Trauma & Orthopaedic Surgery Curriculum
2.1 Purpose of the curriculum
The purpose of the T&O curriculum 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 T&O surgeons able to manage patients presenting with the full range of emergency T&O conditions and elective orthopaedic conditions in the generality of the specialty. Trainees will also be expected to develop a special interest within T&O in keeping with service requirements. They will be entrusted to undertake the role of the T&O Specialty Registrar (StR) during training and will be qualified to apply for consultant posts in T&O in the UK or Republic of Ireland 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 pace.
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 September 2006 the first T&O competence-based curriculum was approved by PMETB. In 2010 the early core surgical training years were included. The 2015 iteration refined the product of the vast amount of work undertaken to write the 2006, 2010, 2013 and 2014 iterations and reflected changes in T&O, as well as training in postgraduate medicine in general. The 2018 iteration added minor changes to reflect the development of major trauma centres.
Through all of these previous curricula, T&O has managed to resist a division of the specialty, so a fundamental principle of this curriculum is that all trainees will be trained in the generality of T&O, with an opportunity to develop special interests in the later years of training. Training in trauma is equally as important as training in elective orthopaedics, having the single aim of ensuring that all new certifying trainees are able to manage trauma from the day they are appointed as a consultant.
The key focus behind this new curriculum has been to maintain the above with an emphasis of the following:
- exposure to the full breadth of the specialty
- emergency safe for the acute unselected take
- focus on principles of orthopaedic surgery applicable in all areas.
The Shape of Training (SoT) review1 and Excellence by Design: standards for postgraduate curricula2 provided opportunities to reform postgraduate training. The T&O curriculum will produce a workforce fit for the needs of patients, producing doctors who are more patient-focused, more general in scope 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 practice medicine. 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 T&O. Trainees who choose to move from a different specialty training programme having previously gained skills transferable to T&O, 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 T&O, 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
T&O 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.
- Shape of training: Securing the future of excellent patient care
- Excellence by design: standards for postgraduate curricula
- Generic professional capabilities framework
- Good Medical Practice
There will be options for those trainees who demonstrate exceptionally swift 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 Guide)5. 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.
Phase 2 will take an indicative time of four years to complete, during which trainees will acquire knowledge, skills and principles in the full breadth of the specialty, defined as the clinical exposure to the eight main general areas of the specialty. These comprise six anatomical areas; (Hand and Wrist, Shoulder and Elbow, Spine, Hip, Knee, Foot and Ankle) and two non-anatomical areas; (Paediatric Orthopaedics and Major Trauma). Whilst most clinical attachments will be six months, we have defined a minimum of three months allowing two areas to be combined in six months to allow for programme flexibility in delivery. These skills are central to the practice in the generality of the full breadth of the specialty, including being emergency-safe for unselected emergency on-call take, and as a foundation for any of the later chosen special interests. In addition, provided all eight areas have been covered, in consultation with the Training Programme Director (TPD), trainees may spend more than six months in one area, or special interest area, during phase 2 in preparation for phase 3. 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 T&O.
Phase 3 will take an indicative time of two years to complete. Trainees will further develop their knowledge, clinical and technical skills in emergency general orthopaedic trauma surgery, but also develop more specific specialist area trauma assessment and technical skills. Current service demands require most consultants to be competent in general trauma and one, or two, special interest elective areas and the more specialist trauma related to these areas. For example, a consultant T&O surgeon with special interest in the upper limb (which may be defined as whole limb or part of the limb such as shoulder and elbow). So, to meet current service demands, and in order to maintain flexibility for employers, trainees will complete two special interest placements, usually for a minimum of six months, during phase 3. These may be any of the main eight areas described above or, in discussion with the TPD, a less common special interest area, such as tumour management or specialised peripheral nerve repair. Major trauma orthopaedics, such as that undertaken in major trauma centres, is considered a special interest area and may be chosen as a special interest in this phase.
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.7At the end of Phase 3 trainees will be eligible for certification and for recommendation to enter the specialist register.
Selection of optional and special interest modules
The selection of optional and special interest modules will be determined in discussion between the trainee and TPD, and will be based on trainee needs, 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 T&O.
By completion of training, all surgeons with certification in T&O will have:
- acquired the knowledge, clinical and technical skills in general emergency trauma and orthopaedic surgery as defined by the syllabus
- acquired the knowledge and clinical skills to independently manage an unselected emergency T&O on-call take
- completed two special interest modules in 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 training pathway in Trauma and Orthopaedics
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 emergency T&O surgery for all trainees in phase 3. On completion of training all trainees will have the surgical competencies in general trauma orthopaedic surgery and the principles of orthopaedics across the full breadth of the specialty and more specialist skills in two areas both elective and trauma.
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