MANPOWER PLANNING IN UPPER GI SURGERY: RIGHT OR WRONG?

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1 MANPOWER PLANNING IN UPPER GI SURGERY: RIGHT OR WRONG? William Allum President-elect, Association of Upper Gastrointestinal Surgeons (AUGIS) John Hammond President, AUGISt (the trainee section of AUGIS) Alan Osborne Trainee Representative, British Obesity and Metabolic Surgery Society (BOMSS) Council ABSTRACT With the development of separate subspecialties within the generality of surgery, manpower planning is critical. This paper determines the number of trainees aspiring to become consultants in upper gastrointestinal surgery, and estimates the number of consultant posts likely to be available. It suggests that there will be an over-production of trainees. A training programme to help address the potential problem is discussed. INTRODUCTION Manpower planning is a notoriously difficult process, reflecting the need for assumptions on service provision, reconfiguration and developments, all of which can occur in a short period of time. However, it is essential for any professional organisation to be closely involved in advising on workforce planning, not only to ensure the NHS is provided with the necessary skill-mix but also as a duty to its trainees so they can make an informed choice about their career decisions. In recent years, upper gastrointestinal surgery has undergone significant changes, not only reflecting the effects of centralisation of cancer surgery but also the development of bariatric and metabolic surgery. In the early days of cancer centralisation, there were concerns that the remaining upper GI surgery in District Hospitals would be very limited. However, the joint statement by AUGIS, ACPGBI (Association of Coloproctology of Great Britain and Ireland) and ALS (Association of Laparoscopic Surgeons) in 2006 defined the opportunities in upper GI surgery [1]. Although this confirmed specialist practice, it also described the characteristics of a general surgeon with an upper gastrointestinal interest. There has, however, been a trend to develop subspecialist interests at the expense of the generality of general surgery, particularly in emergency practice. This has been driven partly by personal and professional preferences but also by patient expectation. Despite these entirely reasonable influences, service requirements have resulted in limited availability of consultant posts in a preferred subspecialty. As a result, in upper gastrointestinal surgery there are already cases of individuals with a CCT/CESR who are unable to secure a consultant appointment. The numbers in training further compounds the issue. There are two types of general surgical trainee with a national training number (NTN), those appointed as SpRs under the Calman process, and those appointed as StRs under MMC. These total over 1,200, with approximately 200 in each year of training. This includes trainees who are out of programme on research fellowships and career breaks. It is anticipated that this will produce an oversupply of CCT holders up to 2016/2017. The Department of Health has, therefore, stipulated that approximately 100 ST3 appointments are made annually; this started in In the context of this background, AUGIS Council decided to assess the current state of upper GI surgery both from the trainee perspective and from the current distribution of service provision, with an emphasis on career opportunities according to demographics of the consultant population. METHODS The AUGIS training review In the absence of a formal registry for trainees, a variety of data streams were used to estimate the number of trainees in upper GI surgery. These included the Joint Committee on Surgical Training (JCST) Surgical Placement and Curriculum Evaluation (SPaCE) data, the Intercollegiate Examination records and a specific review of upper GI training undertaken by the upper GI trainee group, AUGISt. The JCST undertake the SPaCE survey for all UK training posts up to four times per year. This provides an estimate of individual subspeciality interests. In 2011 there were 568 respondents (47% of all trainees). The Intercollegiate Examination records demonstrate that between trainees declare an upper GI interest at the examination each year. Since 2011 it has been possible to express an interest for oeosphagogastric (OG) and hepato pancreato-biliary (HPB) surgery. In the AUGISt review, trainees with an upper GI interest (defined as trainee members of AUGIS) holding a national training number or in a locum appointment for training post were contacted via AUGIS and via training programme directors. They were asked to complete an electronic survey (Google TM ) detailing their training grade, region, and subspecialty interest. They were also asked specifically about their experience, own perceived level of competency and the role of fellowships. 3

