2.1 Purpose of the curriculum
The purpose of the curriculum for Neurosurgery is to produce, at certification, competent doctors, able to deliver excellent outcomes for patients as consultant surgeons in the UK. The curriculum will provide consultant surgeons with the generic professional and specialty-specific capabilities needed to manage patients presenting with the full range of acute neurosurgical conditions up to and including the operation and early aftercare. Consultant surgeons will also be able to manage the full range of acute and elective conditions in the generality of their chosen special interests, including the operations. Phase 2 and 3 trainees will be entrusted to undertake the role of the general Neurosurgery Registrar (StR) during training and will be qualified at certification to apply for consultant posts in Neurosurgery 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, critical progression points, required breadth of experience and levels of trainer supervision needed for safe and professional practice. Upon satisfactory completion of a training programme, 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, appropriate supervision levels, 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 the new curriculum
The Shape of Training (SoT) review
1 and Excellence by design: standards for postgraduate curricula2 provided an opportunity to reform postgraduate training to 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.
The curriculum takes account of and better supports the needs of patients and service providers. It has been developed in consultation with stakeholders, including trainees, trainers, employers, lay representatives, the specialty association, the Specialty Advisory Committee (SAC) for Neurosurgery and other groups, ensuring the development of a curriculum that is fair, flexible, non-discriminatory, fit for purpose today with the capacity to evolve in future iterations in response to the changing needs of patients.
The curriculum will produce neurosurgeons with:
a) Generic competence to participate in an unselected take
Patients presenting to an on-call neurosurgical service often require immediate management including surgery. Employers require all neurosurgeons to be able to contribute to the on-call take.
b) Broad abilities to deal with the majority of common elective cases
The majority of elective Neurosurgery is unspecialised. For example, as much as 70% of the Neurosurgery elective workload is spinal, comprising for the most part, patients with spinal degenerative disease. Employers and the public require as many neurosurgeons as possible to undertake surgery for spinal degenerative disease and for the other common and non-complex neurosurgical conditions. Post-surgical continuity of care is an essential part of Neurosurgery and is standard practice.
c) Flexibility to adapt to changing service requirements
Neurosurgical practice covers a broad spectrum of disease, much of which is quite rare and it is also a rapidly evolving specialty. A consequence of these facts is that the techniques used and referral patterns change rapidly so surgeons have to remain flexible with transferable skills and a willingness to change how they practise. For example, aneurysm clipping that was a very significant part of neurosurgical practice has diminished with the advent of radiological coiling while oncology surgery, spinal surgery and functional surgery have all expanded. Further growth in spinal surgery and stroke clot retrieval are areas neurosurgeons will be expected to develop.
d) Special interest skills in one or more of the key special interest areas
Some elective areas of Neurosurgery are highly complex and rare. There is an increasing body of literature showing that these cases should be concentrated in the hands of only a few practitioners. There has been supra-regional consolidation in some areas of practice including for example paediatric epilepsy, craniofacial and some aspects of the management of neurofibromatosis. However, even at the regional level surgeons have special interests in the key areas of vascular, skull base, oncology, hydrocephalus, spinal, paediatric and functional neurosurgery. The curriculum, therefore allows flexibility for a neurosurgeon to develop special interest skills that can be applied to an elective area of practice but to continue to have the broad generic skills required for the neurosurgical on-call and general elective neurosurgical work. Microsurgical skills learned in one special interest area are readily transferable to other special interest areas.
The curriculum is designed to promote a flexible approach to training. Flexibility is maintained by enabling trainees from other specialties, who have achieved appropriate capabilites to enter phase 1 training at ST2 level directly. The neuroscience specialties that are relevant for phase 1 trainees include Neurosurgery, Neuroradiology, Neurology and Neuro-intensive Care. These specialties do not normally form part of core surgical training programmes and consequently Neurosurgery phase 1 training needs to be provided through a separate training pathway. Nevertheless, it is recognised that Neurosurgery is primarily a surgical specialty so the Intercollegiate Membership examination of the Royal Colleges of Surgeons (MRCS) is required and the common core surgical training has been adopted as part of the phase 1 Neurosurgery curriculum. Experience in Emergency Medicine or a related surgical specialty is also recognised. We encourage bespoke training for trainees entering the specialty in ST1/ST2 to avoid repetition of previously learned skills and enablement of new learning in clinical areas not studied in other training programmes. We anticipate that phase 1 trainees will attain experience in four to six relevant areas of practice (Neurosurgery, Neurology, Neuro-intensive Care, Neuroradiology, Neuropathology, Emergency Medicine, another surgical specialty) which will ensure that trainees are broadly educated in surgical and neuroscience principles consequently promoting the creation of generalists who are patient-focused and have flexible career options.
