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Core Surgical training and Selection into ST3 Surgical Subspecialties

MEDICAL PROGRAMME BOARD

DRAFT FOR DISCUSSION

PAPER 31-6

Core Surgical Training and Experience in Surgical Specialties in England

Issues

  1. The paper raises issues about Core Surgical Training (CST) and experience:
  • The purpose of CST: Is the purpose of CST to provide themed or generic experience in surgery? Is it to prepare doctors with the necessary capability and experience to enter ST3 surgical specialties?
  • Experience in surgical specialties in CST: The two- year CT2 programmes provide variable experience. Programmes are generic or themed, with the composition of themed programmes and the duration of experience in the main specialty varying between deaneries. Currently only 80% of themed CST posts provide one year of surgical experience in the main specialty.

Some surgical SACs wish to increase the essential experience for ST3 application from 6 months to one year in the specialty. This means not all trainees will be eligible to progress to higher specialty training without additional surgical experience outside core training.

If the essential entry specialty experience was increased to 1 year for ST3 entry, trainees are likely only be able to apply for only one surgical specialty at ST3. Because of the content of some training programmes some trainees would be ineligible to apply for any ST3 post.

  • Size of intake into Core Surgical Training (CST): The intake to CST at CT1 621 posts (in 2010) when the number of training appointments at ST3 is only 288 in 2010.
  • Size of headroom for competition into ST3 surgical specialties: It is recognised that there needs to be a level of headroom to take account of competition and specialty choice. In 2010, the level of headroom is 523 trainees.
  • Competition ratios for ST3 posts: The likelihood of progressing to ST3 from a CST post is approximately 36% (overall competition ratio 2.8: 1). This has changed little since 2007 when 35% total surgical posts at ST1/ST2 level were run-through training posts with opportunity to progress in training, the rest being FTSTA one-year appointments.

In 2010 competition for a ST3 post from a themed CST programme varies widely from 1.4:1 for Urology to 7:1 for Plastic Surgery. What is an acceptable level of competition?

  • Freestanding CT2 Posts: The number of posts at CT2 is greater than the number of posts at CT1 because deaneries have established 190 one-year CT2 posts. Some of these 190 posts accommodate trainees unsuccessful in their applications to ST3 in 2009. This practice creates a bulge in training at CT2, which continues to increase in size.
  1. The Task and Finish Group on recruitment and selection requested a review of experience provided in CST programmes and a comparison with opportunities to enter the surgical specialties at ST3.
  1. This paper:
  • highlights the mismatch between the numbers of doctors completing CST and current opportunities to progress into higher specialty training in England.
  • provides information on the composition of current CST posts in England and a comparison of the number of themed CST posts with ST3 posts in each surgical specialty.
  • provides information on the impact of increasing the minimum essential experience in the surgical specialties to 12 months for ST3 surgery application on the applicant pool and competition ratios for each surgical specialty.

Discussion

Numbers mismatch between CST posts and higher specialty training posts in Surgery

  1. There is a mismatch between the number of CST posts and higher specialty training posts available in surgical specialties in England.
  1. Each year approximately 621 trainees enter CT1 and two years later, on completion of MRCS, there are approximately 288 opportunities (current 2010 data) to progress to ST3. In addition, there are currently 190 free- standing core surgical training CT2 posts in England, which means that in 2010, up to 812 trainees in CT2 posts may be eligible to apply for ST3 surgery. Consequently, a minimum of 523 trainees completing CST programmes in 2010 will not proceed to higher specialist training. If the intention of the medical workforce planning model is for self-sufficiency with a minimum top up from outside the training system why are so many trainees being taken in to CST when there are substantially fewer higher specialty training applications?
  1. Higher specialty training posts in surgery should be linked to workforce need. Current workforce planning shows we are over-producing doctors trained to CCT in surgery. Are appropriate numbers of ST3 surgical opportunities provided each year?

How many CST posts are there currently in England?

  1. Figure 1 summarises the CST posts in England. For the purpose of the report, posts are subdivided into:
  • CT1/CT2 rotations: Posts where deaneries provide details of the entire two year CST programme at the outset of the training post.
  • CT1-linked posts and CT2- linked posts: Posts where deaneries provide details of the first year of CST with allocation to a CT2 programme later in the first year depending on learning needs.
  • Freestanding CT2 posts: Posts at CT2 level of one year’s duration. They include CT2- linked posts where they are in excess over the number of CT1-linked posts.

