Trainee Section: The future of orthopaedic training: diversity and education

Ran Wei is a ST8 in South West London with an interest in Knee Surgery. He is currently the President of BOTA and represents trainees on a number of issues, including diversity and inclusion in T&O surgery.

Kathryn Dayananda is a Specialty Trainee on the Welsh rotation currently working in Cardiff. She was elected this year as the Women in Surgery Representative for BOTA in 2019. Kathryn’s experiences working abroad and her ambition to be a representative voice for all has led to her involvement with the BOA D&I Strategy Group as well as with BHS Culture Working Group.

Oliver Adebayo is an ST5 trainee on the Royal National Orthopaedic Hospital rotation in North, East and Central London Deanery. He is currently the BOTA webmaster. He has a passion for global surgery and is a founding member and on the committee for the Global Anaesthesia, Surgical and Obstetric Collaboration, a trainee advocacy group for global surgery since 2015. He has a MSc from Imperial in Surgical Innovation and has a keen interest in quality improvement, education, digital transformation and clinical UX.

The future of orthopaedic training: diversity and education

Ran Wei, Kathryn Dayananda and Oliver Adebayo

Over the last few years, BOTA have utilised our flagship session at the BOA Annual Congress to tackle issues such as bullying in surgical training, barriers to surgical training and the attributes of excellent surgical trainers. The success of our sessions has relied on engaging content as well as its interactive delivery. It was clear from our first BOTA Committee meeting in January 2020 that our main focus this year would be Culture and Diversity / Inclusion in T&O training.

We assumed that our biggest challenge would be to create engaging and thought-provoking content. What we had not anticipated was a global pandemic. Needless to say, the decision to deliver BOA’s Annual Congress over a virtual platform resulted in a few sleepless nights. This new mode of delivery made gauging audience engagement extremely difficult. In a bid to overcome this we employed the Q&A function of the GoToWebinar platform as well as social media channels.

We titled the session ‘The Future of Orthopaedic Training: Diversity & Education’. The Committee unanimously agreed that both culture and diversity / inclusion as well as simulation in T&O education were important areas to explore, irrespective of, but especially in the wake of the current COVID-19 pandemic. We aimed to cultivate discussions regarding these important issues both during and after our session. Our team utilised Twitter (#FutureOfOrthopaedics) to achieve this. A recording of the session has been made available by the BOA for viewing on their website at: https://www.boa.ac.uk/liverecordings. Please check it out if you were unable to attend the live session, using the QR code reader.

Culture and diversity / inclusion in T&O surgery

In the first half of the 90-minute session we explored issues surrounding Culture and Diversity / Inclusion within T&O surgery. Miss Kathryn Dayananda and Mr Jonathan Howell (President of the British Hip Society) delivered thought-provoking presentations that sparked ample debate on GoToWebinar and Twitter.

Miss Dayananda presented data from the triennial BOTA census, undertaken in 2019. She also showcased BOTA’s Culture and Diversity / Inclusion promotion video1, which features recordings of the BOTA National Committee reading out a series of blinded comments collected from a small-scale survey from T&O trainees across the UK.

This video highlights issues of sexuality, gender, ethnicity and overarching culture among the T&O community. Reactions to blinded comments helped provide a real time appreciation of the impact and responses triggered. These acted as a springboard for discussion.

Mr Howell attempted to answer two fundamental questions in his presentation titled ‘Diversity and Inclusion – The Future of Orthopaedics?’.

1) Why do so few female medical students enter into surgical / orthopaedic careers? 2) Why do so few women complete their training in surgery / orthopaedics to become consultants?

He focused primarily on gender but acknowledged that minority groups were likely to have experienced some form of discrimination as well. He expertly explored topics such as habitus, fitting in, why woman leave surgical training, assessment bias, price paid by woman and culture. Having impressed the audience with his progressive and feminist views, he concluded his presentation by advocating some ‘house rules’ at work – Be Polite, Be Kind, Treat People as People and Pull Together as a Team. It may sound simple but it is too often forgotten.

