Clin. Otolarygol. 1992, 17, 51 1-513
Higher surgical training in Otolaryngology J.HILL, J.A.J.DEANS & A.J . N . P R I C H A R D Association of Otolaryngologists in Training, Department of Otolaryngology, Freeman Hospital. Newcastle upon Tyne, U K Accepted for publication 23 June 1992
H I L L J . , DEANS J . A . J . & PRICHARD A . J . N .
(1 992) C h i . Otolaryngol. 17, 5 1 1-5 13
Higher surgical training in Otolaryngology The views of the membership of the Association of Otolaryngologists in Training (all current UK Senior Registrars and Consultants in their first year of post) were sought on topical aspects of Higher Surgical Training. 80 members (72.3%) participated. The main points to emerge were that the intercollegiate exam is unpopular. 66% feel it is neither well suited to the developing career structure nor a good assessor of trainees, 80% of Senior Registrars for whom the exam is voluntary say they will not sit it, 66% have doubts about the confidentiality of the Specialist Advisory Committee (SAC) interview and 73% felt the need for a separate faculty for Otolaryngology at the Royal College of Surgeons. Keywords
training otolaryngology
Higher surgical training in Otolaryngology is currently going through a period of rapid change. The impetus for these changes has come from various quarters. The Specialist Advisory Committee (SAC) has encouraged the establishment of rotations between units at Senior Registrar level’ and is now doing so at Registrar level. Desire for a more specialized examination system to reflect the increasing specialization within General Surgery has led to the introduction of a three-part Fellowship exam. The Royal Colleges have had to introduce a three-part exam in Otolaryngology in order to preserve an integrated sytem. The effects of implementing Achieving a Balance’ and altering the positions of career bottlenecks are also being felt. The purpose of this survey was to canvas the views of those most intimatcly involved by the present changes, namely, the current cohort of Senior Registrars in post. Their views could be expected to be revealing as they have first-hand experience of the present system and are therefore of value, if taken into account, as further changes are undertaken.
Methods The membership of the Association of Otolaryngologists in Training consists of all the current Senior Registrars and Correspondence: Mr J.Hill, Association of Otolaryngologists in Training, Department of Otolaryngology, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK.
Consultants in their first year of appointment in the United Kingdom. 110 members were contacted. Each was sent a copy of the recent review article on training in Otolaryngology by Mr Harold Ludman (Chairman, SAC in Otolaryngology) and a Questionnaire. The questionnaire is reprinted along with the results. In the accompanying letter it was made clear that individual replies would be treated in confidence, no names were attached and replies were therefore anonymous. The survey was conducted in November 1991 and December I99 1.
Results Replies were received from 80 of the I10 contacted (72.3%). The results are displayed alongside each question as it appeared in the questionnaire (values in parentheses are percentages). 1. Are you a Consultant or Senior Registrar? Consultant: 15 ( 1 8.8) SR 65 (81.2)
2. Did you become an S R before or after Jan 1991? Before: 67 (83.8) After: 13 (16.2) 3. Did you pass the ‘old style’ FRCS? Yes: 80 (100) 4.
Did you pass the ‘new style’ FRCS? No: 80 (100)
51 1
512
5.
6.
7.
8.
9.
10.
11.
12.
J.Hill e t al.
Do you feel that the Primary (part I ) FRCS should continue broadly as at present? Yes: 65 (8 I .2) No: 15 (18.8) Should the Primory (part I ) FRCS become more orientated towards Otolaryngology ( ~ f0phthalrrlolog.v Primary j ? Yes: 16 (20) No: 64 (80) Should the part II FRCS for E N T trainees consist oJ a. Surgery in general+ Otolaryngology (as at present) Yes: 24 (30) h. Surgery in general + General Surgery Yes: 4 (5.0) c. Otolarygology alone Yes: 2 (2.5) d. Surgery in general+ Otolrr~ngology but with a heavier emphasis towards Otolaryngology than at present Yes: 44 (55.0) Is time spent in non- E N T surgicul specialties beneficial? Yes: 80 (100) Is 18 months in tion-ENT surgical specialties: a. Too little 5 (6.3) b. About right 61 (76.3) c. Too much 14 (17.4) Which non-ENT specialties are most beneficial? Ire.vponses are percentages) General surgery 24.6 Plastic surgery 27.7 Neurosurgery 19.8 Op t hultrl ology 3.1 A&E 12.5 Cardiothorac,ir. 11.0 Maxillo facial I.T . U . 0.2 Orthopaedics 0.4 At present the notr-ENT requirement ,for the part I I FRCS is 18 months in any surgical specialty. Do you,feel that allocation of’ this time should be: a. left to the trainee’s discretion 55 (68.7) b. controlled to include a particular specialty and if so which 25 (31.3) (no agreement on which specialty) Do you feel that the part III FRCS is: a. well .suited to the developing career structure? Yes: 23 (28.7) No: 53 (66.3)
13.