Figure 1: Summary of Core Training Posts and ST3 Surgical Opportunities in England in 2010

  1. There are 1,432 CST posts in England with 190 more posts at CT2 (811) than at CT1 (621).
  1. When compared with recruitment and selection in 2007, the opportunities to progress to higher specialty training were very similar as shown in Figure 2.
  2. It should be noted in 2010 that:
  • There has been a modest reduction in surgical posts at CT1/CT2 level since 2007 (by 12%)
  • In surgery, there is no difference in progression between 2007 and 2010. About 36% doctors in CST progress to ST3.

Figure 2. Summary of Surgical Run-through training posts and Surgical FTSTA posts in England in 2007

  1. CST is currently provided in a 2-year programme made up of surgical specialties. The first CST programmes were developed in 2008 consequently the first doctors completing CST are applying for ST3 surgical specialties in 2010. Appendix 1 provides an explanation of the development of CST programmes.
  1. In some deaneries, there are excess CST2 posts over CST1 posts. Possible reasons were explored with the CST Programme Directors and several explanations have been suggested:
  • Some standalone CST2 posts were originally fixed term specialty training appointments (FTSTA) posts.
  • Having some standalone CST2 posts available is considered beneficial to enable exposure to additional specialties if the trainee wishes to apply for a ST3 post outside the specialties experienced in the two year CST programme.
  • While these posts provide further training for doctors who have already completed a CST programme, many are used to support surgical rotas allowing doctors to extend their CST without necessarily improving their prospects of entering higher specialty training.
  • Excess CST2 posts are kept by some deaneries in preparation for re-organisation of CST, for example, in case CST is extended in duration.
  1. A consequence of providing stand-alone CST2 posts is they provide posts for trainees to occupy who have failed to secure a ST3 post in surgery. Trainees may complete several standalone CST2 posts in surgery in succession anticipating that additional experience at CST2 will enhance their chance of progressing to ST3.
  1. It is currently unknown whether trainees with more than 2 years experience of CST are likely to be more successful in gaining a ST3 surgical post than doctors applying directly from a 2 year CST programme however data is currently being collected on applicants to ST3 surgical specialties to try to find this out.
  1. Provisional data on applications to ST3 General Surgery are shown in Appendices 2a and b. The graphs show the distribution of applications outside London and applicants to London in relation to the date of acquisition of the primary medical degree. While recognising the limitations of interpreting data based on surrogate markers of clinical experience, provisional data suggests that:
  • Job offers seem more likely to doctors who have acquired their primary medical degree since 2003 rather than earlier on. These doctors may however have completed up to 6 years surgery by the time of commencing the ST3 post.
  • There is no evidence that doctors applying after completing a foundation programme and CST programme are more likely to be appointed to ST3 general surgery than doctors who are likely to have completed several years more surgical training.

Entry requirements for ST3 Surgical Specialties

  1. Doctors applying for ST3 posts in a specialty are required by the Specialty Advisory Committee (SAC) to have gained experience of the specialty during CST. The JCST found consensus in 2008 that doctors applying for ST3 posts would be required to have a minimum of 6 months experience of the relevant surgical specialty. This requirement was articulated as the essential entry experience for ST3 in the national person specifications. This was also agreed for recruitment and selection into ST3 in 2009 and 2010.
  1. For 2011, the SACs in the surgical specialties of general surgery and trauma and orthopaedics have requested doctors applying for ST3 to have a minimum of 12 months general surgical experience and 10 months T&O experience in CST respectively. This fits with the curriculum developed in 2007 for run-through training where doctors completing ST1/2 in a themed programme have previously been required to gain this experience.
  1. Were the entry requirements increased for ST3 general surgery and T&O without altering the composition of CST posts, a group of doctors completing CST would not be eligible to apply for higher surgical training without completing additional surgical posts in these specialties.
  2. To assess the impact of changes requested to the person specifications for entry into ST3 surgical specialties on doctors completing CST, an analysis of the composition of CST posts in England was undertaken.
  1. The analysis sought to identify the experience of doctors completing CST across English deaneries to see what experience CST posts currently provide and whether this is appropriate to meet the new proposed entry requirements for ST3 surgical specialties.