BOTA 2019 census data

Culture

590 trainees completed the BOTA 2019 census. 42% stated that they suffered from stress and anxiety as a result of work. In 16% of cases, negative morale at work was caused by either colleagues (4.9%), other consultants in the department (4.8%), their consultant trainer (3.8%) or the TPD (2.5%). Despite the huge improvements seen following the ‘HammerItOut’ campaign, 16.3% of trainees continue to experience bullying behaviours within the workplace. The top three identified offenders amongst the respondents to this survey were T&O Consultants (38.3%), Hospital Managers (12.1%) and Nurses / Scrub nurses (8.7%).

No one should be subjected to inappropriate behaviours within the workplace. It is vital that we understand that anyone can make another person’s life difficult or unpleasant with racist, homophobic, misogynistic, undermining or harassing behaviours. Anyone can fall foul of these behaviours. It is important that we bear this in mind the next time we engage in ‘banter’ at work.

Diversity

Gender imbalances persist amongst T&O trainees. More than 1,000 trainees (NTN and non NTN) were surveyed and of the 590 NTN holders who responded, 75% were male and 24% were female. The remaining 1% preferred not to disclose their gender. Ethnicity within the T&O trainee body largely reflects the UK ethnicity distribution documented by the UK Census in 20112 . Comparisons made can be seen in Table 1.

White

Asian

Black

Mixed

Other

BOTA Census (2019)

56%

21%

3%

2.6%

12%

UK Census (2011)

86%

7.5%

3.3%

2.2%

1% Specialty training should aim to produce a workforce that reflects the population it serves. A more diverse workforce will help us better understand the needs of our patients. It is therefore an essential piece of the healthcare puzzle.

Inclusion

Engaging with and inspiring future T&O surgeons is one of the most important responsibilities of a T&O surgeon. The BOTA 2019 census found that 51% of T&O trainees decided to pursue a career in T&O surgery either within medical school (39%) or before medical school (12%). Of the remainder, 30% decided during foundation years training, 15% during core surgical training and 4% during time out of training. It is worth bearing this in mind next time you have a medical student or foundation year doctor in your clinic or operating theatre.

To become an inclusive specialty, we must understand and learn to accept that not all trainees will be able to work full time. Our census found that only 4% of trainees were Less Than Full Time (LTFT). The majority were either 60% LTFT (40.9%) or 80% LTFT (36.4%). 4% of full-time trainees stated that they would like to be LTFT. If we are to improve accessibility of T&O training, we must relinquish the false narratives surrounding LTFT trainees.

A change in culture and attitudes within our specialty and across the wider NHS is the first step towards creating an inclusive and more diverse working environment. We must remember (against all odds) to be kind and thoughtful. We must acknowledge our weaknesses, utilise our strengths, and be accepting of our differences.

Simulation in T&O education

The second half of the virtual session explored the utilisation of computer simulation in T&O education. Two of the most accomplished academics in computer simulation education in the UK T&O community, Professor Duncan Tennent and Mr Kapil Sugand, shared with us their thoughts on the subject.

In his talk, titled ‘Simulation in Training – The BOA’, Professor Tennent briefed us on the current state of simulation provision in T&O training across the UK3. He explored the barriers to uptake of computer simulation training as well as a vision for the future of this adjunct to training.

Mr Sugand explained the fundamental principles of surgical simulation and examined the evidence for the tools and methods currently being utilised and >>

developed in simulation technology. He highlighted the need for simulation to recreate the clinical exercise in an immersive, realistic, interactive and controlled environment that enables learning, development and mastering of technical and non-technical skills without compromising patient safety.

On reflection, both presentations highlighted two important themes - limitations of simulation and innovation in simulation.

Limitations of simulation

Loss of training opportunities as a result of disruptions caused by the current COVID-19 pandemic lends support to the mandate for increasing surgical simulation training. However, it is important to understand that simulation is limited by its ability to recreate a true surgical environment. This is known as validity. Validation is what every simulated exercise is measured against and is categorised into four distinct entities (Table 2). Concurrent validity of a simulation tool is the aim of every simulation developer.

Type of Validity

Face

Content

Construct

Concurrent

Description

Does it look real?

Are the operative steps realistic?

Can the exercise differentiate between levels of skill/training/ expertise (e.g. medical student vs. consultant)?

Can the skills learnt in simulation be transferred to the operating theatre? Table 2.

