Listen to Sarah Gill, James Tomlinson and Tom Harding in a round table discussion of orthopaedic training in a COVID climate.
Listen to Sarah Gill, James Tomlinson and Tom Harding in a round table discussion of orthopaedic training in a COVID climate.
[00:00:00] Welcome to the BJ360 October podcast. My name is Sara Gill, an orthopedic trauma consultant at the Queen Elizabeth Hospital in Glasgow. Thank you again for joining us as we continue our new and developing monthly podcast series. We've got an alternating programme between journal club episodes that focus on the latest BJ360 contents and round table discussions on topics affecting our everyday trauma & orthopedic practice. And that's where, in fact we are this month and we are focusing on training - training in a COVID climate, which is a literary reference that I'm sure needs no explaining to our well-cultured orthopedic community.
This month, I'm joined by two colleagues from different regions. Tom Harding is an SD five in the East of Scotland rotation. And he is also the Scottish boater rep. And James Tomlinson, consultant spinal surgeon and academic and educational TPD in the Yorkshire region, recently appointed as deputy director to the faculty of surgical trainers. So good evening, Tom and James.
So guys we're going to kick off, this is a [00:01:00] much discussed topic, I think, across the UK, and that is training during COVID. It's been a time of disruption really to usual practice and usual training practice. There's been disruption of elective clinics and theatre lists, changes in rotas, very much in the first initial wave a restriction of trainee access to theatre. And all of that has really disrupted the changes to the normal consultant trainer partnerships, or workings of the normal firm. However it is in your unit. So Tom, as a trainees in the sort of central period of training, that must be... well, the last seven months must have been pretty atypical.
Tom: Yeah. It's been a very difficult six months for all trainees at all stages of training. I think it's affected trainees at different stages of training in different ways. Obviously the core trainees, the ST3s and ST4s have missed out on vital opportunities and often been the first to be redeployed elsewhere. The people in the middle ground probably less impacted. But still some [00:02:00] ST4s, ST5s, ST6s redeployed, but also a loss of those essential placements, like your arthroplasty placements to get those vital indicative numbers. And then the SD7s, SD8s have suffered from canceled examinations, but also that lack of theatre exposure.
So I think there's a lot of anxiety amongst the trainees as a whole. And it's been a very difficult time. I think orthopedics is probably one of the specialties that's been hit hardest in terms of the impact on training.
Sarah: Yeah, I think that's a really good summary actually Tom of the sort of, as you say, actually the sort of the stratification of challenges to trainees, which isn't uniform it actually is relating to their time of the period of training as it were. And I completely get what you're saying. Actually we have a huge elective practice. You know, we're a very big, very busy surgical department with, as you say, big elective practice. And therefore of course it has.
James to come to you. This would be a good time to actually sort of ask you for maybe a bit of a more central sort of discourse on this. I know that, you've been inundated with meetings, mostly zoom [00:03:00] meetings over the last few months.
James: Yeah, I think the first thing I would say, actually that I have to say on behalf of everyone is I think a big, thank you should go to the trainees. A lot of trainees were redeployed at very short notice and just got on with it and did what was asked. And I think that deserves a lot of recognition. It's very interesting, I was at a school of surgery board meeting yesterday and the theme that came out across all of surgical training in Yorkshire is there's a lot of, I don't know if this is the right word, anxiety amongst trainees, about the lack of clarity at the moment, both of when are we going to get back to normal? And when we do get back to normal, how do we get people back to where they should be?
I think one of the really big challenges when you speak to people around the UK and even around your own region is there's a variation from trust to trust, there's variation from specialty to specialty, there's variation from region to region.
In our region, we have some trusts who've done pretty much no elective work for six months. And we also have [00:04:00] trusts who probably for two or three months now have been almost back to a hundred percent elective capacity, and I think we've more or less got everything in between as well. And so theres a real challenge that there is no real answer because it's almost bespoke solutions, but I think on a trainee basis.
