Introduction: Changes to surgical training and reduction of junior doctors’ working hours has resulted in trainees spending less time in surgical specialties before becoming eligible to apply for specialist registrar posts. A high quality basic surgical training programme is needed to improve the competence of trainees during their shortened period, an essential part of which is to conduct a formal assessment at the end of each training post and regular appraisals during their period of training.
Aims: To analyse the existing practice with regard to conducting assessment and appraisals for basic surgical trainees in the South East Wales region.
Methods: A questionnaire was sent to all the basic surgical trainees in the South East Wales region.
Results: A total of 52 questionnaires were sent out and 44 (84%) were returned. Four candidates were in the first post of their rotation, and were therefore excluded from the study. Nine of the 40 trainees (23%) did not have an assessment in one or more of their posts. There are 17 senior house officer posts available in general surgery in the rotation. Of the 31 “six month” episodes spent in these 17 posts, 27 (87%) underwent an assessment, 12 of the 17 (70%) episodes in trauma and orthopaedics (12 available posts) were assessed, and 31 of the 35 (88%) episodes in accident and emergency (eight available posts) underwent an assessment. Twenty eight of the 40 trainees (70%) did not undergo regular appraisals during the majority of their posts. Only 30%–50% of episodes spent in general surgery, orthopaedics, and accident and emergency underwent appraisals. The majority of the episodes spent in the other surgical specialties (12 posts available in total) had formal assessment and regular appraisals except for urology in which two of seven episodes underwent assessment and one underwent an appraisal. Twelve candidates (30%) expressed the view that operative experience and technical skills must form part of their assessment. Eight trainees (20%) felt that they needed more help from tutors with regard to career advice, preparation of curriculum vitae, and interview techniques for specialist registrar posts. Eight trainees mentioned that they had discussed unsatisfactory posts with their tutors but were not aware of any changes made to these posts.
Conclusions: This study has shown that the formal assessment of basic surgical trainees at the end of each training post has to improve further. The existing practice of conducting regular appraisals for the trainees is grossly inadequate. There appears to be a need for formulating guidelines for conducting such appraisals, which would help to improve practice in the future.
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Surgical training has undergone vast changes in recent years. As a result, a candidate can apply for a specialist registrar post after only two years of basic surgical training. However, a sharp rise in the level of clinical competence, responsibilities, and leadership qualities is expected from a trainee as soon as he or she enters higher specialist training. To achieve this, a systematic and supervised basic surgical training programme is needed, an essential part of which is to regularly assess the progress of the trainee and the quality of training. The Royal College of Surgeons of England states that all basic surgical trainees must have a formal assessment at the end of each training post. This should involve a meeting with the supervising consultant and the completion of a trainee assessment form. Targets and educational objectives should have been previously set and the progress of the trainees monitored to get most value from these assessments. Hence, regular appraisals, whereby meetings are held between the local educational supervisor/consultant and the trainee to monitor his/her progress, are also an important part of the training programme.
One of the aims of this study was to analyse how often the trainees undergo assessment and appraisal during their basic surgical training and the methods used for assessment. Secondly, we aimed to obtain the views of the trainees with regard to assessment methods, and any aspects of the training, that they feel were not reviewed by their trainers.
A comprehensive questionnaire was sent to all the basic surgical trainees in the South East Wales region. Some candidates were also interviewed over the telephone to fill out any incomplete questionnaires.
A total of 52 questionnaires were sent out and 44 (84%) were returned. Of the 44 trainees, eight had passed both parts of the MRCS/AFRCS, and 19 had completed the part 1 MRCS/AFRCS.
Four candidates were in the first post of their rotation, and were therefore excluded from the study. Of the remaining 40 trainees, nine (23%) did not have an assessment in one or more of their posts. There were 17 senior house officer posts available in general surgery in the rotation and 31 “six month” episodes; 27 (87%) underwent a formal assessment. Similarly, of the 17 episodes spent in trauma and orthopaedics (12 available posts), there were 12 assessments performed (70%) and of the 35 episodes in accident and emergency (eight available posts), 31 (88%) were assessed. Sixteen episodes were spent in various other surgical specialties (12 available posts in total), all of which were assessed at the end of six months, except for urology, in which only two of the seven episodes underwent assessment.