The findings are:

Mismatch between surgical training experience gained in the surgical specialties and opportunities to progress to higher specialty training

  1. There is a mismatch between surgical training experience gained in the surgical specialties in CST and the opportunities to progress to higher specialty training.
  1. The number of themed CST programmes developed in England is not based on opportunities to progress to higher specialty training in the related surgical specialty as shown in Figure 3.


Figure 3. A comparison of the number of themed CST posts and ST3 opportunities in surgical specialties in 2010

  1. Competition ratios for ST3 posts vary between surgical specialties, for example, there are 58 themed urology CST programmes and 41 ST3 Urology posts in England (Competition ratio 1.4: 1) whereas there are 64 themed plastic surgery CST programmes and only 9 ST3 plastic surgery posts in England (Competition ratio 7: 1).

Implications of trainees not progressing

  1. With 811 trainees at CST2 and only 288 ST3 Surgical Training applicants there will be a minimum of 523 trainees who will not progress. This has several implications:
  • Some trainees may secure a standalone CST2 post believing that by gaining more experience their chances of progressing to ST3 will be enhanced.
  • If trainees that do not progress remain in regional training posts then this may reduce the number of CST1 posts that are available for Foundation Programme trainees.
  • If each year there are a minimum of 333 – 523 CST2 trainees who do not progress to ST3 why are so many trainees being taken into CST programmes. Not only does this have a significant training cost it also runs counter to the medical workforce training model of training 6000 plus trainees for 6000 plus higher specialty training posts. Less than 6% posts leading to CCT are in surgical specialties (including OFMS and neurosurgery). While doctors pursue a career in surgery in CST they are not available to train in other specialties where progress through training is more likely.
  • The level of mismatch between those being trained in some of the surgical specialties e.g. plastics and ST3 training opportunities mean that each year a large proportions of trainees will not progress and will need to reconsider their career options.

Variable experience in CST Posts currently across England

  1. A summary of the Core Training programmes provided by deaneries in England is shown in Appendix 3a and b. Data has been analysed separately for CST1/CST2 rotations and CST1 and CST2-linked posts in England. An estimation of experience in surgical specialties and the likelihood of progression to ST3 in shown in Appendix 4.

CT1/CT2 ROTATIONS

  1. Deaneries providing CST Programmes with 2 years’ experience defined from the outset are: East of England, Northern, North West, Oxford, South West Peninsula and Yorks and Humber – South. For these two year CST posts a summary of the programmes and experience provided for the whole two-year period is shown in Appendix 4.
  1. 210 of the 223 posts (94%) provide at least 1 year’s experience in a surgical specialty.

CT1- AND CT2- LINKED POSTS

  1. Deaneries providing CST Programmes where only CST1 is defined from the beginning of the programme are: East Midlands, KSS, London, Mersey, Severn, West Midlands, Wessex and Yorks & Humber- West & East.
  1. For these posts, the experience in the Surgical Specialties is provided for CST1 and for CST2 separately in Appendices 3.
  1. Experience in surgical specialties provided by freestanding- ST2 posts is incomplete however where experience has been defined the experience has been included.

What does an overview of core surgical training posts in England demonstrate?

  1. The CST programmes developed in England vary between deaneries.
  • There is no consensus on the composition of CST posts across England.
  • There is variability between deaneries on:
      • Whether 1 or 2 year posts are defined from the outset of the programme
      • Whether CST posts are themed or generic.
      • The length of placements in a CST post
      • The composition of themed- posts: There is a variation in the duration of posts in the main specialty in the theme and in what other posts in related specialties are included in the programme
      • The minimum and maximum experience gained in a surgical specialty
  • Currently not all CST rotations provide one year’s experience in any surgical specialty.
  • There is no consistent relationship between the number of CST rotations providing ≥1 year in the specialty and ST3 opportunities available.