Sarah: I think that's a real point. So there were a few things that came out common themes that came out from things that both of you said there, one was anxiety, another was redeployment. And then a third thing you said there was about inequity James. And I think that's one of the really strong things that I wanted to discuss this evening. So if we take anxiety first, actually, I think that is, you know, to be expected in a time of great uncertainty. But I suppose what we're saying is that, that anxiety is probably fueled by the inequity. And as you say, you know, I dunno it's a bit of a frustrating phrase, the new normal, because I think its a bit tongue in cheek. Cause no one really knows what that is.
So if we talk about you think that essentially a lot of the [00:05:00] anxiety that trainees and, and probably trainers, I think as well have in this time, maybe that could be addressed with more central guidance and at least articulation of the challenges that we're facing.
James: Yeah. I think in fairness to HEE and the JCST, there has been pretty good attempts at communication. And I think it's been interesting as a TPD that if anything, the communication, I think both of those organizations have used social media really effectively. And at times we've had trainees coming up to us saying, Oh, what about this latest HEE update? And we're saying, well, hang on a minute, we haven't gotten the email yet through official channels and theyve heard it on social media before we know about it. But I think that's a really good thing.
I suppose the challenge is that certainly the informal discussions since very much, we can't kind of let people through the end of training and just lower the standards because the standards are there because that's what we think the benchmark is. [00:06:00] But equall y we can't extend kind of 80% of trainees trading time, all of a sudden, because that creates issues in terms of people coming off the top for the job market, people coming in the bottom of recruitment, partly just people's plans because by the time youre an STA and a final year trainee, there's a lot of things in terms of personal life built around that. And I think that's the big challenge, I would say from a TPD perspective, that is the big challenge, the uncertainty, and kind of perception of lack of control over your own destiny. I don't know what you said, Tom?
Tom: I think that is a big issue that not knowing what's around the corner. When am I going to be, if am I going to be redeployed? Am I going to miss out on my training and what's going to happen. And I think that's across the board. People just don't know. I don't think anybody really knows what is around the corner, but I think we just need to work out how we're going to catch up at the end of this and how are we going to make the most of the training opportunities that are there?
Sarah: Yeah. Do you know what I was going to say? I think you're exactly right [00:07:00] Tom. And do you know what? I think it's really difficult to make plans based on a COVID environment where we have to be so responsive and reactive to what the service needs to provide service for patients. And I think maybe our time would be really, maybe better spent looking at how we can regionally maximize training once we've got a green light again , you know, so that we're really getting as much as we can from those opportunities once they're up and running.
We said we're going to talk about deployment. Tom, what are your feelings about redeployment? And redeployment can take lots of different forms. It might be running the minor injuries units. It might be staffing COVID medical wards. It might be going to A&E. What's yours and what do you think the trainee perspective of it is?
Tom: I think no one's against it in the extreme. And so when as extreme circumstances, such as we see in the Lombardy region at the start, or right at the start of COVID where you had orthopedic surgeons wearing ventilators and things, because they just didn't have the numbers on the ground.
I think there's a lot of angst about being redeployed early. [00:08:00] And I think there's a lot of places and there's a lot of feedback from speaking to people on boater. In some regions, people are redeployed very early when they're not really required. And as, uh, almost, uh, I've been redeployed to, to fill out a gap somewhere else.
I think there's a bit of anger and frustration in those scenarios but I think we shouldnt be really redeploying orthopedic trainees to places where they don't have the capabilities to provide a service, so redeploying to a ICU to run a ventilator, is not appropriate, but you might be appropriate to go there to assist, turning patients and things like that. But again, in extreme circumstance.
And I think we need to have quite strict and written down guidelines of when is appropriate to redeploy people from their specialty and in what circumstances that is to happen to protect trainees, just to make sure that people don't get redeployed early and lose their training.
Sarah: I think that's it, isn't it, you know, youre doctors first, so you go [00:09:00] absolutely where is needed, but it's trying to also remember that trainees are in training. They have training needs and that has to be balanced.