Twenty eight of the 40 trainees (70%) did not have a regular appraisal in the majority of their training posts. Only five candidates had undergone regular appraisals in all of their training posts.
When the individual posts were analysed, the surgical specialties other than urology performed well again, with most of the episodes providing regular appraisals. With regards to trainees in general surgery, trauma and orthopaedics, and accident and emergency only 30%–50% of the episodes spent in these specialties received regular appraisals.
These results have been summarised in table 1.
Method of assessment
The assessment was carried out by the respective consultant in the majority of cases. Four candidates were interviewed by the basic surgical training committee during one of their posts. Twenty six trainees replied that the Royal College of Surgeons forms were used for assessment in one or more of their posts. Locally designed departmental forms were used for assessment of 14 candidates, and assessment was by interview for six candidates.
Methods of appraisal
All the appraisals were by interview and were carried out by the local educational supervisor. Spontaneous comments were made by 12 trainees (30%), all of whom felt that operative experience and technical skills should form part of their assessment. Eight trainees (20%) expressed their view that career advice should form a part of the appraisals. Eight of the 40 trainees (20%) stated that they had worked in at least one unsatisfactory post during their rotation.
Changes in surgical training and reduction of junior doctors’ working hours has resulted in candidates spending less time in the surgical specialties before being eligible for specialist training.1 However, during this shortened period, the trainees have to improve their competence, which include clinical and operative skills, and other professional attitudes such as leadership, initiative, and communication skills.2,3 A high quality of training is needed to achieve this, thereby preparing the trainee for the increased responsibilities associated with specialist training. It is also important that a regular and effective assessment programme is used in order to identify and correct any shortcomings on the part of the candidate and to ensure that the posts offer adequate and comprehensive training.
Our survey has shown that overall, the formal assessment of basic surgical trainees at the end of their individual posts is satisfactory in terms of percentage achieved, though there is still room for improvement. However, this study highlights the need for consistency in the methods used for assessment by the surgical departments in the various hospitals that participate in the rotation.
The training board of the Royal College of Surgeons of England recommends that basic surgical trainees must receive regular appraisals during their training.4 This involves an initial meeting with the consultant/local educational supervisor to familiarise them with the work of the unit and to set educational aims and objectives. Thereafter, regular meetings must be arranged to assess if the aims are being met. Twenty eight of the 40 trainees in our study (70%) did not receive any appraisals during the majority of their training posts. The educational objectives of a trainee in any particular post depends on what stage of the rotation he or she is in, future career aims of the trainee, and the type and volume of workload undertaken by the unit in which they train. Hence, the appraisals have to be tailored to meet the individual trainee’s needs. However, there are no formal guidelines or a framework available to the educational supervisor/consultant for conducting such appraisals. Another possible reason for poor compliance rate among the educational supervisors is the lack of “protected time” for conducting appraisals, which may be viewed as an additional burden, considering their clinical commitments. We are currently interviewing all the educational supervisors in Wales to study the existing appraisal methods and practices.
Twelve trainees (30%) expressed the view that operative experience and technical skills were not covered during the appraisals or assessment. A survey conducted among consultant surgeons has revealed that they consider technical skills an important part of the assessment of higher surgical trainees.5 Considering the constraints imposed on the duration of basic surgical training, an objective method of assessment of technical skills may be useful to identify and correct any practical shortcomings in the trainees. Such methods have been tried to assess surgical trainees in other countries.6
Eight candidates (20%) felt that they need more help from tutors with regard to career advice, preparation of curriculum vitae, and interview techniques for specialist registrar posts. Lastly, eight trainees mentioned that they had discussed with their local tutor or training committee about unsatisfactory posts. However, none of them were aware of any changes made to these posts as a result of their complaints.
Formal assessment of basic surgical trainees at the end of their individual posts requires improvement from the current level. Improvement will be obtained by following a consistent method of assessment in each post. The current practice of conducting appraisals is grossly inadequate. The formulation of guidelines on the conduct of appraisals is therefore necessary. Furthermore, changes to include evaluation of technical skills, operative experience, and career advice may help to improve the overall standards of assessment.