27 May 2012

Exactly what it says on the tin?

Generalist GI surgery has no place in the elective management of colorectal disease.  And by that I do not mean the super specialised surgery of recurrent cancer or ileoanal pouches – I mean everyday bread and butter elective cases of colorectal cancer, inflammatory bowel disease, functional and pelvic floor problems and proctology.   You can now choose to disagree with me.  And as long as you take your nearest and dearest with a caecal cancer, your child with colitis, your elderly mother with incontinence and your very own painful bottom to the General Surgeon -irrespective of his subspecialty training – then I have to respect your position.   But if in any or all of these circumstances, you would seek the expertise of a Colorectal Surgeon, then the recent reversed (for the second time) decision of the SAC not to seek subspecialty recognition on the GMC register requires some careful thought.  (see the correspondence overleaf). For the purposes of this discourse – I will discount vascular trainees, breast trainees and the transplanters.  Their subspecialisation has “de facto” recognition, whether or not they appear as General Surgeons on the GMC register; few are going to dabble in arterial surgery, breast cancer or plumb the odd kidney in, without the necessary badged knowledge and technical training.  The problem lies in gastrointestinal surgery and whether or not a generalist or the current product of upper GI training has anything to offer the patient seeking the elective management of colorectal disease. Best elective care for “bread and butter” Coloproctology is delivered by the trainee who has specialised in the relevant disease management as well as requisite technical skills in his/her final years – validated by taking the relevant subspecialty component of the Intercollegiate Examination.   Current training does not produce super specialists (and never did) but it does produce Colorectal Surgeons with logbooks of anterior resections, fistula in ano procedures and prolapse repairs that can assume the elective colorectal workload expected at appointment.  By contrast, the upper GI trainee with a logbook of 140 cholecystectomies at CCT is patently unable to deliver this elective care.  And for the sake of clarity that is the difference between the products of upper and lower GI training delivered by current training, right now. The counter view is that current training produces Consultants that can do a cholecystectomy, a breast lump excision, a hernia repair, an appendicectomy, a right hemicolectomy and possibly a haemorrhoidectomy.   As a trainer of 20 years and an Intercollegiate Examiner for 5 years I do not recognise this as the final product of 8 years of UK surgical training.  And if true, such a state of affairs would be a total condemnation of the ability of the General Surgery SAC and the Deaneries to deliver surgical training in this country. The real challenge of elective subspecialisation is Emergency Abdominal Surgery – surely we all need to be able to do Hartman’s operation, small bowel obstruction and close a perforated ulcer?  Yes we do – and each trainee has to be exposed to the practice of emergency surgery throughout his/her surgical training, emerging with at least 100 emergency laparotomies by CCT and again being examined in Critical Care and Emergency Surgery at the Intercollegiate Examination.  There is no contradiction to completing training in a Subspecialty and in Emergency Abdominal Surgery simultaneously.  Indeed the real challenge is not training in Emergency Abdominal Surgery, but the need to stay relevant in Emergency Abdominal Surgery after Subspecialty Consultant appointment. The fundamental role of training is to produce a professional who can transparently do exactly what it says on the tin – be it surgeon, airline pilot or a plumber on the Gas Safe Register.  At present we are not doing that; instead we are producing very different strands of “General Surgeon” who despite very dissimilar expertise can change clinical practice at managerial whim or notepaper caprice.    From a public interest point of view this is not sustainable and if allowed to continue will lead to a collapse in confidence in this profession’s ability to regulate itself.   For if the currency of professional credentialing cannot be both trusted and readily accessed by the paying public, then surgical training structures have neither credibility nor purpose.  Allowing such a situation to continue invites another MTAS-style intervention, to impose an external definition of expertise on a seemingly muddled and insecure professional training structure.