James, do you think this, you know, we sort of had the first wave were maybe at the beginning of a second wave, and that's going to combine with sort of winter, bed pressures and the flu et cetera. Do you think we will have a more proportioned response? You think it be different if it happens again?
James: I hope so, but I think it's difficult, isn't it? I mean, I suppose the biggest challenge at the moment is this is still not a well-understood disease and that discussion at the moment seems to be a lot of this actually, because of some of the mitigation strategies, are we going to see a slightly different pattern in terms of admissions and severity of disease this time? So may there be a reduction in the kind of severity of pressure on services, but it seems like at the moment we're still in kind of that unknown period of where things haven't quite become clear how it's all going to pan out.
And again, it seems there's quite [00:10:00] marked regional variation as well, that there are some parts of the country where actually admissions are still very low and disease prevalence is still very low and orthopedic trainees in those parts of the country probably haven't needed to change. And equally some areas are in extremist already. And again, that's going to create huge disparities in the kind of trainee picture nationally.
Sarah: So one of the things we talked about was trying to get the most out of training and I was particularly talking about post-covid, you know, when we can be a bit more predictable about the opportunities and plan for those well, but the variation across the country is very evident in terms of unequally affecting parts unequally affecting jobs, in terms of trauma versus elective, et cetera.
But Tom, we were discussing recently about what has been a very proactive change in your trauma rota in the East of Scotland, mostly the hospital in Dundee to really try and maximize the operative experience that trainees have had during COVID. And I would start off by [00:11:00] saying that Tom and I were discussing this previously and through this in the last few months, the trainees have been able to get their indicative numbers. So what would you be 300 cases a year on track to get the 300 cases year through these changes. So can you tell us a bit about that Tom and how you've achieved that?
Tom: Yeah. So in Tayside with a little bit of background on how we run the rota is its a two tier system, but basically SHO grade, ST1s through to fours. And then as a junior tier and a senior tier, as ST5s through to eight. The key change we made - it came from the consultants top down was to switch to a trauma team-based pattern of working. And that came out of the COVID era. We split into three different teams.
Now we work in four different teams. Each team has three consultants. Each team got two senior registrars and two junior registrars. And the way we are able to maximize our training in that is that all trauma activity happens in one week - one in four weeks. [00:12:00] And all elective activity happens outside of that. So all of our on calls for the junior guys, who do the night shifts and the holding the bleep all happen in that one week. And the senior guys do that 24 hour on calls also during that week.
But essentially we've made things a lot more flexible, but means that the junior guys don't miss the consultants elective practice due to night shifts and out of hours on-call working and those zero days, and we've made zero days flexible.
We managed to achieve the same eight weeks compared to last year and 91% increase in the juniors access to 30 sessions. And even the seniors have a 13% increase in their access to certain sessions, despite a 65% elective capacity at present. And really the biggest thing we changed was we made juniors and seniors in trauma theater together.
Sarah: Yeah.
Tom: Always a junior and always a senior nine to five, [00:13:00] Monday to Friday and that's maximizing the training opportunity for both of those training groups.
Sarah: Yeah. So that presumably means that, you know, the juniors are getting good access to still doing hemiarthroplasties, the DHSs, you know, the something that is grade appropriate and it sort of increases the exposure of the senior guys to the more senior trauma, you know, the periarticular stuff, the periprosthetic, maybe the pelvic work, et cetera.
I mean, that's a big change to the rota and that's a sort of very proactive change I would say, which is just really interesting to hear about. James, your thoughts on that sort of that? This is obviously one region, one unit, but it's interesting to hear.