14.
15.
16.
17.
18.
19.
20.
21.
b. a better assessor of trainees than the old exam? Yes 22 (27.5) No: 53 (66.3) As it is intended that the part II FRCS will beconze 11 requirement fbr uppointmeiit to a career Registrar post, do you feel that the part III should be taken: CI. 3 years or more after passing Part III (as at present) Yes: 31 (38.8) b. Earlier Yes: 12 ( 1 5.0) c. A s an exi[ exuni Yes: 13 (16.3) d. Other Yes: 4 (5.0) I f you becume an S R beJ)re .Ian. 1991 will you take the part III FRCS: a. Yes 2 (3.8) h. N o 42 (80.8) c. Possibly if others do 8 (15.4) d. Probably if others do 0 (0) These figures exclude consultant responses Should Registrars be made ineligible,for SR posts in their own unit? Yes: 31 (38.8) No: 49 (61.2) Should the distinction between Registrar and S R he dropped to create one training grade:) Yes: 40 (50) No: 40 (50) A s an assessment of’ individual training is the S A C interview at the end of the 2nd year: 13 (16.3) a. Good 42 (51.3) b. Reasonable 24 (30) c. Poor As on U S S ~ S S I Iof ~ training posts is the SAC: 13 (16.3) a. Good 46 (57.5) b. Reasonable 19 (23.7) c. Poor I f problems occurred during your training would you: a. Consider approaching the SAC of your volition. Yes: 52 (65) No: 27 (33.8) b. Have any concerns that your complaints would not be treated confidentially. Yes: 53 (66.2) No: 22 127.3) When the part 111 FRCS is mandatory should the S A C interview he retained? Yes: 52 ( 6 5 ) No: 27 (33.8) H o w much time is theoretically allocated to rrsetirchi stuclv on your present timetable.? a. none 4 (6.2)
Higher surgical training in Otolaryngology 5 13
22.
23.
24.
25.
Any
b. f day 7 (10.8) c. I day 49 (75.4) d. I ! days 0 (0) e. 2 days 0 (0) H O Nmuch of that time do ~ o get u in prcictice? a. > 90% 20 (30.8) b. 70-89% 10 (15.4) C. SO-69% 12 (18.5) d. 30-49% 23 (35.4) e. < 30% 0 (0) Is the time your get: 43 (66.2) CI. udeyuate 1 (1.5) 6. too much 21 (32.3) c. too little Responses from SRs only are given to questions 21, 22 and 23 Is there a need for a separate Otolaryngology faculty at the Royal College of Surgeons? Yes: 59 (73.8) No: 20 (25) Should we aim ,for a separate College of Otalaryngologists.9 Yes: 31 (38.8) No: 48 (60) other comments . . .
Discussion The response rate of over 70% is high for a postal survey and reflects the strength of feeling held on these subjects by the respondents The present Primary (part I) FRCS is thought to be along appropriate lines by the great majority (81.2%). However, only 30% feel that the part I1 exam is satisfactory and just over half (55%) thought this exam should have less of an emphasis on Surgery in General. Everyone agrees that nonENT posts are beneficial and the present requirement for 18 months seems correct to 76.3%. There was little agreement as to which specialties are most helpful and 68.7% feel that this choice is best left unregulated. Several replies from enthusiasts for General Surgery as a necessary post, pointed out that early results from the new part I1 exam suggest that the ‘Surgery in General’ component presents a formidable hurdle to candidates who have little General Surgical experience. If the emphasis is to remain unchanged it would therefore seem a sensible career plan to include some General Surgery a t SHO level. (The 25 respondents who did want regulation did not concur on which specialties to include.) The part I11 exam is not popular. Large majorities feel that it is neither well suited to the developing career structure nor a good assessor of examinees. 80% of those SRs for whom the exam is voluntary say that they will not take it and only 15% say they may respond to peer pressure and sit the exam if their contemporaries take it. There were many vehemently
expressed additional comments on this subject. To trainees who have already passed the ‘old’ fellowship, the imposition of an additional exam either compulsorily or optionally (depending on the date of acquisition of SR post) has undoubtedly created great bitterness. Points repeatedly raised were, ‘If it has a high pass rate-why have it?’ ‘How can you fail someone so late in his training?’ and ‘Assessment at this stage is as much an assessment of the training as of the trainee and better carried out by the SAC’. Plans to merge the grades of Registrar and SR received a mixed reception (50-50) although 1 1 respondents who replied ‘No’ to question 16 added that they would say ‘Yes’ if the amount of rotation was increased so as to avoid a narrow training. Four indicated that the resultant shift of the career bottleneck from Registrar-SR3 level to SHO-Registrar should be welcomed. The SAC in Otolaryngology is regarded as a reasonable assessor of posts and trainees by the majority and 65% wished it to be retained despite the adoption of the new exam system. The point was repeatedly made that the SAC interview is a more appropriate, wide-ranging and effective forum for assessing a trainee towards the end of his career than the part I11 exam. However. 