Impact of increasing the minimum surgical specialty experience requirements for entry into ST3 surgery

  1. Entry into ST3 surgical specialties currently requires at least 6 months experience in the surgical specialty during CST. All doctors completing CST in 2010 will have completed at least 6 months of experience in at least one surgical specialty and consequently all will be eligible to apply from CST for ST3 surgery.
  1. If the minimum essential entry experience required for ST3 in a surgical specialty was increased to at least 12 months in the specialty, not all trainees in CST would be eligible to apply for a ST3 surgical post on completing CST.

How many CST programmes currently provide ≥ one year of surgical specialty experience?

  1. 92% CST1/ CST2 rotations provide one year's surgical experience in a specialty.
  1. It should be noted that while the experience for CST1/CST2 rotation is clearly defined, the experience for CST 1- linked posts and CST2 -linked posts relates only to the experience gained in one year of the programme consequently the total number of two year CST posts providing one year of surgical specialty experience will be more than is defined here.
  1. At least 604 out of 756 themed CST posts provide one year's surgical experience in a specialty (80%).
  1. Experience in the surgical specialties has been considered individually for each surgical specialty and the following relevant to SAC requests noted:
  • Not all posts with a General surgery theme provide at least one-year of general surgical experience.
  • In trauma and orthopaedic themed CST rotations, many rotations do not provide 10 months of trauma and orthopaedic surgery, for example, there are no CT1/CT2 rotations at all providing 10 months of T&O experience.
  • In ENT surgery, some doctors currently complete more than 16 months experience in ENT surgery over a two-year period.

Recommendations

  1. The Medical Programme Board is asked to approve the following recommendations on the number of CST posts and the content of CST programmes.
  1. Number of CST Posts:

It is recommended immediately for 2011 that:

  • Transitional arrangements to manage the excess of doctors trained in CST are introduced:
  • The number of CST1 posts recruited to in 2011 should not be greater than the ST3 opportunities
  • Free-standing CT2 posts should be removed
  • Reliable and transparent career planning information is made available for all doctors pursuing and wishing to pursue a career in surgery.
  1. It is recommended by 2011 that:
  • Acceptable headroom is determined for CST posts and that this be reviewed on an annual basis.
  • Alignment is made between the number of themed CST posts and the ST3 opportunities in the surgical specialties.
  1. Content of Core Surgical Programmes:

It is recommended immediately for 2011 that:

  • The essential experience for ST3 surgery should be maintained at “at least 6 months experience in the specialty”.
  • A review should be undertaken as early as possible on the purpose of core surgical training and recommendations made on the composition of themed and generic surgical programmes in England linking to the curriculum.
  1. It is recommended by 2012 that:
  • Agreement on the minimum essential experience required for entry into ST3 surgical specialties should be reached for each specialty.
  • If the essential experience required for entry into ST3 surgical specialties is increased to 1 year or a maximum limit on specialty experience is required, the composition of CST rotations be appropriately reconfigured so all CST programmes provide the required experience.
  1. It should be noted that If changes are agreed to the person specifications, a lead-time of up to 2 years will be required if CST programme restructuring is required to allow doctors currently in CST posts to not be disadvantaged in applying to ST3 surgical specialties.

Dr Alison S Carr

Senior Clinical Advisor

Medical Education and Training Programme England


Appendix 1: The background to the development of Core Surgical Training posts in England:

In 2007, surgical training was run- through training and programmes were either themed to the specialty or generic. Themed surgical training programmes were developed bearing in mind the specific requirements for posts in ST1 and ST2 dependent on the theme of the programme, for example:

  • Doctors completing a themed general surgical programme would have completed 1 year of General Surgery at ST1 /ST2 level.
  • Likewise all themed Trauma and Orthopaedic core surgical training programmes provided at least 10 months of T&O experience at ST1/ ST2 level.

In 2007, FTSTA posts were advertised also as one-year CT1/ CT2 rotations at ST1 or ST2 level. They were made up of one or more surgical sub-specialties.

In 2008, surgical training was uncoupled and deaneries developed Core Training programmes for surgery from the ST1 and ST2 posts that had been run-through posts. Joining together posts that were previous FTSTA posts made many more 2-year core surgical training programmes. By doing this, a number of surgical rotations developed were made up of 4 x 6 monthly rotations in surgical specialties (i.e. FTSTA level 1 + FTSTA level 2 posts combined) and some had no theme.