2 Consultant Manpower AUGIS Council Regional Representatives were asked to complete a questionnaire to identify all of the upper GI surgery posts in the hospitals in their Regions. In addition, they were asked to identify the Cancer Centres, both oeosphago-gastric and hepato pancreatobiliary, and determine the numbers of surgeons in each centre. Finally, they were asked to record the ages of all the surgeons within three ranges (35-44; 45-54; 55-65). RESULTS The SPaCE data demonstrates that colorectal surgery is the most popular subspeciality, followed by upper GI, breast and vascular surgery (see Figure 1). Looking at the trainees declaring an upper GI interest, 15% of trainees in years ST 5-8 wish to train in oesophagogastric surgery and 7% hepato pancreatico-biliary surgery (see Figure 2). The Intercollegiate data shows a 1.3:1 preference for OG surgery over HPB surgery. This difference from the SPaCE data probably reflects the cohort of examination candidates including trainees and those not in formal training. Figure 1: Subspecialty preferences of all General Surgery Trainees (SPaCE survey 2011) Figure 2: Subspecialty and special interests of trainees in ST5-8 (SPaCE survey 2011) There were 83 responders to the AUGISt survey, 56 (67%) declaring an OG interest and 27 (33%) an HPB interest. In OG 32 (57%) wanted to train in resectional OG surgery and 41 (73%) in bariatric surgery. In HPB 23 (85%) wanted to train in resectional HPB surgery and 13 (48%) wanted transplantation training. When trainees were asked to clarify their level of experience as they approached completion of training, 77% stated that they would require additional training at the end of their programme with 95% of trainees wishing to undertake a fellowship after completion of training. Consultant Manpower The manpower survey identified 414 surgeons with an upper GI interest working in 172 Trusts in the United Kingdom, of which 41 were Cancer Centres. There were 148 (35%) with an oesophago-gastric cancer interest, 98 (24%) with an HPB interest and 168 (41%) with a general upper GI interest. Table 1: Age ranges of Upper GI Surgeons The age ranges are shown in Table 1. The key features are the young age of the majority, particularly in HPB centres, and the small number of those currently undertaking major cancer resectional surgery in the over 55 years group. At the same time as the survey, all consultant general surgery posts advertised in the BMJ were recorded. During the first 6 months of 2011, 67 posts were advertised. Nine were in general surgery with an upper GI interest and there were 5 specialist posts (3 OG and 2 HPB) (see Table 2). Table 2: General Surgery Consultant posts advertised in the BMJ January (July 2011) DISCUSSION Interpretation of this data has to be cautious and cannot be conclusive. Whilst the SPaCE and AUGISt data provide a representative overview of subspeciality preference, it is likely to be an underestimate of total trainee numbers. However, it is possible to determine trends and draw inferences for the future. From the posts advertised in the first 6 months of 2011, there are approximately 30 consultant post vacancies annually in upper GI surgery. The majority of these are of a general nature. Upper GI surgery remains the second most popular area of special 4

3 interest amongst general surgery trainees with OG preferred to HPB at a rate of 2:1. There does appear to be a mismatch between trainee expectations for a specialist practice and the job opportunities at consultant level. The demographics of the upper GI consultant population do show some differences from those across all surgical specialties. The upper GI surgeons tend to be younger. The RCS England survey [2] shows over 20% are over 55 years of age, contrasting with 15% for upper GI; 34% overall are under 45 compared with 37% for upper GI. This probably reflects the increase in consultant posts in the specialist centres associated with centralisation of cancer services, but it also has implications for new opportunities related to retirements. Although the different sources of information about trainees are incomplete, the proportions are consistent. Thus, across the 1,200 general surgery trainees, there are likely to be 264 (22%) with an interest in upper GI. Assuming these are distributed across the 6 years of training, there would be 44 per year. The AUGISt survey shows a 2:1 split between OG and HPB. Thus, there would be 29 OG and 15 HPB trainees per year. As regards specialist OG and specialist HPB interest, there would be 17 and 13 trainees respectively. These estimates would suggest a significant oversupply for the available consultant posts. If the same calculations are repeated for a total of 100 trainees in each year, there would be approximately 22 with an upper GI interest. This would potentially produce an undersupply based on 2011 consultant opportunities. Despite the limitations of extrapolating from these calculations, this does suggest the need for better coordination between training and service requirements. Input from the professional associations to training would appear to need strengthening. Many studies have confirmed that the combination of the New Deal and the EWTR have resulted in a reduction in training opportunities. The AUGISt survey has added further evidence as 77% of trainees stated they needed further experience at the end of training, most of whom preferring a specific fellowship. The reduced training opportunities and the implied lack of confidence in their ability expressed by the need for extra experience would suggest that it is not possible to train to full competence in the current structure. This has already been taken into account in the ISCP upper GI syllabus, where trainees are not expected to attain full competence in the advanced procedures of upper GI surgery [3]. Thus, by the end of training, a new CCT holder does not have the ability to meet the demands of all aspects of the specialty and would not reach the expectations of the public for a specialist. It would thus seem appropriate to consider a different model for upper GI surgery training. All trainees with an upper GI interest should follow a general syllabus in both general surgery and the breadth of upper GI disease. The latter would include modules in all the principle topics (eg. benign pancreato-biliary, reflux and hiatus hernia, morbid obesity), which could be