66.2% of respondents d o not believe that comments made to the SAC would remain confidential. Many point out that if the SAC makes specific recommendations to a small unit after contact with a n SR it is difficult to maintain confidentiality. A suggested way around this problem was that the SAC make arrangements to re-contact SRs once they have attained their consultant post and ask for any further information that may have been more awkward to divulge at the original interview. Time allocated to research is variable; one day a week is typically timetabled but many find other commitments encroach upon this time. Several SRs were concerned that adoption of ‘Trust Status’ would increase these problems by leading to pressure to increase the clinical throughput. Despite increasing pressure to publish, 35.4% actually get less than half their allocated time. However 66.2% did feel that they got adequate amount of time for research/study. There was a strong call for a separate faculty within the Royal College for Otolaryngology. This may be a reaction to the bitterness felt about the part I11 exam which is largely seen as having been implemented by a college dominated by General Surgeons, but it does reflect a frustration that the College hierarchy has such little Otolaryngological representation.
References I LUDMAN H . (1990) The Specialist Advisory Committee -Training in Otolaryngology. C/in. Otolarvngo/. 15, 83 92 2 DHSS ( 1 987) Hospital Medical Staflng. Adtieving a Balance - Plan for Action 3 SLACK R.W.T. & KISSINM.W. (1988) What do you have to do to become an ENT Senior Registrar? Clin. Ofolaryngol. 13, 411-413
Higher surgical training in Otolaryngology J.HILL, J.A.J.DEANS & A.J . N . P R I C H A R D Association of Otolaryngologists in Training, Department of Otolaryngology, Freeman Hospital. Newcastle upon Tyne, U K Accepted for publication 23 June 1992
H I L L J . , DEANS J . A . J . & PRICHARD A . J . N .
(1 992) C h i . Otolaryngol. 17, 5 1 1-5 13
Higher surgical training in Otolaryngology The views of the membership of the Association of Otolaryngologists in Training (all current UK Senior Registrars and Consultants in their first year of post) were sought on topical aspects of Higher Surgical Training. 80 members (72.3%) participated. The main points to emerge were that the intercollegiate exam is unpopular. 66% feel it is neither well suited to the developing career structure nor a good assessor of trainees, 80% of Senior Registrars for whom the exam is voluntary say they will not sit it, 66% have doubts about the confidentiality of the Specialist Advisory Committee (SAC) interview and 73% felt the need for a separate faculty for Otolaryngology at the Royal College of Surgeons. Keywords
training otolaryngology
Higher surgical training in Otolaryngology is currently going through a period of rapid change. The impetus for these changes has come from various quarters. The Specialist Advisory Committee (SAC) has encouraged the establishment of rotations between units at Senior Registrar level’ and is now doing so at Registrar level. Desire for a more specialized examination system to reflect the increasing specialization within General Surgery has led to the introduction of a three-part Fellowship exam. The Royal Colleges have had to introduce a three-part exam in Otolaryngology in order to preserve an integrated sytem. The effects of implementing Achieving a Balance’ and altering the positions of career bottlenecks are also being felt. The purpose of this survey was to canvas the views of those most intimatcly involved by the present changes, namely, the current cohort of Senior Registrars in post. Their views could be expected to be revealing as they have first-hand experience of the present system and are therefore of value, if taken into account, as further changes are undertaken.
Methods The membership of the Association of Otolaryngologists in Training consists of all the current Senior Registrars and Correspondence: Mr J.Hill, Association of Otolaryngologists in Training, Department of Otolaryngology, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK.