In 2009, surgical training continued to be provided by core training programmes as in 2008.

In 2010, the first doctors completing the 2-year Core Surgical training programmes apply for ST3 posts in surgical specialties.


Appendix 2a: Provisional data on applications to ST3 General Surgery outside London linked to the year of acquisition of the Primary Medical Degree

Appendix 2b: Provisional data on applicants to ST3 General Surgery in London linked to the year of acquisition of the Primary Medical Degree

1


MEDICAL PROGRAMME BOARD

DRAFT FOR DISCUSSION

Appendix 3a. CST posts where the 2 year programme is defined from the outset (CT1 / CT2 rotations)

Deanery

No. of

CT1 / CT2

rotations

Are the two-year CST programmes defined from the outset?

i.e. CT1/CT2 rotations?

How many excess free-standing CT2 posts are there?

Themed?

Generic?

Duration of CT1 posts

Duration of CT2 posts

Maximum experience in the main specialty (months)

East of England

33/33

Yes

ü

3 x 4 months

2 x 6 months though both placements in CT2 may be in the themed specialty

18 months

26

Northern

30/30

Yes

ü

3 x 4 months

2 x 6 months or 1 x 1 year- all provide 1 year in the main specialty

CT2 Free-standing posts are themed and are 1x1 year placements

16 months.

19

Northwest

69/69

Yes

ü

2 x 6 months

2 x 6 months or 1 x 1 year

Most provide 18 months

3

Oxford

24/24

Yes

ü(some)

2 x 6 months

2 x 6 months

18 months

0

SW Peninsula

36/36

Yes

ü

2 x 6 months or 3 x 4 months or a combination of 3 month and 6 month posts.

CT2 is generally in the main specialty: placements are

mainly 1 year though 2 x 6 months or a combination of 3 month and 6 month posts are provided.

18 months.

4

Yorks & Humber - South

34/34

Yes

ü(most)

ü(4)

3 x 4 months

3 x 4 months and provide 8 or 12 months in the main specialty

Most themed posts provide 12- 24 months

0

(includes 4CT rotations developed from 8 FTSTA posts)

TOTAL

52

Appendix 3b. CST posts where only the first year of the CST programme defined from the outset i.e. CT1-linked and CT2- linked posts

Deanery

Total CT1 and CT2 linked posts

CT1- linked posts

CT2- linked posts

How many excess free-standing CT2 posts are there?

Themed

Generic

Duration of most posts

Experience (months)

Themed

Generic

Duration of most posts

Experience (months)

East Midlands North

23/36

ü

3 x 4 months

Most posts provide 4 months, a few 8 months and one 12 months in the main specialty

ü

3 x 4 months

Most posts provide 12 months in the main specialty

13

East Midlands South

21/24

ü

3 x 4 months

Most posts provide 4 months experience in 3 specialties

ü

1 year or 2 x 6 months

Most posts provide 12 months in the main specialty

3

KSS

23/43

ü

(except 1)

3 x 4 months

Most posts provide 4 months experience in 3 specialties, others provide 4 + 8 months experience

ü

(all posts described as ‘Generic with a theme’)

1 year (most) or 2 x 6 months

44% posts provide 12 months in the main specialty, the rest 6 months in two specialties

20

London

126/156

ü

3 x 4 months

Most posts provide 4 months experience in 3 specialties, less commonly, others provide 4 + 8 months experience

ü

2 x 6 months

‘FTSTAs’ are 1 year standalone posts

45% posts provide 12 months in the main specialty

30

Mersey

30/56

ü

2 x 6 months

All posts provide 6 months in the main specialty, 37% provide 1 year in the main specialty

ü

mostly 1 year in the main specialty, 14% provide 2 x 6 months

No information has been provided about standalone posts

26


Deanery

Total CT1 and CT2 linked posts

CT1- linked posts

CT2- linked posts

How many excess free-standing CT2 posts are there?

