February issue.indd

C. Bulstrode and V. Hunt
University of Oxford Medical School, Headington, Oxford, U.K.

Correspondence to: C. Bulstrode, Stream House, Mill Street, Stanton, St John, Oxon, OX33 1HQ

If the public are to be assured that surgeons are safe, then there must be some form of competence assessment on which a licence to practice is based. However, the assessment and the licence needs to be both appropriate to the training received by the surgeon and to the requirements of the post they propose to take up. The ‘key-concept’ described in this paper attempts to address this problem

INTRODUCTION
A professional organisation has a primary responsibility to its membership to protect their interests. However, in professions where safety is paramount (such as surgery) the organisation may also have a statutory responsibility to the public to ensure that the standard of work of all its members is acceptable. In return for this responsibility, the members of that profession may be given a monopoly right in law to make a living from that craft. This reciprocal arrangement dates back at least to the early Middle Ages in Europe, and is the foundation on which the great guilds were formed. One of the banes of this system has been the repeated abuse of the apprenticeship model. In France, this finally resulted in the abolition of all guilds by Royal Decree early in the 18th Century.¹

One common abuse of the apprenticeship system was a gradual increase in the time that trainees were required to remain apprentices which extended far beyond the needs of their training. This had many advantages for the masters of a guild. First, they had access to a large pool of trained, but disenfranchised labour, who could be ordered to do unattractive tasks for minimal wages. Second, they were able to give spurious status to their trade by pointing to the length of time it took for an apprentice to train to become a journeyman. A third important advantage for the expenses of the guild was that by the time trainees had finished their apprenticeship, they had so much experience of the trade that even if they were poor learners, or the training was indifferent, they would still be competent to practice to a high standard. This meant that the guild had no need to put in place rigorous criteria for selecting apprentices, checking the training programmes or assessing the competence of apprentices at the end of their training. The parallels between the goldsmiths in France in the early 18th Century and the medical profession today are too clear to ignore.

The issue of competence at the end of training is coming to a head because the European Community has proposed that the time allowed to train a specialist should be reduced, just at a time when the working hours of all doctors is also being cut. This means that we can no longer rely on the training period being so long that, even if no training is provided, and/or the trainee has little aptitude, we will always produce competent consultants. There is a danger that the competence of newly trained surgeons will fall unless the following areas are addressed.

Firstly, a reliable method is needed for selecting the best doctors to train as surgeons. This selection would need to be based on aptitude and trainability.² Secondly, only those centres offering adequate quality and quantity of training should be allowed to have trainees (licensing of training programmes). These programmes would then need to be adequately resourced.

Thirdly, every trainee would need to be checked to ensure they were competent to do their work safely before allowing them to become a consultant, as there would not be the time or resource to over-train them as before.

Fourthly, the profession would need to be sure that no newly appointed consultant was asked or expected to do work for which they were not trained. There would then need to be a much closer linkage between assessed competence and the agreed ‘job plan’ throughout a senior’s career.

Finally, there would need to be regular checks that each consultant remained fit to do the work for which they were contracted. If not, their job plan would need to be renegotiated, or they would need to be retrained.

Figure 1: The competence key of a typical orthopaedic surgeon in mainstream practice with an interest in joint replacement and on call for trauma. He has competence at-

Level 1 in diabetes - has heard of it but could not safely manage it
Level 2 in scoliosis - can recognise, and refer, but would not treat
Level 3 in joint replacement and trauma - can take referrals and treat competently.

SELECTION OF TRAINEES
There is currently no objective method for selecting surgical trainees, but luckily there is still strong competition for places on surgical training programmes. A validated method for measuring aptitude and trainability in prospective trainees would help training programmes select the best potential trainees. This assessment should not be competence-based, it should be competitive. In other words, candidates would not just be marked as suitable or not suitable, they would be ranked so that a training programme with large numbers of applicants could select the best, on objective evidence.

MEASURING TRAINING PROGRAMMES
One simple measure already available is to monitor the proportion of a programme’s trainees who pass the intercollegiate exam first time. This has poor sensitivity. However, there are other methods such as ‘training receipt pads’ and properly organised RITA panels which are starting to be used, and which do measure training on a day-to-day basis and which are independent of the quality of the trainees.³

Measuring the competency of trainees before allowing them to become full members of the profession
The only person who can really know if a surgical trainee is fit to start unsupervised practice is their trainer. He/she should have been observing them on a daily basis, doing every aspect of their work. There is no substitute for the quality and comprehensiveness of that opinion, but it is difficult to make objective decisions. This, therefore, creates a problem. All trainers are naturally biased to say that their trainees are competent, because it reflects badly both on the trainee and themselves if they say otherwise. A trainer’s partly subjective opinion must, therefore, be complemented by an external and independent opinion. This may only be a snap-shot (such as an exam) but it serves two functions. It makes sure that the opinion of a trainer is not biased by their prejudice for (or against) the trainee. It also serves to make sure that all trainers across the country are working to the same standards.

These two diametrically opposite forms of assessment, one a continuous assessment on-the-job, the other a snap-shot by a panel of independent and external experts share the common characteristic of measuring at only one level - competence. Unlike the assessment at the entry to training, which should be competitive, this assessment must only be competence-based, because any normative element reduces the reliability of the assessment of competence.