It is vital to understand that every simulation tool is different and will therefore fulfil different roles within the education journey. Cognitive task simulations, popularised by the smart phone application ‘Touch Surgery’, allows users to rehearse steps of a procedure. This may help junior trainees learn the knowledge required for a particular procedure but does not improve their technical skills for that procedure. In order to improve their technical skills, augmented reality or desktop simulation (e.g. saw bones workshop) would be required.

It goes without saying that there remain significant limitations to simulation technology and its implementation. The aim of simulation training is not to replace real-life surgical training but to supplement it. Understanding a trainee’s need will ultimately allow trainers to employ the most appropriate simulation tool for the development of that trainee. The ultimate goal being a curriculum which fully utilises simulation to enhance surgical training.

Innovation in simulation

The BOA continues to advocate for the development of a surgical simulation curriculum. This will require close collaboration with a number of stakeholders (i.e. trainee organisations, subspecialty associations, governing bodies, etc.). The main challenges to successful implementation of simulation in surgical training are funding and willingness to embrace simulation culture.

We are all exposed to simulation from as early as medical school. Desktop simulation such as saw bones workshops and cadaveric labs remain in the mainstream of post-graduate T&O training. We must now start to embrace alternative forms of simulation training. Various methods have been validated in the literature. These include Virtual Reality simulators, Augmented Reality simulators, Hologram images and Virtual worlds, and Distributed Interactive simulation.

Distributed Interactive simulation is a type of desktop simulation that allows creation of a realistic bone and patient model to be used with real tools and instruments in a fully modelled environment (e.g. simulated operating theatre). The use of actors to simulate the multi-disciplinary team within this medium creates a fully immersive experience. As such, it is expensive but could well form the basis of evaluation and training in the future.

Regardless of modality, in order to improve simulation, we must all engage with the resources currently available. The Virtual Reality and Simulation in Healthcare Summit is a fantastic opportunity for those interested in simulation to gain further insight. The BOA also offers opportunities for trainees to be recognised for their contribution to simulation. These include the education and simulation free papers at the BOA Annual Congress and the Innovation in Simulation Award.

With ever increasing utilisation of technology in healthcare, not least due to restrictions imposed as a result of the COVID-19 pandemic, there has never been a better time to truly move into the future with simulation for T&O education in the UK.

Conclusion

The current COVID-19 pandemic has presented the whole nation with significant challenges to overcome. BOTA is acutely aware of the additional stresses endured by trainees as a result of disruptions to training activities. It is now more important than ever that we look out for one and another. We must reflect on our behaviours within the workplace. We must aim for a diverse workforce that represents the patients we serve. We must strive to be inclusive in order to inspire the next generation. We must also look to the future and welcome new technologies that help enhance surgical education. Out of adversity comes opportunity. We must now seize this opportunity to better our profession and improve the training of future T&O consultants. n

References

1. BOTA’s Culture and Diversity / Inclusion promotion video. Available at: www. youtube.com/watch?v=3kCQBvaFJTU.

2. GOV.UK. Population of England and Wales.

Available at: www.ethnicity-facts-figures. service.gov.uk/uk-population-by-ethnicity/ national-and-regional-populations/populationof-england-and-wales/latest#by-ethnicity.

3. James HK, Gregory RJH, Tennent D, Pattison GTR, Fisher JD, Griffin DR. Current provision of simulation in the UK and Republic of Ireland trauma and orthopaedic specialist training: a national survey. Bone Joint J. 2020;1(5):103–114.

Note from the Editor:

The BOA was delighted to hear and see how BOTA tackled the issues of diversity and inclusion at the Virtual BOA Congress which fitted in well with the launch of our Diversity and Inclusion Policy earlier this year. It was particularly pleasing to see that BOTA membership is 24% female while the 2019 NHSE statistics quote 18.9% women at registrar level and 29% at Core Training: BOTA is clearly managing to engage with female trainees. The BOA was also delighted to see that the NHSE 2019 ethnicity statistics for T&O show that core trainees identifying as English Asian were the largest ethnic group at this level accounting for 35% of trainees. At registrar level they represented 29% of trainees.

Whilst it remains true that only 6.6% of consultant T&O surgeons are women, 30% of BOA female consultants are within 5yrs of CCT and hence Early Years Consultants. We do believe that the tide is turning and with the support of our members, consultant and trainees alike, we can continue to ensure that progress is made in all areas of our Diversity and Inclusion Policy.