taken as options within training and as out of programme fellowships, as well as developing advanced endoscopy and laparoscopy skills. This should equip them with the skills to fulfil the role of a general surgeon with an upper GI interest. Since the number of posts for specialist OG and HPB can be predicted annually, there should be national selection into a limited and appropriate number of peri-cct fellowships. Such fellowships would start in ST8 and last for two years. In this model it would be more appropriate for all upper GI trainees to be examined in the breadth of upper GI in the Intercollegiate exam, rather than specifying OG or HPB. The curriculum for the fellowships would include appropriate assessments for OG and HPB specialism respectively. Such fellowships would need to be carefully quality assured by the relevant training specialists. CONCLUSIONS Manpower planning requires a great deal of information and close involvement of all stakeholders. These surveys have highlighted the issues in upper GI surgery. In recent years, training in an area of special interest has been pursued without careful coordination with the service needs. This has resulted in inappropriate career aspirations for trainees and a mismatch with career opportunities. Both professional associations and training organisations need to work more closely to advise on service provision to reduce the risks seen in other specialties, where over or undersupply of trainees has created significant employment problems. ACKNOWLEDGEMENTS The authors wish to acknowledge the help of Mr Ji Chung Tham, Research Fellow, Musgrove Park Hospital, Taunton and the AUGIS Council Regional Representatives with data collection. REFERENCES [1] Specialist Gastrointestinal Surgical training: A discussion document Shorthouse A J, Griffin S M and McMahon M ASGBI Newsletter, No. 14: 8-10 (2006) [2] Surgical Workforce 2010: Profile and Trends Greatorex R and Sarafidou K Royal College of Surgeons of England (2011) [3] Intercollegiate Surgical Curriculum Programme 5

4 COMMENTARIES MANPOWER PLANNING IN UPPER GI SURGERY: COMMENTARY ONE The article by William Allum and colleagues has hit on a fundamental problem with the surgical training programme but, unfortunately, has failed to take into account the cyclical trends of opportunity we have all seen from time to time. Trainees are aware of the job market, and we have seen a noticeable decline in the number of HPB trainees in the London Deanery. Whilst we all clearly acknowledge that the current number of vacancies in OG and HPB seem to be significantly less than previous years, it does parallel the economic cycle and perhaps this has relevance. Extrapolating long-term workforce requirements based on a period of cost-saving is flawed from the outset. One of the most important strategies highlighted in the manuscript is the need for more generalised training. Surgical practice is hugely dynamic and, unlike in years past when the skills of the trade were transferable, this has become increasingly less acceptable. The dynamic nature of surgery is highlighted, for example, by the cataclysmic decline in O-G MANPOWER PLANNING IN UPPER GI SURGERY: COMMENTARY TWO The centralisation of upper gastrointestinal cancer services is one of the drivers that have led to major changes within general surgery. This has followed similar reconfigurations in vascular and breast surgery. Although it is beyond the scope of this commentary to cite the evidence, there is little doubt that this centralisation has brought benefits to patients having major oesophagogastric and hepatobiliary cancer surgery. It is now possible to be confident about complications and long-term outcomes and, hence, this is not a trend which will reverse. Patients with cancer do have an expectation and, indeed, a right to be managed by experts. There is, however, another side to surgical services, that of the emergency workload. Here the situation is far from satisfactory. It is well known that standards and outcomes vary greatly, with different results in different hospitals. Further, the level of consultant input into emergency work, principally gastrointestinal, is highly variable. For this commentator, dealing with improving emergency surgery is the challenge for this decade, just as centralising upper GI cancer services was for the last. In this context, the contribution from Mr Allum and colleagues makes interesting reading. It is clear that the reconfiguration of upper GI cancer services has led to the appointment of a number of new consultants in large specialist units. The resections rates due to advances in chemoradiotherpy. Such decline is likely to happen in liver resectional surgery as advances in percutaneous ablative techniques, colon cancer screening programmes, and sitespecific chemotherapy are showing increasing promise. Although HPB surgeons are relatively young, the vast majority lack the skills necessary for laparoscopic HPB surgery or, indeed, benign Upper GI surgery. This effectively reduces their chances of gaining a consultant post. Therefore, I agree whole heartedly that surgical training for future HPB and Upper GI surgeons should be based on a common pre-cct programme. Such individuals can then make a choice of either following oncological fellowships, revisional bariatric surgery programmes, or settle for non-specialist vacancies. The current cohort of relatively young consultants is likely to ride out the now surgical trend, only to find the landscape has changed beneath them in their golden years. Zak Rahman Consultant Upper Gastrointestinal Surgeon Royal Free Hospital, London number of patients needing