Themed

Generic

Duration of most posts

Experience (months)

Themed

Generic

Duration of most posts

Experience (months)

Severn

37/47

ü

mainly 2 x 6 months though a few posts provide 4 + 8 months experience

All posts provide 6 months experience in the main specialty (a few provide 8 months experience)

ü

2 x 6 months

79% posts provide 12 months in the main specialty

10

West Midlands

75/93

ü

mainly 3 x 4 months though a few posts provide 4 + 8 months

Most posts provide 4 months experience in the main specialty, a few provide 8 months experience

ü

mainly 1 year

94% posts provide 12 months in the main specialty, the rest 8 months

18

Wessex

36/34

ü

3 x 4 months

All posts provide 4 months experience in 3 specialties

ü

All CT2 posts provide 12 months in the main specialty

-2

Yorks & Humber- West East

27/49

ü

2 x 6 months

81% posts provide 6 months experience in 2 specialties, 19% provide 1 year’s experience in one specialty

ü

2 x 6 months

90% posts provide 6 months experience in 2 specialties, 10% provide 1 year’s experience in one specialty

22

TOTAL

140


Appendix 4. An estimation of experience in surgical specialties and the likelihood of progression to ST3

Surgical Specialty

No themed CT1/CT2 rotations*

Distribution of themed CT1/CT2 rotations in deaneries*

No CT1/CT2 rotations providing at least one year in the specialty

No themed CT2-linked posts in deaneries

Distribution of themed CT2 linked posts in deaneries*

No standalone CT2 posts providing 1 year in the specialty (C)

Total No Themed CST posts*

(D = A+B+C)

Total No CST posts (all categories) providing at least one year in the specialty (E) **

Likely % Total Themed CST Posts providing at least one year’s experience in the specialty (E/D)

No. ST3 Opportunities in specialty in 2010 (F)

Competition for progression to ST3 from a themed CST post in the specialty (=D/F)

General Surgery

83

E of E 9,

Northern 15,

Oxford 8.

SW Peninsula 15,

Wessex 12,

Y&H E&W 24

36

174

EM (North) 15,

EM (South) 3,

KSS 15,

London 56,

Mersey 3,

North West 23,

Severn 17,

West Mid 36,

Y&H South 6

13

270

210

78%

93

2.9: 1

T&O

74

E of E 11,

Northern 9,

Oxford 3,

SW Peninsula 13,

Wessex 12,

Y&H E&W 26

27

164

EM (North) 13,

EM (South) 12,

KSS 9,

London 43,

Mersey 16,

North West 19,

Severn 20,

West Mid 27,

Y&H South 5

22

260

218

84%

90

2.9: 1

Plastics

18

E of E 3,

Northern 3,

Oxford 5,

SW Peninsula 2,

Wessex 3,

Y&H E&W 2

9

43

EM (North) 1,

KSS 6,

London 20,

Mersey 3,

North West 3,

Severn 2,

West Mid 6,

Y&H South 2

3

64

48

75%

9

7: 1

Paediatric Surgery

7

Oxford 4,

Wessex 1,

Y&H E&W 2

3

15

EM (North) 2,

London 6,

North West 1,

West Mid 3,

Y&H South 3

0

22

9

41%

6

3.7: 1

Urology

14

E of E 4,

Northern 3,

Oxford 1,

SW Peninsula 2,

Wessex 2,

Y&H E&W 2

7

40

EM (North) 2,

KSS 4,

London 16,

Mersey 1,

North West 5,

Severn 2,

West Mid 9,

Y&H South 1

4

58

43

74%

41

1.4: 1

ENT

19

E of E 5,

Northern 3,

Oxford 3,

SW Peninsula 2,

Wessex 4,

Y&H E&W 2

8

50

EM (North) 3,

KSS 5,

London 14,

Mersey 1,

North West 11,

Severn 4,

West Mid 9,

Y&H South 3

3

72

65

90%

27

2.7: 1

Cardiothoracic Surgery

1

E of E 1,

2

8

EM (South) 1,

London 1,

North West 1,

West Mid 3,

Y&H South 2

1

10

11

100%

22

0.45: 1

Total

A= 216

92

B= 494

C= 46

D= 756

E= 604

80%

F= 288

2.6: 1


* Many of these posts do not provide one year of surgical specialty experience in CT2

** This may be underestimated for rotations made up of CT1-linked and CT2-linked posts

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