Trainees who have undertaken Neurosurgery phase 1 training will acquire generic competencies and skills that are highly relevant to other surgical specialties but also to Radiology, Anaesthetics, Neurology and General Practice; consequently trainees who later 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.
This flexible approach with acquisition of transferable capabilities will allow training in Neurosurgery 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. For example, at a senior level, recent developments in Interventional Neuroradiology (stroke clot retrieval) and Spinal Surgery (complex instrumented fixations) have provided new opportunities for career flexibility. These two examples are given here to demonstrate how career flexibility is maximised by keeping the Neurosurgery curriculum as broad as possible.
2.3 The training pathway and duration of training
Trainees will enter Neurosurgery training via a national selection process at either the ST1 or ST2 level. Trainees will learn in a variety of settings using a range of methods, including workplace-based experiential learning in a variety of environments, formal postgraduate teaching, simulation-based education and through self-directed learning. Neurosurgery training is outcome-based rather than time-based. However, it will normally be completed in an indicative time of eight years for those entering run through training at ST1 (two years in phase 1, five years in phase 2 and one year in phase 3) or 7 years for trainees entering at ST2 (one year in phase 1, five years in phase 2 and one year in phase 3).
There will be options for those trainees who demonstrate exceptionally rapid development and acquisition of capabilities to complete training more rapidly than the current indicative time of eight 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). Trainees who choose less than full time training (LTFT) will have their 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.
The programme will be divided into 3 phases (Figure 1):
Phase 1 will take an indicative time of two years to complete for run-through trainees, during which time trainees will gain many of the GPCs and the knowledge, clinical and technical skills in Neurosurgery, as defined in the CiPs and syllabus. The neuroscience specialties that are relevant for phase 1 trainees include Neurosurgery, Neuroradiology, Neuropathology, Neurology and Neuro-intensive Care. The common core surgical training has also been adopted as part of the phase 1 Neurosurgery curriculum. Experience in Emergency Medicine or a related surgical specialty is also recognised.
At the end of phase 1 there is a critical progression point for phase 2 entry, assessed at the Annual Review of Competence Progression (ARCP), where trainees will demonstrate competencies in knowledge, clinical skills and professional behaviours commensurate with the CiPs and defined syllabus. The MRCS examination will be achieved by this point in the training programme.
Phase 2 will take an indicative time of five years to complete during which time trainees will train in the full breadth of neurosurgical practice. Towards the end of this period they will sit the Intercollegiate Specialty Board (ISB) examination in Neurosurgery. To apply for a first sitting of the examination in Neurosurgery, a trainee will have demonstrated the knowledge, clinical and professional skills of a day-one consultant and the ability to acquire microsurgical skills in Neurosurgery as defined by the syllabus. It is anticipated that most trainees will reach this level by four to five years after entering phase 2 of the curriculum.
Phase 3 will take an indicative one year to complete and allow a trainee to develop technically, especially with regards to the essential transferable microsurgical skills required of a day-one consultant in Neurosurgery and to focus on one (or two complementary) special interest areas of practice. Phase 3 training in approved fellowship schemes in external centres is encouraged subject to deanery approval. Completion of phase 3 occurs at the final ARCP with the award of an outcome 6.
In this outcomes-based curriculum, some trainees may reach the end of phase 3 in less than the indicative time. On completion of phase 3, trainees will be eligible for certification and for recommendation to enter the specialist register. Trainees who do not meet the requirements of phase 2 within seven years may require an extension of training time in accordance with the Gold Guide.
Figure 1: Training pathway in Neurosurgery
2.4 ST2 entry to Neurosurgery training
Neurosurgery training is run-through training that is specialty-specific. Some but not all of the competencies required for phase 2 training can be obtained in other recognised specialty training pathways. To promote career flexibility these competencies are transferable, thus some trainees will be eligible to enter Neurosurgery training at the ST2 level, shortening the phase 1 training period.
Shape of training: Securing the future of excellent patient care
Excellence by design: standards for postgraduate curricula
Generic professional capabilities framework
Good Medical Practice
Gold Guide 8th edition