The impact of COVID-19 on orthopaedic training

Rob Gregory and Mark Bowditch

Rob Gregory is a Consultant T&O surgeon who works in Durham. He has a longstanding interest in surgical training and is currently Chair of the SAC for T&O. He is also a Trustee of the BOA.

Mark Bowditch is a Consultant at the Ipswich NHS Trust where he was appointed in 2000. He is Head of School of Surgery East of England, Past Chair of the SAC in T&O, and the current BOA Treasurer.

The size of the problem

Even in the early stages of the global pandemic it was apparent that orthopaedic training would be at risk, but the precise focus of harm was unclear. With international travel severely restricted, fellowships were threatened; courses, conferences and meetings were cancelled; alternative teaching methods were untested; and redeployment cut off access to traditional work-based assessments. But in reality, the specialty has been able to adapt to such a degree that many necessary changes are now seen as innovative benefits and a return to training as practiced in the pre-COVID era is now rarely discussed. It is only in the area of the acquisition of surgical skills gained in the operating theatre that there has been a real impact, and the impact for large groups of trainees has been devastating.

Both the current and the new curriculum require access to 1,800 operative cases, but it is rare for trainees to fail to reach this target, with a mean case total at CCT historically being much higher at 2,150. The nature of this requirement is often misunderstood: 1,800 is an indicative rather than mandatory figure and was selected as it was felt to represent the surgical exposure required to gain the competencies that are mandatory.

We are fortunate in having e-logbook evidence to help us quantify the impact of COVID-19. A comparative analysis of data entries over the course of the last two years (Figures 1-3) shows that whilst there has been a small (15%) but significant reduction in trauma entries, it is elective case numbers that have been hit most severely with over a quarter of a million (58%) training opportunities lost. This represents an average of around 260 cases lost per trainee in the first year of COVID-19. When this figure is considered alongside the ‘reserve’ of 350 cases, and alongside the fact that trainees have been restricted in their ability to access the full range of subspecialties demanded by the curriculum, the potential consequences are clear.

Figure 1: Total e-logbook entries, UK, T&O, 2019-21

Figure 2: Elective e-logbook entries, UK, T&O, 2019-21

Figure 3: Trauma e-logbook entries, UK, T&O, 2019-21

The e-logbook data, whilst starkly demonstrating the impact of COVID-19, can only be used as an indirect predictor of the numbers of trainees who will require a training extension this year, but at current rates, the 350-case reserve average will have been exceeded by time of the summer ARCP round.

Further evidence that can be used to try to predict the number of training extensions that will be required can be derived from ARCP outcome analysis (Figure 4) which demonstrates that in 2020 around a third of trainees were given an Outcome 10. Whilst only a small proportion were given the training extension through Outcome 10.2, the remainder are at risk of requiring training extensions this year. Given that there is little likelihood that the influence of COVID-19 on training will disappear in the foreseeable future, the spectre of training extensions may well be with us for several years and we are obliged to try to mitigate this by maximising access to operative training for all trainees, not just those approaching CCT.

But does it matter if large numbers of trainees require a training extension? Unless additional funding is made available, it would be impossible to maintain input at ST3 to the previously predicted levels and bottlenecks at junior doctor levels would be inevitable. We are approaching a time when due to the waiting list legacy of COVID-19, pressure on consultants to meet service targets will escalate and a reduction in the size of the pool of appropriately trained surgeons to fill vacant consultant posts would be disastrous.

Figure 4: ARCP outcome analysis

The solution

In common with all other surgical specialties, T&O is a craft specialty that demands hands-on training opportunities to achieve the necessary competencies to allow independent, safe practice across its full breadth as a consultant. No regulator of training, training provider, School of Surgery, or Royal College could accept an end point to training without having the confidence of this goal having been achieved. This is clearly under great threat from the lack of access to operating and must be mitigated or removed.

There are a number of possible solutions that we can identify, these being as follows:

• There should be a rapid restoration of the opportunity to operate. T&O must be given sufficient level of prioritisation and resources to access the facilities required to meet the waiting list demands, including access to beds, staff, theatres and rehabilitation facilities. The BOA has made this its top priority in discussions with the Royal Colleges, NHSE and patient partnerships.

• We need to maximise the use of every available theatre-based training opportunity as the system recovers, wherever the activity is undertaken. A heavy reliance will be inevitably be placed on NHS providers, but the Independent Sector (IS) has an important role to play. Regarding its training role, IS contracts should be less ambiguous and novel ideas such as tariff uplifts for the facilitation of training should be considered.

• Consultants have, now more than ever, a responsibility to consider the construction of operating lists with pro-active planning of which cases will be allocated to the trainee as a first surgeon opportunity. Lists without trainees attached should be publicised in advance as such, to allow trainees to decide how to spend their training time. This may require a re-evaluation of how clinics are run, remembering that trainees are allocated to healthcare providers not simply to meet service demands.

• The requirements of trainees should be considered on an individual basis. It has been suggested that a blanket extension of training time for all trainees should be given but this is unnecessary, counter-productive and would penalise those trainees who have been fortunate enough, perhaps by virtue of having a large, planned trauma commitment, not to have been significantly affected by COVID-19. The needs of individual trainees should be uppermost in the minds of all those with whom the trainee has contact, whether TPD, AES or CS. Whilst we must accept that some trainees will undoubtedly need more time, others may avoid the need to be given training extensions if a more focused approach to the allocation of their remaining training time is given. CoPSS – the group representing the Heads of Schools of Surgery – has asked HEE for additional TPD/AES time (and funding) in order to undertake this type of gap analysis assessment, and to build bespoke personal recovery plans. This could include secondments to other units or even alternative programmes. Trainee passports, either within or external to programmes have been suggested and the idea deserves exploration. More than ever, the often underappreciated work of the TPDs and committed educational supervisors needs to be recognised and support must be provided if difficult decisions need to be made.

• If a training extension is required, we need to ensure that the post provided will deliver the competencies denied by COVID-19. More time, without the opportunity to gain these competencies, will just be wasted time.

• With a full complement of ST3s recruited in 2021, there is an inevitability that financial pressures will emerge, but what in effect would be a temporary expansion of training posts should be possible (TPD survey Dec 2020) and funding already exists locally for many non-training posts currently occupied by doctors hoping to enter the formal training system in the near future. An enlightened and flexible approach to funding from local healthcare providers is required and pro-active, constructive dialogue with post-graduate deans should provide a means of facilitating the necessary expansion.

• An alternative approach to funding the training expansion would be to reduce the entry into ST3 but this temptation should be avoided at all costs as it would be counter-productive, not least when considering long term quality workforce provision, something that T&O, when compared with other specialties, has proudly been able to maintain by proactive workforce planning through the BOA and SAC. We are facing a time of unrecognisable service demands, we need more well-trained surgeons, not fewer.

Conclusions

It is clear that providing maximum access to theatre-based training is a current priority but even with the widespread roll-out of the national vaccination programme a resumption of elective operating to pre-COVID levels in the near future is unrealistic. The persistent reluctance of the Independent Sector to facilitate training should be challenged more firmly but we should recognise that it is the NHS providers that have the greatest ability to support our trainees. We mustn’t let service demands obscure the need to give equal priority to training, and every one of us with a training role should ensure that no training opportunity is lost.