Practical training in all craft specialties has been compromised during the pandemic.
In obstetrics and gynaecology the lack of opportunities has mainly affected gynaecological operating (which was already under pressure) but also ultrasound, hysteroscopy and colposcopy because of space constraints. The situation is urgent particularly for some senior trainees completing ATSMs and subspecialty training, who now need extra time in training.
This document represents an attempt to rectify the situation and the College is grateful to everyone who offered suggestions and those who put it together.
RCOG Vice President, Education
The RCOG acknowledges the issues surrounding the delivery of high-quality gynaecological surgical training in the UK.
The COVID-19 pandemic has interrupted routine and elective surgery, and further exacerbated the problem. The priority, as always, is to remain committed to maintaining safe and effective standards in gynaecology, now and in the future.
Many factors have impacted on gynaecological surgical training, including EWTD with change of working patterns and loss of the traditional apprenticeship model, along with developments of non-surgical and outpatient management of many conditions. Surgical treatments are often associated with complexity and the service is often heavily dependent on ‘senior’ gynaecologists. Prioritising succession planning in this area is essential as continued inadequate and insufficient hands-on surgical training today is the largest threat to ensuring competent and safe consultant gynaecologists of the future.
As elective gynaecological surgery services are restored the inevitable demands and pressures placed on the service need to be balanced against the widening deficit in the provision of training caused by the pandemic. The aim of this page, whilst highlighting the issue, is to produce guidance and recommendations that can facilitate strategies to plan effective recovery of training in gynaecological surgery.
This page outlines a set of principles and actions at a national, regional, and local level.
- The ethos of teaching and training needs to be embedded in our NHS clinical practice
- A formal and structured RCOG simulation training programme should be developed and subsequently implemented by all regions. The strategy should be outlined by collaborative work of the RCOG with specialist gynaecological societies such as the BSGE, BGCS, BSUG
- Human factors courses grounded in clinical practice are essential to support trainees within the surgical environment. In addition, ‘Train the Trainers’ type courses may aid trainers to optimise surgical teaching with more limited training opportunities
- Specialist societies are likely to play a more pivotal role in specialist areas of gynaecology and trainee membership should be supported
- We need to help clinical service/operational managers to understand that supporting training today will improve safety and efficiency long after this restoration period
- The RCOG recommends remuneration for national and regional strategies by HEE/NES/HEIW/NIMDTA to improve surgical training. Trusts should support local organisation of strategies to implement and support training needs through protected time in consultant job plans for surgical and simulation teaching.
- Derogations of the curriculum may persist in 2021 but a long-term plan must consider specialist gynaecology training pathways to ensure appropriate succession planning
- Organisations utilising private sector capacity for elective surgery should allow equal opportunity for surgical training.
Each region needs to identify a structure for the delivery of Gynaecological Surgical Training. The proposed structure would be expected to include:
- At least one Simulation Hub for hands on training to be identified within in each region.
- A nominated Surgical Lead within each training unit who can work with the College Tutor to assess the surgical needs of each trainee within the unit and match them to appropriate live surgical training lists. In smaller units this role may be taken by the College Tutor. It is also important to involve trainees in this work.
- Collaborative working with the School of Surgery should be encouraged to ensure efficient use of equipment and multi-disciplinary training, with the associated benefits.
- Trainees within a unit requiring top up training to be identified to the TPD or HOS. Where a trainee needs additional surgical training the options for how this can be achieved within the region will be identified and published to the trainees in line with the Gold Guide. For some trainees it may be that period of Out of Program (OOP) should be considered. Consideration for involvement with the regional professional support unit should also be given and where needed additional study leave applications can be considered.
- The Head of School working with the support of the Post Graduate Dean to consider appointing a regional lead for surgical training/simulation who would support the Unit Leads with the delivery of the curriculum. This person would lead on ensuring the equipment needs for the units and the hub are met and support the application process for all additional equipment for the region. The Regional lead will identify placements for targeted surgical training in association with the TPDs. They should provide the evidence to quality assure the programme by submitting the data for both the live and simulated training to the Specialist Training Committee and the RCOG. (The data to be submitted will be agreed by RCOG committee). The Regional lead will work with members representing the breadth of gynae surgery to ensure simulation opportunities for subspecialties are built in where possible. The regional lead will work with industry to identify courses that trainees can access and signpost the trainees to these.
- Training opportunities in the independent sector where possible should be used and the simulation lead working with the Head of School should ensure that trainees have the correct permissions in place so that they can operate under supervision in this environment. Where there are lost training opportunities within the independent sector these should be fed back to the Post Graduate Dean.
- Consideration to be given to top slicing ST1 and ST2 study leave budget to support the purchase of a lap box simulator from the start of the training programme
- Consideration should be given to appointing a Trainee Rep to work with the Simulation Lead and to support the visits to the units and collation of the data and feedback regarding training experience.
