General Surgery Curriculum
2.1 Purpose of the curriculum
The purpose of the General Surgery curriculum is to produce, at certification, consultant-level general surgeons able to manage patients presenting with the full range of emergency general surgery conditions and elective conditions in the generality of General Surgery. Trainees will also be expected to develop a special interest within General Surgery in keeping with service requirements. They will be entrusted to undertake the role of the General Surgery Specialty Registrar (StR) during training and will be qualified to apply for consultant posts in General Surgery in the UK after successful completion of training.
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, critical progression points, required breadth of experience and levels of trainer supervision needed for safe and professional practice. Upon satisfactory completion of training, we expect trainees to be able to work safely and competently in the defined areas 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 and confirmed as meeting the needs of the health services of the countries of the UK.
2.2 Rationale and development of a new curriculum
In the past ten years there has been increased emphasis on emergency general surgery care, the development of an oncoplastic philosophy of care in breast surgery, the establishment of major trauma centres, increased specialisation in the management of upper gastrointestinal conditions and rationalisation of transplant services. Nevertheless, Employers have identified a need to train some individuals in a broader range of skills. General Surgery of Childhood (GSoC) is recognised as an area requiring training and expansion to allow children to be treated in hospitals close to home. In addition to service changes, there has been scrutiny of individual surgeon outcome data and associated increased patient expectations. These workforce and service demands together with patient expectations have been some of the drivers for change to the General Surgery curriculum.
The Shape of Training (SoT) review1 and Excellence by design: standards for postgraduate curricula2 provided opportunities to reform postgraduate training. The General Surgery curriculum will produce a workforce fit for the needs of patients, producing doctors who are more patient-focused, more general and who have more flexibility in their career structure. The GMC’s introduction of updated standards for curricula and assessment processes laid out in Excellence by Design requires all medical curricula to be based on high-level outcomes. The high-level outcomes in this curriculum are called Capabilities in Practice (CiPs) and integrate parts of the syllabus to describe the professional tasks within the scope of specialty practice. At the centre of each of these groups of tasks are Generic Professional Capabilities3 (GPCs), interdependent essential capabilities that underpin professional medical practice and are common to all who practise medicine. The GPCs are in keeping with Good Medical Practice (GMP)4. Equipping all trainees with these transferable capabilities should result in a more flexible, adaptable workforce.
All the shared CiPs are transferable to other surgical specialties and some may be transferable to non-surgical specialties. In addition, core knowledge and skills gained in any surgical specialty training programme are transferable for entry into General Surgery. Trainees who choose to move from a different speciality training programme having previously gained skills transferable to General Surgery, therefore, may be able to have a shorter than usual training pathway in their new training programme. While most of the specialty syllabus is not transferable because the knowledge and detailed technical skills are specific to General Surgery, some limited areas of the syllabus may be transferable e.g. critical care skills. This flexible approach, with acquisition of transferable capabilities, allows surgical training to adapt to current and future patient and workforce needs and change in the requirements of surgery with the advent of new treatments and technologies.
2.3 The training pathway and duration of training
General Surgery training is divided into two phases and will take an indicative time of six years (four years in phase 2 and two years in phase 3).
Uncoupled trainees will enter phase 2 after completion of core surgical training (phase 1) and successfully gaining a National Training Number (NTN) through the national selection process.
There will be options for those trainees who demonstrate exceptionally rapid development and acquisition of capabilities to complete training more rapidly than the indicative time. 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). Trainees who choose 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.
This will take an indicative time of four years to complete, during which trainees will acquire knowledge and skills in elective general and gastrointestinal surgery together with emergency general surgery. These skills are central to the practice of General Surgery and a foundation to any of the later chosen special interests. In addition, in consultation with the Training Programme Director (TPD), trainees will spend up to one of the indicative four years of phase 2 gaining early exposure to one or more special interest areas in General Surgery through an option module, as shown in figures 1 and 2, which can be developed further in phase 3.
In addition to special interest areas, an option module will be available in Rural and Remote Surgery. This will allow trainees to gain exposure in areas which may be pursued further with some post-certification training. Such training will develop competencies in the interdisciplinary Rural and Remote Surgery, where General Surgery contributes only 30% of the scope of the role. Another option module will be available in GSoC which trainees may pursue further either as an integral part of the gastrointestinal module or alongside other modules in phase 3. This will enable them to deliver general paediatric surgery as consultants in District General Hospitals (DGHs), participating in treatment networks. At the end of phase 2 there is a critical progression point where trainees will demonstrate competencies in knowledge, clinical skills and professional behaviours and become eligible to sit the Intercollegiate Specialty Board (ISB) examination in General Surgery.