James: Yeah, I think this is the key isn't it is trying to be flexible and I think one of the great difficulties is a lot of the stuff doesn't get shared. And it's frustrating that this is the kind of work that you don't always hear about at the national meetings and things but actually some often you kind of sit in apartment and think, actually we need to try and rework things [00:14:00] here and improve the opportunities. And eventually you hear on the grapevine that somebody somewhere has already done it, and they're more than happy to share what they've done and their learning. Its just you didn't know they did it. And I guess the key really is having local solutions that again each department's just so different, whether you're in an MTC, whether you're in a DGH and trying to flex and adapt for both what trainings you've got the seniority, what lower level core trainees, or whether you've got AMPs on that rota. But I think there is a pressure going forward that as we start to return to normal, I think we need to be pretty creative with looking at how we maximize opportunities while yes, there's a service to deliver and we have to ensure safe patient care, but we also, I would say have a duty to the trainees who have stepped up when required to help during COVID. Well, we have a duty to them now to step up and kind of accelerate their training and pay back that debt that they've given to the service.
Sarah: Yeah, I think that's a good way of looking at it. It's well articulated. [00:15:00] I think I really liked what you've done, Tom, because I think it's really ambitious. It's like, there's an issue. There's a problem. And rather than being a slave to that, it's saying, well, actually we can do better. And I really like that idea.
It's something that I've thought about, moving away from operative stuff towards the outpatient department, my practice is purely trauma. So, you know, my outpatient stuff is really fracture clinics. And we really had to change because of patient needs. We really had to change the way we did that. We moved to a lot more telephone review. We saw people face-to-face much more on a needs base rather than I'd like to see you at three months to get an x-ray, just so that I can feel better about that.
And what it did was it meant that we could really run a more consultant delivered service. And it's making me think once we're back to having trainees back in the clinics, more of the time, can we train better in the outpatient department? Can we move the focus away from service provision for trainees, which I think is the case in some units more towards [00:16:00] closely supervised teaching and really getting more educational benefit from that?
Tom, your thoughts about that as a trainee, when you're going through your training, there's always things you think you you could do differently. Any thoughts about the outpatient clinic?
Tom: Well, you mentioned there that we've switched to sort of telephone clinics and things. And you said when we go back to normal training we should think about how we get the trainees back in the clinic. I think the telephone clinics still present an opportunity for trainees to learn this new way of consulting patients, a new way of delivering a service. I think if you're doing something virtually, there's no reason why someone else can't log into that virtual consultation. And even the trainee leading that virtual consultation, having their supervisor watching them do it, to critique them and go through things. I think that's useful. I think that's another opportunity that can made useful and thats something locally that wed be able to do.
Sarah: Yeah. So you're saying don't shield the trainees from that. [00:17:00] Invite them in to this way of consulting, into this new practice.
Moving away from the outpatient clinic. One of the things I wanted to discuss with you guys, cause I think this has changed a lot over the last few months is post-graduate teaching and sort of academic activities.
James, you and I were discussing recently, and in fact, you'd just come off or I think that day just had several zoom teaching sessions with trainees. Tom, I know you guys in the East of Scotland have gone to an online PGT over the last few months and we've done the same in the West. So what's the feedback from that? What's your experience about it? Do you think it's got benefits going forward?
Tom: I was going to say there's certain benefits to it. We've seen a massive increase in the consultant uptake and consultant input to post-graduate training locally. And even nationally, you look at the number of the wealth of a resource there is out there or from consults across the place. I think it can't fully replace postgraduate training in the traditional sense. It cant teach practical [00:18:00] skills or examination skills through it. But I certainly think it has a role moving forward. The only other thing I would say is it had a really good uptake in the height of lockdown. But I think when people get their lives back, whether they're doing teaching in the evenings, we will need to have a way of accrediting that as work and work time, rather than just expect people to use their spare time, which is also already sparse.
Sarah: Yeah. I've got a feeling about that, but James I'll come to you first of the back of what Tom is saying.