Expose trainees to every possible training opportunity available
- Carry out an immediate surgical training delivery impact assessment for the unit.
- Consider appointing a consultant to the role of ‘unit surgical champion’ with time allocated through job planning to optimise training in gynaecology surgery and develop an educational surgical program and targeted training for all levels of trainees. If this is not possible then consider asking the Clinical Lead for Gynaecology to be involved.
- Plan training delivery for all trainees on a weekly basis to optimise best use of theatre lists for training. Units also need to consider the training needs of recently appointed consultants
- Encourage the use of simulation in more surgically inexperienced trainees where the benefits are well demonstrated and deliver specific training needs particularly for those trainees nearing the end of their training and required to complete ATSM training
- Optimise rota design to facilitate predictable work patterns so that trainees can have fixed work patterns. This would allow trainees to undertake surgical training with the same trainer
- Develop good multiprofessional working and relationships so that other members of the team understand the importance of training. This requires the sponsorship of the clinical director and business/operational manager
- Ensure release of trainees to the independent sector training opportunities by operating with unit consultants where applicable but only when hands on training will occur.
- Surgical training in gynaecology should be placed on the department risk register and educational risk register through the Director of Medical education, ensuring that the Board has an awareness of the problem.
Encourage and support trainers
- Highlight the scale of the problem of training in gynaecological surgery and the key role that trainers play- ‘your trainees need good trainers like never before’.
- Unit surgical champion and College Tutor to provide examples of how to make the most of every training encounter and how to give focussed, meaningful feedback after each session.
- Develop local teaching events that focus on gynaecological surgery and develop local simulation teaching session for laparoscopy
- Attempt to ring fence time for surgical and simulation teaching in job plans.
Top tips for trainers to maximise surgical training
The list below are examples of how trainers can optimise more components of training in their daily clinical work and therefore increase delivery of learning opportunities and high-quality feedback.
1) Involve a trainee in all clinical work that you undertake:
- Clinics, wards, emergencies, theatre, MDM, Clinical administration (letters and review of results)
2) Aim to ensure a training interaction with every patient
3) Use spare time to teach and train:
- Get the trainee to describe what steps they are going to take for the procedure prior to starting and the challenges anticipated.
- Discuss surgical options for a difficult case whilst on the ward or walking to theatre
- Use the time whilst waiting to start an emergency case in theatre to go over skills on a box trainer
4) Adapt your approach to maximise learning
- Involve trainees in telephone and virtual consultations
- Ask the trainee to do a pre and post op ward round whilst you watch and complete NOTSS
- Observe trainees assessing emergency patients prior to theatre and complete workplace-based assessments
- Deliver all the training you can from theatre cases
- 2 trainees-enable the junior trainee to do the open and closing or laparoscopic entry and the senior trainee to undertake the complex part of the case with your supervision throughout.
- buddy consultant operating- take it in turns to supervise the trainee and identify which parts of the case require both consultants whilst explaining the rationale. Identify parts of the case that are suitable for the trainee and enable them to do.
- Pre theatre brief- use this as an opportunity to explain the importance of training, how important surgical training is to develop the surgical gynaecologists of the future and explain what the trainee will be doing on the list
- Give feedback and complete OSATs in a timely manner on every occasion
- Involve trainees in reviewing ultrasound scan, CT or MRI images and discuss them
- Encourage the trainee to get the most out of every day and facilitate reflection on the learning at the end of the day
- Build a rapport with the trainees
- get to know them
- discuss current challenges and career plans
- make them feel that they belong to the unit
- make them feel valued
Top tips for trainees to maximise surgical training
It is important that trainees are proactive and self-direct their learning to meet the needs of the curriculum and individual learning plans:
The list below are suggestions of how to optimise training in gynaecological surgery
- Use other methodologies to increase knowledge of surgical techniques and pelvic anatomy e.g., U-tube videos.
- Make the most of all simulation opportunities available locally and regionally
Use laparoscopic trainers to practise surgical skills out with simulation teaching and operating lists.
- Ensure preparation for theatre lists by reviewing patient records and the plans for surgery
- Discussion with the consultant coordinating the list in advance of the list if possible
- Use every training interaction with a patient to complete a high-quality workplace-based assessment and complete these in a timely manner.
- Keep an anonymised logbook of all surgical cases involved in with details of involvement in the case
- Consider completing the Training Recovery Discussion Template or equivalent with your Educational supervisor.
Published 17 May 2021
Alastair Campbell: Chair of SEAC, RCOG
Heidi Stelling: Incoming Chair National Trainees Committee
Melanie Tipples: Head of School KSS
Donna Ghosh: Laparoscopic training Lead, BSGE