complex oesophagogastric liver and pancreatic resections is fairly circumscribed but, because of the expertise involved in these complex conditions, benign presentations such as severe pancreatitis also tend to be referred to the same units. Furthermore, because many of the surgeons in these large specialist units are young, the number of opportunities for the current trainees is going to be very limited. There is currently no indication that there will be an increased need for more surgeons working in these specialist areas. Thus, we are placing many trainees in specialised programmes training for jobs which may not exist. Further, although currently consultants are being appointed in District General Hospitals who have upper GI but not resectional interests, it is really not clear that this is the best use of a surgeon produced by a UK training programme. So, where should we go from here? One thing is clear, and that is that emergency presentations and colorectal cancer are common and will continue to be managed in large District General Hospitals. Indeed, many of the most complex acute presentations are with colorectal disease. Therefore, putting aside divisions of the past, what is clearly needed is a surgeon with expertise in gastrointestinal surgery and an emphasis in colorectal surgery that will provide the majority of specialist in GI surgical services in District General Hospitals. It should be borne in mind that the current upper/lower GI divisions within GI surgery in the UK came, not from necessity or needs of the service, but from the vagaries of the formation of sub-specialty associations. Other 6

5 countries, for instance the Netherlands, have avoided such unnecessary divisions. The paper on specialist gastrointestinal surgical training published in the ASGBI Newsletter No 14 (2006) provides a model for gastrointestinal surgical training whereby all surgeons would have upper and lower GI experience and would have experience in laparoscopy. Most would ultimately have a subspecialty interest in upper or lower GI surgery. Even since then, however, things have moved on. Upper GI surgery is not in any sense homogeneous. Hepatobiliary surgeons and oesophagogastric surgeons in large centres have little commonality in their clinical work, certainly in terms of the elective surgery. So the model for training proposed in the 2006 paper may not be ideal. This commentator s view is that we should move back towards creating an experienced gastrointestinal surgeon at CCT who has the expertise to deal with all gastrointestinal emergencies at a high standard, whether they be in the upper or lower gastrointestinal tract. The advantage of this more generic higher training is that it allows subsequent specialisation to be built on a solid foundation that is to the benefit of the service, particularly to the emergency workload. It also shields the consultant from becoming unemployable should the disease of their specialised interest disappear. The disappearance of surgery for peptic ulcer disease is only one example of how quickly this can happen. The same risk currently must clearly be seen by surgeons who choose to make a career interest in bariatric surgery. A broad GI training does allow surgeons to develop and reinvent themselves during a long career without having to undertake formal retraining. So, to come back to the paper by Mr Allum and colleagues, a sensible way forward is to train pluri-potential GI surgeons and then allow further training to meet the manpower needs of the large units with highly specialised needs. It is perfectly reasonable that entry to such programmes should be competitive and also tailored to the needs of the service. This would allow a position whereby we were not training highly specialised surgeons for jobs which do not exist. Finally, a word about the CCT. Although there have been moves to develop, through the GMC, sub-specialist recognition for upper and lower GI surgery, it is not now clear that this is not a sensible way forward for trainees. It is noteworthy that orthopaedics has retained a general Trauma and Orthopaedics CCT, in spite of a very similar range of subspecialties as in general surgery. Retention of a general surgical CCT as a core, with appropriate additional subspecialty training by competition, may be the optimum model that deals with both routine and complex elective surgery and emergency care. John Primrose Vice President, ASGBI INTERCOLLEGIATE SPECIALTY BOARDS The Royal College of Surgeons of Edinburgh The Royal College of Surgeons of England The Royal College of Physicians and Surgeons of Glasgow The Royal College of Surgeons in Ireland PANEL OF EXAMINERS General Surgery The Intercollegiate Specialty Board in General Surgery is looking to recruit new examiners to join its Panel. The Board would welcome applications from interested and motivated Consultants who have a proven track record in examining and all applications will be considered. Applications are invited from surgeons of consultant status (with a minimum of 5 years experience) wishing to be considered to join the Panel of Examiners in General Surgery in the following areas: Breast Colorectal Endocrine General Surgery Upper GI/OG Transplant It may be helpful for those interested to speak to a current or past member to gain some insight into examining for the Intercollegiate Specialty Boards. Further details and an application form are available to download from Upper GI/HPB Vascular Or for further information please contact Suzanne Rich, Specialty Manager s.rich@intercollegiate.org.uk Tel: COMMENTARIES 7

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