Consultants in their first year of appointment in the United Kingdom. 110 members were contacted. Each was sent a copy of the recent review article on training in Otolaryngology by Mr Harold Ludman (Chairman, SAC in Otolaryngology) and a Questionnaire. The questionnaire is reprinted along with the results. In the accompanying letter it was made clear that individual replies would be treated in confidence, no names were attached and replies were therefore anonymous. The survey was conducted in November 1991 and December I99 1.
Results Replies were received from 80 of the I10 contacted (72.3%). The results are displayed alongside each question as it appeared in the questionnaire (values in parentheses are percentages). 1. Are you a Consultant or Senior Registrar? Consultant: 15 ( 1 8.8) SR 65 (81.2)
2. Did you become an S R before or after Jan 1991? Before: 67 (83.8) After: 13 (16.2) 3. Did you pass the ‘old style’ FRCS? Yes: 80 (100) 4.
Did you pass the ‘new style’ FRCS? No: 80 (100)
51 1
512
5.
6.
7.
8.
9.
10.
11.
12.
J.Hill e t al.
Do you feel that the Primary (part I ) FRCS should continue broadly as at present? Yes: 65 (8 I .2) No: 15 (18.8) Should the Primory (part I ) FRCS become more orientated towards Otolaryngology ( ~ f0phthalrrlolog.v Primary j ? Yes: 16 (20) No: 64 (80) Should the part II FRCS for E N T trainees consist oJ a. Surgery in general+ Otolaryngology (as at present) Yes: 24 (30) h. Surgery in general + General Surgery Yes: 4 (5.0) c. Otolarygology alone Yes: 2 (2.5) d. Surgery in general+ Otolrr~ngology but with a heavier emphasis towards Otolaryngology than at present Yes: 44 (55.0) Is time spent in non- E N T surgicul specialties beneficial? Yes: 80 (100) Is 18 months in tion-ENT surgical specialties: a. Too little 5 (6.3) b. About right 61 (76.3) c. Too much 14 (17.4) Which non-ENT specialties are most beneficial? Ire.vponses are percentages) General surgery 24.6 Plastic surgery 27.7 Neurosurgery 19.8 Op t hultrl ology 3.1 A&E 12.5 Cardiothorac,ir. 11.0 Maxillo facial I.T . U . 0.2 Orthopaedics 0.4 At present the notr-ENT requirement ,for the part I I FRCS is 18 months in any surgical specialty. Do you,feel that allocation of’ this time should be: a. left to the trainee’s discretion 55 (68.7) b. controlled to include a particular specialty and if so which 25 (31.3) (no agreement on which specialty) Do you feel that the part III FRCS is: a. well .suited to the developing career structure? Yes: 23 (28.7) No: 53 (66.3)
13.
14.
15.
16.
17.
18.
19.
20.
21.
b. a better assessor of trainees than the old exam? Yes 22 (27.5) No: 53 (66.3) As it is intended that the part II FRCS will beconze 11 requirement fbr uppointmeiit to a career Registrar post, do you feel that the part III should be taken: CI. 3 years or more after passing Part III (as at present) Yes: 31 (38.8) b. Earlier Yes: 12 ( 1 5.0) c. A s an exi[ exuni Yes: 13 (16.3) d. Other Yes: 4 (5.0) I f you becume an S R beJ)re .Ian. 1991 will you take the part III FRCS: a. Yes 2 (3.8) h. N o 42 (80.8) c. Possibly if others do 8 (15.4) d. Probably if others do 0 (0) These figures exclude consultant responses Should Registrars be made ineligible,for SR posts in their own unit? Yes: 31 (38.8) No: 49 (61.2) Should the distinction between Registrar and S R he dropped to create one training grade:) Yes: 40 (50) No: 40 (50) A s an assessment of’ individual training is the S A C interview at the end of the 2nd year: 13 (16.3) a. Good 42 (51.3) b. Reasonable 24 (30) c. Poor As on U S S ~ S S I Iof ~ training posts is the SAC: 13 (16.3) a. Good 46 (57.5) b. Reasonable 19 (23.7) c. Poor I f problems occurred during your training would you: a. Consider approaching the SAC of your volition. Yes: 52 (65) No: 27 (33.8) b. Have any concerns that your complaints would not be treated confidentially. Yes: 53 (66.2) No: 22 127.3) When the part 111 FRCS is mandatory should the S A C interview he retained? Yes: 52 ( 6 5 ) No: 27 (33.8) H o w much time is theoretically allocated to rrsetirchi stuclv on your present timetable.? a. none 4 (6.2)
Higher surgical training in Otolaryngology 5 13
22.
