The new T&O curriculum

Rob Gregory, Lisa Hadfield-Law and Deepa Bose

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.

Lisa Hadfield-Law has spent 20 years in clinical practice and surgical education. She has managed an orthopaedic/trauma service of a teaching hospital and has insight into the circumstances and challenges facing surgical teams. She is Education Advisor to the British Orthopaedic Association & AOUKI, and contributes to the T&O SAC, FST Advisory Board and ISCP Management group.

Deepa Bose is a Consultant in orthopaedic trauma and limb reconstruction at the Queen Elizabeth Hospital Birmingham. She is Vice Chair of the Specialist Advisory Committee for Trauma & Orthopaedics, and the lead for CESR application reviews. She has also contributed to the revision of the curriculum. She holds an MSc in Medical Education and is a member of the Academy of Medical Educators.

The implementation of any new curriculum is naturally greeted by its users with anxiety and frustration, enthusiasm being a rare initial response. As we recover from the impact of COVID-19, the prospect of having to adapt to the first major curriculum change for seven years may seem daunting, but the changes reflect a desire to improve training advocated by most of us for many years.

Our curriculum is a living entity that must evolve in response both to the way in which healthcare delivery changes and to advances in knowledge about how we learn, but must also evolve in a way that raises the standards of the care we deliver.

So, what can we expect? The principal change relates to the way in which trainees are assessed through the Multiple Consultant Report (MCR). This more holistic approach to assessment is based on the new Generic Professional Capabilities (GPCs), with assessment of these Capabilities in Practice (CiPs) being fundamental. What hasn’t changed is the vast majority of the syllabus – which is why the exam remains unaltered.

The recent shift towards an outcome based, rather than time based, curriculum continues, but it is envisaged that most trainees will still require six years from ST3 to progress to CCT. Whilst the outcomes are well defined, the means of achieving those outcomes are less clear and this perhaps represents the major challenge for us. If we take the example of research, the current requirements are easy to list, and everyone knows for example the importance of completing a Research Methodologies Course. Whilst the new requirements are no less difficult to list, the authors of the new curriculum were constrained by the GMC, in their ability to influence the means by which evidence of compliance can be demonstrated. The arguments in favour of the continued inclusion of mandatory courses were pressed strongly, but ultimately with little success, and as a result we have been left with ATLS (or the ETC) as the sole mandatory course. This may well be a cause of confusion amongst trainees, trainees and TPDs alike, and may prove to be a source of friction if funding bodies refuse to accept that courses previously held in high esteem and often delivered nationally, fail to deliver ‘value for money’ and their goals must be achieved by other, more nebulous means. We must hope that pragmatism prevails, and that the quality of training maintained in these areas.

Implementation

Increasing numbers of programmes have started to use the MCR format in shadow form to assess their trainees, and the response appears to be almost universally favourable. The value of the process lies in the constructive nature of the conversations that can potentially involve large numbers of colleagues, not necessarily all doctors, who have contact with the trainee in a wide range of clinical environments. Although the MCR is restricted in terms of who can make entries, contributions from all established clinical team members can help the trainee identify areas of strength and weakness. No longer are we assessing isolated events such as how well a trainee can perform an operation, we can now assess how well a trainee can communicate in the operating theatre whilst operating, a quality just as important as the possession of technical skills.

How will training programme directors (TPDs) make sure their trainers and trainees are ready for all these changes? The BOA has fully funded the Virtual Training Orthopaedic Educational Supervisors (V-TOES) programme regionally, in conjunction with TPDs. Supervisors are asked to spare just eight hours with the vast majority being spent at a time convenient to suit them, with just one fixed two hour live virtual session. So, supervisors can take a day’s study leave without bringing departments to a standstill. We have worked hard to limit the preparation to activities that supervisors will be able to use on a repetitive basis and this should save them significant time and effort in the future.

The new curriculum addresses concerns expressed by many surgeons about the over-refined structure of ISCP with too many tick boxes and forms. If our trainees need to acquire professional judgement, insight and the ability to work with others, alongside operative skills, then this programme should help supervisors make the necessary changes work for them and their trainees. At the end of the event, participants can:

• Assess how the changes to the T&O curriculum will affect us all

• Integrate the new GCPs and CiPs

• Make the best use of assessment tools including the MCR

• Maximise their trainer portfolio

• Use assessment of reflective writing to support trainee progress

The programme is facilitated by TPDs themselves alongside the BOA educational advisor and trained virtual teacher. The BOA has now run over 80 fully online programmes and have trained over 1,500 T&O supervisors, examples of some of the feedback being as follows:

“You have excelled delivering this in my humble opinion. All the very best for your great legacy - a generation of better prepared orthopaedic surgeons (of all grades, even us 52-year-olds)”.

“Superb course, which far surpassed my expectations, and found the ‘homework’ highly relevant and applicable to my current practice”.

“I’d go so far as to say that this is far superior to the more traditional course with face-to-face contact time. I think you’ve done an outstanding job”.

Our V-TOES programmes have allowed us to iron out our wrinkles. The screencasts and activities in the learning log have helped to identify areas which might have caused problems in the future. For example, what happens to the CiP around managing an emergency take if the trainee is at an elective only hospital and how do you record areas for development in the GPCs without also recording that the trainee has notreached the expected level for their stage of training? It was trainers and trainees who located these wrinkles before the formal launch of the curriculum.

How does it work? The BOA sets up a group in MS Teams for participants in each cohort. So far these have ranged from 12 to 70 individuals. Each participant is issued with a learning log in their channel file which they complete and have reviewed, either by a facilitator or a colleague who will:

• Confirm that all modules are complete

• Provide some written feedback in their partner’s learning log

• Pass to the TPD if there are any problems e.g. failure to complete etc.

The two hour live virtual session is driven by unresolved issues from the learning logs. These are usually concerned with:

• How will we engage our unwilling colleagues?

• How will we use WBA in the future?

• What’s the difference between a learning agreement and a PDP?

• Won’t this take much more time?

• How can we engage other specialties in the interspecialty CBDs?

• What’s the point in creating a trainer profile?

We are now in the process of designing an optional module dealing with difficult feedback conversations. Supervisors now have a balanced curriculum with integrated assessment tools that work. The next step is to help trainers and trainees tackle sensitive conversations around performance.

For those who are not able to access a V-TOES programme, there are briefing videos on the on the BOA website (www.boa. ac.uk/curriculum) and useful information, including the curriculum itself, can be found on the ISCP website (www.iscp.ac.uk/ iscp/curriculum-2021).

Summary

We are confident that the changes deliver more flexibility for trainees in how they demonstrate achievement of learning, and a more holistic evaluation of their capabilities compared to the snapshots previously provided by rigid numbers of WBAs. CiPs reflect the reality of how consultants work, and if trainees can demonstrate increasing competence in these, the transition from trainee to consultant should be both smoother and better.

We hope that we have explained the need for a new curriculum and the rationale behind the changes in the way trainees will now be assessed. Although some assessment methods are quite different and will take time to bed in, it is important to recognise that by and large most areas remain unchanged. WBAs for critical conditions, index procedures, and competencies related to minimum logbook numbers,are still required. Research and quality improvement objectives have remained unchanged and even though most courses are no longer mandatory, trainees may find that the best way to demonstrate a good grasp of research methodologies is to complete a research methodology course!

Postgraduate training in T&O in the UK and Northern Ireland is amongst the most rigorous and robust anywhere in the world. We are proud that our curriculum continues to grow and develop to meet the needs of our trainees and in turn, our patients, and are confident that both trainers and trainees will rise to the challenges posed by the latest version.