The Effect of the Restructuring of Postgraduate Medical Training on training in Hand Surgery in the United Kingdom: A personal view
P Gill, D Power
P Gill, D Power. The Effect of the Restructuring of Postgraduate Medical Training on training in Hand Surgery in the United Kingdom: A personal view. The Internet Journal of Hand Surgery. 2008 Volume 2 Number 2.
Postgraduate training has undergone significant restructuring in the last 5 years. Graduates from UK medical schools apply for a 2 year Foundation Training Programme during which they will rotate through 6 placements in a number of sub-specialties in medicine and surgery, each lasting 4 months. At this stage, trainees may fine themselves working in Accident and Emergency or in complex subspecialty areas of surgery for which their medical school training has failed to prepare them adequately.
As a Foundation Year One doctor aspiring to become a surgeon, I recognized that a deficient area of my training was Hand Surgery. I took it upon myself to participate in a hand course run by the Birmingham Hand Centre, the largest regional tertiary referral hand unit in the UK.
The course was entitled “Assessment and Early Management of the Injured Hand” and was approved by the British Society for Surgery of the Hand. I found the course to be thought-provoking and highly relevant to the fields of Accident and Emergency, Trauma & Orthopaedics and Plastic Surgery.
The course was run over a Saturday, costing £75 per participant and finished with each participant receiving a certificate of attendance and 5.5 hours CME. It was open to all levels of doctors from Foundation Year One to Consultants. It was more suited for those wishing to pursue careers in Trauma & Orthopaedics, Plastic Surgery and Acute Medicine, although additional medical courses are always seen as a good way forward for personal development.
There were numerous good points about the course, such as the very thorough nature of the content that was taught, which managed to bring to surface deficiencies in the Medical School Education that had been experienced by all involved. We followed a fast-track syllabus for anatomy at Medical School, which lacked dissection, but instead used prosection for the main part of our limited practical teaching. The course highlighted hand anatomy extensively throughout the day including surface anatomy workshops with demonstration of important examination points on live models. This made the learning experience detailed and relevant to seeing and treating real patients.
Case studies were used to pinpoint pitfalls that are often faced in the acute situation and to highlight the hand emergencies that are often oblivious to new junior doctors in the Accident and Emergency setting.
A whistle-stop tour of paediatric emergencies was much appreciated as although we are privileged to have a Children’s Hospital with its own Accident and Emergency department in Birmingham, as doctors we are bound to come across hand injuries in a child at some point in our long careers.
The course was split into lectures, small group teaching and question & answer sessions. The theory aspect of the course set a good foundation for us to build upon and the practical aspect enabled us to practice examination skills and identify landmarks within the anatomy of the hand on live models. The staff members were approachable with questions and queries, offering tips and overall making the day enjoyable.
As there are always two sides to every coin, the course also had some setbacks. The first is the fact that we had to pay £75 for a one day course to substitute for deficiencies in our basic medical training. I appreciate however that a career in medicine requires a lifelong commitment to learning and professional development.
It does seem unreasonable that we as junior doctors are expected to pay to supplement our training. There is little money available nowadays to provide for postgraduate medical education. It is a bargain however when you consider the cost of other courses offered by the Royal College of Surgeons, such as Basic Surgical Skills costing £700 or ATLS costing £550.
The anatomy of the hand was covered extensively, but due to the restraints on time it was difficult to grasp it comfortably and I did feel that maybe some reading done beforehand may have alleviated this problem to some degree.
Although the team who ran the course were aiming to get a spread of lectures versus practical teaching, it may have been more beneficial for participants to have had more practical sessions or role-plays, thus making the training more realistic.
Overall I found this course to be interesting and helpful in increasing my confidence dealing with hand injuries as a junior doctor. It is definitely worth the money, offering the skill of highly experienced consultants from Trauma & Orthopaedics and Plastic surgery based at the largest tertiary trauma unit in the West Midlands. It was an enjoyable day, meeting a range of well driven and enthusiastic doctors, who made the experience unforgettable.
One question that jumps out is “Why do we as junior doctors need to attend such courses so early on in their Foundation training?” The issues perhaps need to be addressed at a national level and medical school education should be tailored to the practicalities of working as a Foundation trainee.
Trainees understand that the competition for applying to core training posts is immense and anything that boosts an applicant’s CV is a bonus. Trainees also accept that they have to develop a professional training portfolio and take control of their career progression. However, many Foundation trainees find themselves having to pay for courses such as this hand course, using their annual leave time to attend as there is no study leave offered and this seems unjust.
UK Medical Schools have deficiencies when is comes to teaching anatomy. Dissection has taken a back-seat in the present day Medical School Curriculum, with more emphasis placed in developing good communication skills. Medical students are now taught anatomy with only a few hours spent in a prosectorium. The impact of the lack of anatomy training, or more so the lack of high quality anatomy training at Medical Schools, has resulted in many doctors feeling they need to attend further courses to get their knowledge base to an acceptable level. They feel unprepared for the practicalities of working as a doctor.
The European Working Time Directive (EWTD) is a directive of the European Union to protect the health and safety of workers in the European Union. It lays down minimum requirements in relation to working hours, rest periods, annual leave for all workers and working arrangements for night workers. The EWTD originally did not apply to junior doctors but the Amending Directive removed this exclusion. The European Working Time Directive (EWTD) has changed the rules for the maximum hours that junior doctors can legally work in the UK, with the current total being 56 hours per week. The aim by August 2009 is to decrease this to a 48 hour working week, however this may be changed in 2012 with a maximum of 56 hours per week. Consequently junior doctors are exposed to a considerably reduced amount of clinical training and thus miss out on many experiences that are often gained during on-call or night shifts. This deprives the junior doctors of today from developing their skills and maturing into more clinically competent clinicians as a result of skills gained from hands-on experience. This pushes junior doctors to seek further training in the form of these extra courses which are made available to post-graduates. One cannot really be sure in whose favour the EWTD is working – Foundation Year Trainees or government figures.
The general set up of House Officer Training has been changed since the Foundation Training was commenced in 2006. Our predecessors were entitled to 6 months of general surgery training and 6 months of general medicine training in hospitals during their house jobs. Currently Foundation Trainees are given six blocks lasting four months each in specialist training rotations, before having to think about their final career choice. We no longer have the time to try out different specialities before making a final decision about core training. Instead we are forced by the system to make decision within the first 4 rotations. Once we have been offered a core training post, we do not have the choice to change path easily due to the inflexibility of the current setup. Consequently, foundation level doctors who have decided upon the branch of medicine they would like to follow have to pursue the appropriate extra courses in order to stand a realistic chance of making the short list for their chosen speciality jobs.
The Birmingham Hand Centre has noted the training deficiencies in Foundation doctors that have joined the unit. The course was developed to prepare doctors for their placements. It was designed to supplement the in house training provided.
Overall, although many doctors would voluntarily attend courses to improve their clinical skills, due to time and cost restraints many are not able to do so. The restructuring of postgraduate medical training can be seen to have played a part in affecting the level of junior doctor participation in these extra courses, both in a negative and a positive way.
As the first post graduate course that I have attended as a Foundation Trainee, I would highly recommend it for those wishing to improve their knowledge and practical skills in assessing and managing the injured hand.