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Certification in Colorectal Surgery – What Next?

In the past, a senior registrar in General Surgery amassed sufficient experience during training to enable him or her to apply for consultant posts requiring differing subspecialty interests. A colorectal surgeon was usually identified as someone whose consultant practice involved a substantial proportion of colorectal surgery, but often there was little hard evidence to back up a surgeon’s claim to be a bona fide colorectal surgeon. Currently, training in General Surgery is threatened by what could be considered a ‘perfect storm’, arising from the combined effects of increasing specialization in surgery, increasing complexity of surgery, the European Working Time Directive, the debacle of MMC, falling morale amongst the training grades and increasing pressure on consultants to concentrate on delivering targets at the expense of training the surgeons of the future. Weathering this storm requires a change of tack in surgical training. With the markedly decreased time available to trainees, there will no longer be the luxury of the traditional slow apprenticeship. Innovative methods of teaching technical skills will have to be embraced, including greater use of skills courses and skills laboratory training on models before embarking on live operating. To produce high quality colorectal surgeons for the future there need to be robust criteria for certification in the speciality. These should include: (i) a thorough knowledge of the speciality as set out in a curriculum, (ii) a defined period of training in recognised colorectal training units, (iii) performance of an appropriate number of cases under direct supervision, and (iv) demonstrated competence in clinical practice and operative techniques. These criteria will be met in future by changes brought in by the Intercollegiate Surgical Curriculum Project (ISCP). There is now a defined curriculum for colorectal surgery, developed by ISCP from the existing ACPGBI curriculum. On-going changes to the final examination should provide a fair and vigorous assessment of trainees’ knowledge, particularly if the exit examination includes a module covering the trainee’s chosen subspecialty. Training committees have been able to identify units suitable for training in colorectal surgery, aided by the ACPGBI Unit Recognition Process. There is no consensus on what constitutes an appropriate number of cases, even for index procedures, but the process of European Certification will include guidelines on the number of specific procedures to be performed. A crucial part of the certification process will be assessment of trainees, to make sure they achieve satisfactory standards of practice before appointment to a consultant post. Traditionally a bulging log book was seen as evidence of adequate competence on the basis that enough surgery should equate to competence, even though 100 anterior resections performed poorly is probably inferior to 25 performed well under appropriate supervision. What is needed now is a robust method of assessing and feeding back a trainee’s performance during the learning phase, which is signed off when the trainee is deemed competent at specific procedures. Procedurebased assessment (PBA) and operative competence (OpComp) forms have been developed to assess trainees’ progress, allowing completion of training to be dependent on competence rather than simply on time served in training posts. Improving certification in colorectal surgery is a desire that extends beyond the United Kingdom and is driven, in part, by greater mobility of medical graduates. With surgeons plying their trade in countries distant from where they received their training, it is difficult for employers to compare differing training systems. To this end, agreement has been reached within the Division of Coloproctology of the Section of Surgery of the UEMS on standardized criteria for certification as a colorectal surgeon across Europe. The ACPGBI has been at the fore-front of these discussions and has widened the debate in the United Kingdom to include the Specialist Advisory Committee in General Surgery and other specialist associations in the hope that Europe-wide criteria can be recognized by the statutory bodies responsible for surgical training. On the face of it these are uncertain times for consultants and trainees alike. However, colorectal surgery is in a more fortunate position than some of the other subspecialties which have traditionally been part of general surgery. Colorectal diseases are common and furthermore form a large proportion of the acute surgical take. Medical advances do not look likely to reduce the need for surgical intervention for colorectal diseases. It is how colorectal surgeons respond to these challenges that will determine the future success of our speciality.