Making sure that consultants only do the work for which they are trained
There are three basic levels of competence in unsupervised surgical practice, which are represented diagrammatically below by the cross-sections of a mortice key.

Level 1 is the lowest level, is a working knowledge of the facts relating to a condition and its treatment. It does not require any competence or experience in actually managing the condition, and should not license anyone to do more than ‘start’ training, or to work in a team where the expertise to manage these cases is available elsewhere. For a consultant surgeon, Level 1 competence might apply to the diagnosis and management of conditions such as diabetes or hypertension. They should know enough about the condition to know that if they are told that one of their patients suffers from it, they will understand the principles of management. They also know that it should be managed by others who are expert in the subject.

Level 2 is the ability of a competent professional to recognise a condition, and in an emergency to manage the first few minutes of care. They should also know how and where the case should be referred. An example might be the management of a complex pelvic fracture by an orthopaedic surgeon on call who has no super-specialist expertise in this area. This is not the same as the concept ‘Emergency safe’ which seems to consider that any surgeon can and should be able to deal with the overall care of any surgical emergency in their specialty. Level 2 competence relates only to recognition of an emergency, knowing the appropriate route of referral and knowing what needs to be done while specialist support is awaited.

Level 3 is the competence to take referrals from other specialists and to manage the cases safely, and represents the highest level of specialist care.

Any exit assessment designed for the future needs to recognise that no specialist can or should be at Level 3 across the whole of their specialty. Surgeons working in general hospitals may have Level 3 expertise across a wide range of common conditions, while those working in super specialist centres may only have Level 3 expertise in one narrow but difficult to manage area.

Any surgeon completing their specialist training should be competent at Level 2 across the whole range of the specialty, and then should offer to be assessed at Level 3 in one or more subspecialties where he/she has received the appropriate training. If successful in their assessment such surgeons should then receive a qualification certifying completion of training. However, this qualification should explicitly list the areas in which they are Level 3 competent. They should then only be able to apply for a post, which requires the highest level of expertise in areas where they are certified to be Level 3 competent, unless they are prepared to undertake extra training.

The qualification, therefore, is still competence based. It is just that the competence is tested at two different levels, depending on the training received, and the job being offered. If the key represents the surgeon’s competence then the lock represents the appropriate job plan for that individual.

Figure 2: The competence key profile of a surgical trainee at MRCS. Level 1 overall. Level 2 competence in some common areas.

Figure 3: Theoretical expectation at CCST. Level 3 competence across the whole of the specialty.

Figure 4: Competence key profile of a consultant in a busy General Hospital. Level 3 apart from special areas (such as scoliosis) which are referred to a subspecialist.

Figure 5: Competence key profile of a specialist in a tertiary referral centre. Level 3 competence in a rare and narrow area such as scoliosis. No other level 3 work.

REVALIDATION
Expertise should increase with regular use, so consultant surgeons should not have any anxiety about being re-assessed providing the test is relevant, set at the appropriate level, and relates only to the work that they regularly perform. Most surgeons, as they get older, reduce the areas in which they are Level 3 competent, for various quite appropriate reasons. This is not a problem, provided that the method used to reassess their competence takes this into account. The job plan must also be modified accordingly, or retraining must be offered.⁴

The key of competence must fit the lock of the job plan throughout the professional life of the surgeon. If surgical units are going to respond to the changing needs of the public and new developments in surgical technique, then retraining must be available to enable surgeons to move into new areas of Level 3 competence, when they and their employers feel that it is appropriate. There will also be a need for training to keep surgeons up to date with what is happening in areas where they have chosen only to be Level 2 competent, as well as sub-specialist groups whose role will be to keep those who are Level 3 in this subspecialty up to date with the advances in the subject. It is one of the responsibilities of a professional organisation to provide this training and assessment.

The transition from the traditional system of long surgical training followed by even longer but un-assessed surgical practice to a system where surgeons are licensed and revalidated to practice in certain areas only, will be the most radical change that has ever been seen in surgery since the introduction of aseptic technique and general anaesthesia. It will be very expensive, uncomfortable and very time consuming. It may be that it is just too big a task for the current professional organisations to embark on. If this is the case surgeons may have to simply rely on the passion for high standards which are to be found in most practitioners already.⁵ If however, we do decide to go down this route, and it looks as if European legislation on length of training is inadvertently going to precipitate this, then there can be no half measures, as otherwise there is a real danger that standards of surgery in Britain tomorrow will fall rather than continuing to rise.

REFERENCES
1. Elliott A. Krause Death of the Guilds: Professions, States, and the advance of Capitalism, 1930 to the Present. Yale University Press 1996.
2. C. Bulstrode, V Hunt Selecting the Best from the rest Surg J R Coll Surg Ed Ire 2002; 1 (6) 328-331.
3. Christopher Bulstrode Victoria Hunt Training in Practice Oxford 2000.
4. Christopher Bulstrode Victoria Hunt What is Mentorship Lancet 25 Nov 2000 vol 356 9224 p. 1788.
5. Onora O’Neill 2002, A Question of trust, The Reith Lectures, London, BBC.