This will take an indicative time of two years to complete. Trainees will further develop their knowledge, clinical and technical skills in elective general surgery. In addition, to meet current service demands, trainees will complete two special interest modules (figure 1). Emergency general surgery is considered to be one of the special interest modules in phase 3. The majority of trainees will follow this module together with one other module allowing the development of technical skills in emergency aspects of the specialty and development of a second special interest area as defined by the syllabus.
The trainee will complete permitted combinations of modules from the training pathway shown in figure 1. In addition to the main modules shown, trainees will be able to complete training in GSoC or a component of another module, for example parathyroid surgery, to complement renal transplantation. This flexibility and the combination of modules allow development of a surgeon with the skills appropriate and relevant to the needs of patients and the modern service. Options allow for differences in scope of practice between nations and for special interests to be appropriate for smaller and larger hospitals. The knowledge, clinical and technical skills required for each module are defined in the syllabus. At the end of Phase 3 trainees will be eligible for certification and for recommendation to enter the specialist register.
Selection of option and special interest modules
The selection of option and special interest modules will be determined in discussion between the trainee and TPD and will be based on trainee aptitude, service and workforce requirements. It is anticipated that this might be informed by an exploration of workforce requirements with statutory education authorities across the four nations via the Lead Dean for General Surgery.
At the end of training: All trainees will have completed modules in elective general surgery, emergency general surgery (EGS), upper and lower gastrointestinal surgery and at least one additional option module in phase 2.
By completion of training, all surgeons with certification in General Surgery will have:
- acquired the knowledge, clinical and technical skills in elective general surgery as defined by the syllabus
- acquired the knowledge and clinical skills to independently manage an unselected emergency general surgical take
- completed two special interest modules at phase 3 and will have acquired the knowledge, clinical and technical skills as defined by the syllabus relevant to these special interests.
Figure 1: Overview of the training pathway in General Surgery.
Trainees can enter General Surgery training at phase 1, following the curriculum for core surgical training and running through without further selection into phase 2 of the General Surgery curriculum, or trainees can enter at phase 2, having successfully completed the curriculum for core surgical training and been successful at a national selection process into General Surgery training. Core surgical training is uncoupled from specialty training for the majority of trainees. The availability of posts is at the discretion of the statutory postgraduate medical education bodies.
Output from the curriculum
The modular structure of the curriculum will permit flexibility to respond to changing service demands. Underpinning this is a commonality of training in phase 2 and elective general surgery for all trainees in phase 3. On completion of training all trainees will have elective general surgical competencies and EGS knowledge and clinical skills. In addition, the curriculum will offer development of the following skill sets within General Surgery, summarised in figure 2.
- Emergency General Surgery and Colorectal
- Emergency General Surgery and Oesophagogastric (OG)
- Emergency General Surgery and Hepatopancreaticobiliary (HPB)
- Emergency General Surgery and Breast Surgery
- Emergency General Surgery and Gastrointestinal (GI) with General Surgery of Childhood (GSoC)
- Emergency General Surgery and Endocrine Surgery
- Emergency General Surgery and Renal Transplant with Dialysis Access
- Emergency General Surgery and Trauma Surgery
- Breast Surgery with Oncoplastic Reconstruction
- Multiorgan Transplantation and Retrieval
- Hepatopancreaticobiliary and liver/pancreas transplant
Trainees following any of the first eight of these module combinations will have completed the EGS module during phase 3. As such, approximately 80-85% will undertake a phase 3 module in EGS. These trainees will be able to perform common emergency general surgical operations fluently without guidance or intervention and be able to anticipate, avoid and/or deal with common problems/complications by completion of training.
Those trainees following the three special interest module combinations that do not include EGS in phase 3 will have acquired some technical skills in EGS during phase 2 but all will be able to manage the unselected take up to the point of operation and all will be able to manage post-operative care.
Figure 2: Outputs of the General Surgery curriculum, demonstrating commonality in phase 2 and that elective and emergency general surgery are at the core of the curriculum.
Shape of training: Securing the future of excellent patient care
Excellence by design: standards for postgraduate curricula
3 Generic professional capabilities framework
4 Good Medical Practice
5 Gold Guide 8th edition