23.
24.
25.
Any
b. f day 7 (10.8) c. I day 49 (75.4) d. I ! days 0 (0) e. 2 days 0 (0) H O Nmuch of that time do ~ o get u in prcictice? a. > 90% 20 (30.8) b. 70-89% 10 (15.4) C. SO-69% 12 (18.5) d. 30-49% 23 (35.4) e. < 30% 0 (0) Is the time your get: 43 (66.2) CI. udeyuate 1 (1.5) 6. too much 21 (32.3) c. too little Responses from SRs only are given to questions 21, 22 and 23 Is there a need for a separate Otolaryngology faculty at the Royal College of Surgeons? Yes: 59 (73.8) No: 20 (25) Should we aim ,for a separate College of Otalaryngologists.9 Yes: 31 (38.8) No: 48 (60) other comments . . .
Discussion The response rate of over 70% is high for a postal survey and reflects the strength of feeling held on these subjects by the respondents The present Primary (part I) FRCS is thought to be along appropriate lines by the great majority (81.2%). However, only 30% feel that the part I1 exam is satisfactory and just over half (55%) thought this exam should have less of an emphasis on Surgery in General. Everyone agrees that nonENT posts are beneficial and the present requirement for 18 months seems correct to 76.3%. There was little agreement as to which specialties are most helpful and 68.7% feel that this choice is best left unregulated. Several replies from enthusiasts for General Surgery as a necessary post, pointed out that early results from the new part I1 exam suggest that the ‘Surgery in General’ component presents a formidable hurdle to candidates who have little General Surgical experience. If the emphasis is to remain unchanged it would therefore seem a sensible career plan to include some General Surgery a t SHO level. (The 25 respondents who did want regulation did not concur on which specialties to include.) The part I11 exam is not popular. Large majorities feel that it is neither well suited to the developing career structure nor a good assessor of examinees. 80% of those SRs for whom the exam is voluntary say that they will not take it and only 15% say they may respond to peer pressure and sit the exam if their contemporaries take it. There were many vehemently
expressed additional comments on this subject. To trainees who have already passed the ‘old’ fellowship, the imposition of an additional exam either compulsorily or optionally (depending on the date of acquisition of SR post) has undoubtedly created great bitterness. Points repeatedly raised were, ‘If it has a high pass rate-why have it?’ ‘How can you fail someone so late in his training?’ and ‘Assessment at this stage is as much an assessment of the training as of the trainee and better carried out by the SAC’. Plans to merge the grades of Registrar and SR received a mixed reception (50-50) although 1 1 respondents who replied ‘No’ to question 16 added that they would say ‘Yes’ if the amount of rotation was increased so as to avoid a narrow training. Four indicated that the resultant shift of the career bottleneck from Registrar-SR3 level to SHO-Registrar should be welcomed. The SAC in Otolaryngology is regarded as a reasonable assessor of posts and trainees by the majority and 65% wished it to be retained despite the adoption of the new exam system. The point was repeatedly made that the SAC interview is a more appropriate, wide-ranging and effective forum for assessing a trainee towards the end of his career than the part I11 exam. However. 66.2% of respondents d o not believe that comments made to the SAC would remain confidential. Many point out that if the SAC makes specific recommendations to a small unit after contact with a n SR it is difficult to maintain confidentiality. A suggested way around this problem was that the SAC make arrangements to re-contact SRs once they have attained their consultant post and ask for any further information that may have been more awkward to divulge at the original interview. Time allocated to research is variable; one day a week is typically timetabled but many find other commitments encroach upon this time. Several SRs were concerned that adoption of ‘Trust Status’ would increase these problems by leading to pressure to increase the clinical throughput. Despite increasing pressure to publish, 35.4% actually get less than half their allocated time. However 66.2% did feel that they got adequate amount of time for research/study. There was a strong call for a separate faculty within the Royal College for Otolaryngology. This may be a reaction to the bitterness felt about the part I11 exam which is largely seen as having been implemented by a college dominated by General Surgeons, but it does reflect a frustration that the College hierarchy has such little Otolaryngological representation.
References I LUDMAN H . (1990) The Specialist Advisory Committee -Training in Otolaryngology. C/in. Otolarvngo/. 15, 83 92 2 DHSS ( 1 987) Hospital Medical Staflng. Adtieving a Balance - Plan for Action 3 SLACK R.W.T. & KISSINM.W. (1988) What do you have to do to become an ENT Senior Registrar? Clin. Ofolaryngol. 13, 411-413
