:

Level I: Able and trusted to observe only

a: passive observation
b: active observation

Level II: Able and trusted to act with direct supervision:

a: some of the capability conducted under direct supervision
b: most of the capability conducted under direct supervision
c: capability performed completely under direct supervision

Level III: Able and trusted to act with indirect supervision

There are no critical progression points within this curriculum other than completion of training at an indicative two years after entering training. This curriculum forms phase 1 of surgical specialty training except in Neurosurgery, in which phase 1 includes the common content described in the syllabus of this curriculum.

Excellence will be recognised by:

a) Achievement of Level III in any of the CiPs
b) Exceeding the supervision level expected for the end of phase 1
c) Achievement of a supervision level at an earlier stage than would normally be expected
d) Recognition of particularly good performance in any of the descriptors within a CiP

Table 2 - Supervision levels to be achieved by the end of training
Capability in practice (shared) Supervision level (end of phase 1)
1. Manages an out-patient clinic Level IIb
2. Manages the unselected emergency take Level IIb
3. Manages ward rounds and the on-going care of in-patients Level IIc
4. Manages an operating list Level IIb
5. Manages multi-disciplinary working Level IIa

The curriculum requires trainees to accrue a rich experience that promotes deep learning of knowledge, clinical skills, technical skills, professional behaviour, leadership and all other generic professional skills that are considered necessary to ensure patient safety throughout the training process and specifically at the end of training.

3.5.1 The syllabus

Core surgical training is diverse and is uncoupled from specialty training for the majority of trainees. The Neurosurgery curriculum describes a run-through programme for all ST1 entrants. Cardiothoracic Surgery and OMFS curricula are divided with both run-through and uncoupled programmes. The availability of posts is at the discretion of the statutory postgraduate medical education bodies. In addition, ACFs grant run-through status to successful applicants. While some core surgical training programmes provide two-year rotations themed to one of nine specialties, others are generic. In recognition of the time spent in dental surgery by its trainees, OMFS training omits the CT2 year. The required final competencies of successful trainees are also diverse with each specialty having its own expectation of a new ST3 trainee represented in distinct recruitment person specifications. Despite this diversity, there remains a commitment to retain within core surgical training a generic training in that which is common to all surgical practice.

In order to satisfy the many diverse requirements and stakeholders laid out above in a single document, the syllabus maintains the modular structure of the 2017 curriculum (figure 2). It identifies domains of knowledge, clinical skill and technical skill to inform the development of the CiPs and GPCs as core surgical trainees learn within diverse clinical teams. The detailed syllabus is given in appendix 2.

Figure 2 – the Core Surgical Training syllabus, which in turns informs the development of the CiPs, is modular (full description of the modules in appendix 2). There are three types of module. All trainees address the knowledge and skills laid out in the common content module. In addition, when training with a particular clinical team, they will include the respective core specialty module in their learning, from amongst the eleven available in the ten surgical specialties and Intensive Care. These modules specify the knowledge and skills that all surgical trainees in such a placement should address, regardless of their surgical specialty of choice. Trainees choose the ST3 preparation module which matches the surgical specialty they will pursue in phase 2 (i.e. 1 of 9 available modules will be chosen by a trainee, corresponding to surgical specialties, excluding Neurosurgery, where only the common content module is followed by those in neurosurgical training).

Common content

Those items of knowledge and clinical and technical skills which represent the generic competence required of all future surgeons are represented in a module to inform the learning of all CT1 and ST1 surgical trainees. The Intercollegiate Membership examination of the Royal Colleges of Surgeons (MRCS) aligns to this module which also serves to define the CT1 competencies required by the OMFS ST3 person specification. It is here that those specific areas of knowledge and skill transferable to other training programmes are to be found.

Core specialty

As they rotate from specialty to specialty in years one and two, trainees will take on the relevant core specialty modules, which will specify the knowledge and skills that all surgical trainees in such a placement should address, regardless of their surgical specialty of choice. These modules align with the quality indicators suggested by the Specialty Advisory Committees (SACs) for Core Surgical Training posts in their specialties. Most trainees will wish to incorporate at least three of these modules, one of which will be in the same specialty as their ST3 preparation module. Very few trainees will spend their entire programme in just one specialty.

ST3 preparation

Bystart of their CT2 year, trainees in uncoupled programmes should have made a choice regarding the specialty in which they wish the rest of their career to develop. Run-through trainees will already be bound to a specialty. Starting in an indicative second year, trainees will inform their developing CiPs with the knowledge and skills listed in the ST3 preparation module in their chosen specialty. These modules align with the entry expectations of the specialty surgical training programmes and with the essential criteria of the person specifications for national recruitment at ST3 level.

3.5.2 Critical skills (see appendix 3)

Basic critical skills have been identified which are of significant importance for patient safety and demonstration of safe practice. Across surgery, these generic skills lie at the heart of patient assessment and good practice in the operating theatre, where mistakes can be associated with devastating consequences for patients. These critical skills are assessed individually by means of workplace-based assessments (WBAs). They provide formative feedback to the trainee and collectively contribute to the summative assessment of the trainee’s performance in the clinical environment and should inform the Assigned Educational Supervisor’s (AES) report for the ARCP. A list of critical skills together with the prescribed WBAs for their assessment for Core Surgical Training is given in appendix 3 and is also included in the requirements for completion.

3.5.3 Requirements for completion of core surgical training

The requirements for satisfactory completion of this Core Surgical Training curriculum and, therefore, progression to phase 2 of specialty training in a surgical specialty in the UK, are shown in section 5.4.