The conflict between service and training in our specialty, in common with most others, is the result of a number of factors.  To an extent some of these factors are more apparent in the practice of cardiothoracic surgery than in other medical and surgical crafts. The most obvious reasons for the currently perceived difficulties are:

• Increased consultant accountability

• Decreased number of hours of work available for trainees

• Less surgically experienced trainees at the start of specialist training

• Increasing complexity of case-mix

• Accelerating technological progress

• Increased pressure from Health Authorities and Trusts to maintain and increase throughput as a result of targets in the NSF

These and other issues have raised considerable disquiet amongst both trainees and trainers.  As a Society we need to find constructive ways forward, so that patients continue to receive the best possible care, whilst at the same time we maintain our tradition of training sufficient numbers of first-class cardiothoracic surgeons for the future.  It may be useful to contemplate the problem as having both fixed and flexible components. 

Fixed aspects include the necessity to reduce trainees working hours as a result of the following immutable considerations:           

• No trainee can be paid in band 3 by August 2003

• 11 hours minimum rest per 24 hours by August 2004

• Maximum 48 working hours per week by 2007

•  Increased trainee numbers for the present

•  Increased consultant numbers.

However much we wish otherwise, these fixed components are with us to stay.  It is not possible to put the clock back, and we should not attempt to do so.  It would be wasted effort on our part.  The working group believes that there are many practical ways in which the conflict can be resolved, and the remainder of this report sets out those views

Process of the working group

There are certain conditions that can be achieved in any cardiothoracic department that make teaching easier and in so doing, more enjoyable for both trainee and trainer.  The first of these is an acceptance by healthcare systems that training must take place and has to be given priority as appropriate.  From a national perspective the future of the service is dependent on producing new surgeons of high quality.  From a local point of view it seems to be the case that units with the best reputation for training frequently also have the best reputation for service.  Good training units attract a higher calibre of candidate for both training posts and consultant posts.  The second condition is that it should be acknowledged that operative training cannot be undertaken without increased risk for the patient, no matter how much we may pretend otherwise.  The training process must be designed to reduce this risk as much as possible.

It therefore becomes clearer that training cannot be expected to happen by accident.  In order to resolve the conflict, training must been seen as something that requires dedicated time and effort.  The systems that we put in place also need to be flexible.  It may well be that in 10 years time the NHS will not need anything like as many trainees to maintain an adequate number of consultants.

Individual trainers clearly have different strengths.  Increasing consciousness of these strengths can be used to enhance training.  As an example, surgeon A may prefer to teach relatively junior trainees who still require close supervision, whilst surgeon B may be happy to allow more senior trainees to operate under his name with a lower level of supervision.  Recognition of such strengths by the surgeons themselves and the groups in which they work may allow better allocation of trainees within the operating program.  Most cardiothoracic surgical departments are now of sufficient size that there is likely to be a good distribution of trainer types, albeit currently under-recognised.  The strengths and weaknesses of trainers should be searched out and the strengths utilised accordingly.

The introduction of the Calman reforms to training grades in the 1990’s led to great  extent to the demise of the senior trainee, previously called the senior registrar.  In the past, such a trainee was expected to undertake a considerable role in the administrative function of a unit, as well a high volume of surgery with a low level of trainer supervision.  It is not entirely clear why the change in name to Specialist Registrar resulted in the loss of this species.  We believe that 5^th and 6^th year specialist registrars should be restored to the equivalent position of the extinct senior registrar even though they may at the same time be undertaking subspecialty training.  We see no reason why they should not be called senior registrars with appropriate slots available on training programs to emphasize the point.  As part of the training to become a consultant they should be given specific administrative tasks, as well as allowed greater exposure to operations with level 2 and 3 supervision.

For those at an earlier stage, training should be directed at specific goals.  Thus at the start of, for example, a cardiac surgical attachment, the first thing to learn thoroughly would probably be opening and closure of a median sternotomy.  Similarly, on a thoracic surgical attachment, opening and closing a lateral thoracotomy might be considered the first priority.  Once those goals are recognised by both trainer and trainee they will be easier to achieve.  This of course is the basis of the educational contract that is now mandatory for basic surgical trainees.  Achievement of  a satisfactory standard at the initial stage will allow progression on to the next. 

Only by making the most effective use of trainees’ available hours will we continue to produce high calibre consultants.  Many hours are currently taken up by being resident on call.  Most often these duty hours are spent covering cardiothoracic intensive care.  We believe this to be a poor form of training for our registrars and almost certainly unnecessary for the adequate care of out patients.

There is widespread variation in practice across the country.  While some units employ 2 resident layers of cover (SHO and registrar) with a consultant non-resident, others have only 1 resident layer (usually SHO) and 2 non-resident (registrar and consultant).  If both work equally effectively and provide a safe environment for cardiac surgical patients, we should consider moving to the system that is most training-friendly.  By avoiding being resident on-call, a far greater proportion of the 48 hours of work available to the trainee can be used for high value training.  Further flexibility can be achieved by a less rigid adherence to the ‘firm’ principle.  A greater emphasis on the needs of each trainee as an individual would enhance the training experience. 

From the responses we received from trainees we know that they are not in favour of extending the number of years in the training grades.  We also know that they are not in favour of shift systems, believing quite rightly that this leads to an inevitable loss of exposure to practical surgical experience and loss of continuity of care for patients.  There is almost unanimous support for the resurrection of the old senior registrar role, albeit at the expense of some loss of the ‘firm’ structure.  We received mixed responses to questions about residency on-call.  We believe that there would be a similar response from consultant members, probably reflecting each individual’s current practice.  We would advise that if non-residency for the registrar grade provides better training opportunities, and is found in many hospitals to provide satisfactory care of patients, then it should be adopted by all units.             

At present that skills tutor at the RCS is concerned with developing skills courses for trainees within the first 3 years of the specialist registrar grade.  These together with further skills courses targeted at more advanced trainees must gain more widespread availability.  It should not be beyond the capability of any existing training unit to set up regular skills laboratory sessions in anastomotic technique, valve insertion and other basic components of the cardiothoracic surgeon’s armamentarium.  

1.                  A conflict between training and service exists.

2.                  This conflict is a cause of disquiet amongst trainees and trainers.

3.                  All stakeholders should accept the training is essential for a sustainable service.

4.                  Good training usually coincides with good practice.

5.                  The specific strengths of trainers should be identified and utilised.

6.                  5^th and 6^th year specialist registrars should adopt the equivalent role of the old-style senior registrar.

7.                  On the job training should be co-ordinated with the curriculum and skills training courses.

8.                  Resident on-call commitments should be reduced to the minimum to increase time available within a 48 hour week for training.