ACPGBI letter to SAC

Dear Bill, re:  TERMINATION  SAC SUBSPECIALISATION APPLICATION TO GMC The Council of this Association was made aware that the General Surgery SAC, following the ASGBI Council meeting in December 2011 and subsequent email correspondence, no longer wishes to continue the process of subspecialty recognition with the GMC. We understand that the basis of this latest stance, not to seek subspecialty badging at CCT, is to maintain the “generality” of General Surgery and that this new position has the support of some within the English Royal College,  the Council of the ASGBI and  the chair and chief executive of  the GMC.    As the General Surgery SAC is the statutory body responsible for setting standards for the specialty training of surgeons, on behalf of the General Medical Council – this Association can do nothing but lament this latest SAC posture. However, ACPGBI is obliged to record that the latest SAC stance is both a reversal of its stated 2010-2011 position and represents a change that appears contrary to the interest of many patients with a colorectal disease – the central charitable purpose of ACPGBI.  This Association fails to see how the current 5 radically different streams of surgical training to produce a Consultant “General Surgeon – 5 different surgical syllabuses accompanied by 5 distinct surgical subspecialty exit examinations (Vascular, Breast, Transplant, Colorectal and Upper GI surgery) – can  be passed off to the public as “General Surgery” .  Indeed the case for distinguishing the fundamentally different training of “General Surgeons” was (and remains) so persuasive that subspecialty badging was the stance promoted by the current SAC and accepted in principle by the two GMC panels we both appeared before just 12 months ago. The changed stance of the General Surgery SAC ignores the evidence base of patient benefit from specialisation, flies in the face of views expressed by multiple patient groups and disregards government initiatives that daily dictate increasing specialisation of care in the surgical management of colorectal cancer, inflammatory bowel disease, functional bowel disease and proctology.      It remains the view of this Association that the patient interest rests with a CCT register that allows an ordinary member of the public to distinguish which surgeon has or has not gained surgical expertise in radically different areas of surgical practice – but recognises that the responsibility for not advancing this interest lies with this latest and regrettable change in SAC policy. Yours sincerely Nigel Scott President ACPGBI

SAC letter to specialist associations

Dear Presidents In the light of recent correspondence we would like to state the SAC's current position on subspecialty recognition . At the latest SAC meeting there was a lengthy debate in the context of the previous discussion at ASGBI Council and the Surgical Forum document Training Surgeons for Future Service Requirements. The SAC appreciated the position prevailing at the time of the GMC application for subspecialty recognition 12 months ago not the least because of the comprehensive curricula that were presented. However the fact that the application process was put on hold has allowed a careful reconsideration of the situation in the context of training capacity and changes in the training environment. The recent experience of all SAC members is that it is currently not possible to train fully all trainees in general surgery and in the full breadth and depth of a subspecialty because of the constraints placed on training. By CCT trainees have acquired knowledge and clinical skills as tested by the Intercollegiate examination but have not achieved the technical skills to be a specialist able to manage the breadth of a subspecialty. There are strong recommendations from Medical Education England, the DH and from the Future Forum report on the White Paper that the service does not need large numbers of specialists. The SAC has taken the view that training should ensure trainees acquire the skills for the breadth of general surgery and begin to develop their special interest which will form the basis of specialisation in consultant practice. This will require modification of the curriculum. As a result the SAC decided unanimously not to pursue the GMC subspecialty application in its current format. The current debate on Training Surgeons for the Future is crucial to inform the shape of training in general surgery. The outcome of this debate will structure the re-design of the curriculum which will need GMC approval in due course. We would like to emphasise that the SAC is not against the development of subspecialist skills but feels strongly that these skills cannot be acquired to the necessary level alongside all that is needed for general surgery within the time available for CCT. The SAC feels that priority should be given to learning the skills required for general surgery by CCT. Some degree of special interest development can take place prior to CCT but this will have to fall short of full subspecialist expertise. We would welcome your comments. We would particularly welcome input from your Education and Training Committees as previously when the curriculum re-design is undertaken. Best wishes Bill Allum SAC Chair Gareth Griffiths SAC Chair- elect

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