The state of medical education and practice in the UK: a response by Dr David Rawaf

In response to the GMC’s latest annual report “The state of medical education and practice in the UK” in addition to the RCS Vice President Miss Fiona Myint’s comments, I am writing to highlight the immediate action that should be taken by the bodies responsible for surgical education.

Workers in this generation are undergoing an identity crisis where the lines between work and home are heavily blurred, and whilst employers – such as the NHS – focus on what the employer must provide; the personal needs of the healthcare worker is largely ignored. This includes both mental health, wellbeing and personal / professional development. We have seen courses & exams cancelled or delayed or adjusted without careful consideration on the subsequent effects on training and morale of the workforce.

Calling for amendments to the Health and Social Care Bill should be a part of the action plan due to the current legislation in itself “woefully falling short of a long term solution to workforce planning”.[1]

However, change is needed now. Staff shortages are crippling the NHS. The lack of focus on workforce retention is dire and as it stands more than half (53%) of surgical trainees felt they have not been able to compensate for lost training opportunities during the pandemic; 25% felt they were not on course to progress towards their curriculum competencies or outcomes; 30% said they felt unable to cope with their workload (up from 19% in 2020); 17% are at high risk of burnout (up from 10% in 2020) and 23% said they were planning on leaving the profession (up from 19% in 2020) [2].

Comparing this last figure to the USA who are experiencing a similar, if not worse, level of COVID pressures, 7% stopped treating patients with 1% not returning to work (roughly 6,000 doctors) [3]. Despite the pressures being on the service-provision ‘attendings’, training needs by residents have been under scrutiny and clear guidelines have been provided to residency programs [4].

We are on a dangerous path, and whilst there is admittedly no ‘magic wand’ for the state-of-affairs with COVID, winter pressures and hospital resources, there certainly are options for training bodies and colleges. One of which I will aim to focus on with this piece.

Surgical skills are traditionally learned by surgeons through repeated practice on patients [5]. This is a time-consuming, costly and ineffective process with potential negative impact on our patients. During COVID this situation has worsened due to a lack of ability for surgical trainees to operate secondary to redeployment of staff and services. This was compounded by the impact of social distancing on traditional simulated training modalities with simulation centres closed during the pandemic. Even prior to COVID, access to simulation centres was highly limited due to costs with a lack of comparable alternatives for accessible distance learning [6]. This, coupled with the insidious emergence of a highly litigious world directly effecting the Kings Fund [7,8], means we can no longer afford to have most of the surgical learning curve on patients. We cannot rely on studying for an operation from a book, a video, or even an expensive one-off course [9].?

The pandemic allowed us to evolve into utilising video conferencing technology to remain productive and to see and hear loved ones. This technology allowed us to incorporate video-linked supervised operative training sessions with a new high fidelity surgical training platform, LapAR. The laparoscopic simulator includes hardware, a native application and a cloud-based learning management system. This “Augmented Reality – AR” solution meant that we were able to increase accessibility by keeping costs down and maintaining high enough fidelity to improve surgeon ability through building muscle memory and technical skill.?

We implemented this strategy across deaneries that were receptive to keeping training moving. We provided each trainee with a simulator which allowed the trainee - once requested by their faculty member – to perform a set of tasks ranging from basic “LapPass” modules all the way to full operations such as laparoscopic appendectomies & hysterectomies. Once complete, objective metrics were provided to the trainees, and furthermore the faculty member could provide subjective comments either in real-time on a live course, or remotely and in retrospect. The overarching aim of training in this manner is to reduce operative time, reduce risk of complications and to save the NHS money in addition to teaching & maintaining surgical skills.

What we have seen in these small successes are indeed one large step towards a concurrent training-focussed pathway for surgeons despite being in a highly service-provision focussed situation during the pandemic.

In summary, the pandemic has provided us not only with an opportunity to drive the paradigm shift in surgical training to the benefit of our patients’ safety, but also to provide an opportunity for significant cost savings across the NHS in addition to prioritising and ring-fencing real surgical training for our disillusioned trainees. We believe these are just the first steps in a new era of surgical training and we can only be successful if, as a collective, training bodies, unions, trusts and colleges cooperate in harmony and utilise all resources available – including those from the emerging health tech industry.

References:

1.?????The Big Issue. 2021.?Health and care bill: What threat does it pose to the NHS? - The Big Issue. [online] Available at: <https://www.bigissue.com/news/health-and-care-bill-what-threat-does-it-pose-to-the-nhs/> [Accessed 20 December 2021].

2.?????Gmc-uk.org. 2021.?State of Medical Education and Practice in the UK. [online] Available at: <https://www.gmc-uk.org/-/media/documents/somep-2021-full-report_pdf-88509460.pdf?la=en&hash=058EBC55D983925E454F144AB74DEE6495ED7C98> [Accessed 20 December 2021].

3.?????Kare11.com. 2021.?COVID 19 Interrupted the practice of medicine - some doctors never returned to the profession. [online] Available at: <https://www.kare11.com/article/news/health/covid-19-interrupted-the-practice-of-medicine-some-doctors-never-returned-to-the-profession/89-cfa515e3-c9d6-4205-96d9-31dd5495c4d2> [Accessed 20 December 2021].

4.?????Meo, N., Kim, C., Ilgen, J., Choe, J., Singh, N. and Joyner, B., 2021.?Redeploying Residents and Fellows in Response to COVID-19: Tensions, Guiding Principles, and Lessons From the University of Washington.

5.?????Kneebone, R. and Aggarwal, R., 2009. Surgical training using simulation.?BMJ, 338(may14 2), pp.b1001-b1001.

6.?????Zendejas, B., Wang, A., Brydges, R., Hamstra, S. and Cook, D., 2013. Cost: The missing outcome in simulation-based medical education research: A systematic review.?Surgery, 153(2), pp.160-176.

7.?????Resolution, N., 2019. [online] Resolution.nhs.uk. Available at: <https://resolution.nhs.uk/wp-content/uploads/2019/01/FOI_3539_Fail-To-Warn-Informed-Consent-v.pdf> [Accessed 23 November 2021].

8.?????Kings, F., 2021. [online] Available at: <https://www.kingsfund.org.uk/> [Accessed 23 November 2021].

9.?????Needham, P., Laughlan, K., Botterill, I. and Ambrose, N., 2009. Laparoscopic Appendicectomy: Calculating the Cost.?The Annals of The Royal College of Surgeons of England, 91(7), pp.606-608.