James: I do think virtual teaching has a role. I think the key aspect is it's a tool and like everything it's the right tool for the right job. I think thinking about our region, we some, some self trainees driving two hours to teach on a Friday afternoon. And so last madness, both in terms of actually by the time you get there, you're not in a useful state of mind to engage in the teaching. And also it's just not good from a safety point of view that you're driving [00:19:00] in a rush worrying about trying to get there. So I think accessibility is really good. Its already been mentioned but another great bonus is in theory, you can get speakers from all over the world if you want, or you can pull resources and say, actually, there's someone from the US is going to give a talk. Why don't we invite another region to join us? Then we've got a bigger audience and it makes them feel it's worthwhile.
I think the big challenge we found is that regional teaching for a lot of trainings, it's more than just teaching. It's kind of a way you come together as a community and you kind of see your friends chat about things, catch up with people, maybe catch up with trainers about different things the TBDs could drop in and people can kind of have a quiet word in the corridor or over a coffee.
And the stuff that happens around the fringe is much harder on an online platform. And if anything, maybe doesn't happen. And I think the comment about evenings is absolutely. I know a couple of people who've run webinars series, and they've commented that attendance in the lesson couple of months has really, really dropped and maybe there's [00:20:00] role for a bit more of a coordinated national picture of kind of revision series webinars, and, you know, trying to tailor it. Again going back to Tom's point of specific trainees - actually the pre-exam guys want something quite exam focused, whereas like a national ST3 has had to be an orthopedic wedge webinar series will probably be equally popular, but for a very different group.
Sarah: Yeah we've all touched on that. And it's something that's really occurred to me, especially to begin with, there was this real thirst for, you know, where we've got reduced access to clinical learning opportunities, we really want to maximize in terms of the academic stuff, in terms of the post-graduate teaching programs and things.
But I had great concerns about that because I think avoiding driving, as you say, two hours on a Friday, or pre nights, post nights, et cetera, those things. I think it was a really good thing in the same that, you know, loads of people then started working from home and it was like, well, why did I need to go into the office? I think a lot of PGT can happen, um, on online platforms. But what I was a [00:21:00] bit concerned about was this bleed through effect of suddenly people are never off. It's like on a Tuesday night we've got a seminar from so-and-so, on Thursday night we've got a talk from so-and-so. And I think that there is this sort of loss of work and not work time. And I think going forward that is not a good thing. And I think some regulation about it is important.
You were making a point there, James, about the coordination of these things and, you know, I really wanted to ask you guys about this in terms of the coordination of teaching opportunities and sort of tailoring teaching opportunity so that trainees can access the things that they need because this is really something that I've been thinking about or has occurred to me is that in the climate of decreased clinical opportunity, this is an opportunity for trainees to say, well, what do I not normally get time to do? You know, if I look at my CV, where is it light? Is it research and audit? Do I struggle to keep up to date with my reading? [00:22:00] And could we create some more centralized programs so that people can dip into that?
Tom, do you think, as a trainee, there would be appetite for that.
Tom: I think there is- there's always appetite for more centralized learning and particularly collaboratives in terms of research and audit. I think there is a rise in the number of collaboratives, happening and starting to happen, particularly with the COVID surge, work and things like that and working together. I think that's valuable. I think we can achieve more if we do work together with different regions and different areas. Certainly I think that is something that's going to increase with time, but I think it's something that all or most most trainers would be interested in.
Sarah: Yeah, I think you're right about the collaboratives. You know, there's certainly increasing ones in Scotland, particularly in relation to sort of COVID and orthopedic and trauma papers. And I've just certainly noticed a lot more trainees coming to me in the last few months looking for academic opportunities, which is, I think, a sign of trainees being [00:23:00] quite proactive about managing their training, which is a credit to them as well. James, again with your TPD or faculty of surgical trainings hat on, is there anything that we can be doing better in relation to that or, anything we ought to be looking for?
James: Teaching wise or academic wise or both, or...
Sarah: Yeah both.
James: I suppose, I think the thing with online teaching, and again, I think you've got to be clear about what you're doing, havent you? I think online teaching works really well when it's interactive and ideally, you know, based around cases and lots of changes of pace and changes of style. I think what's one of the big benefits is you can record things. But then the challenge of that is if you want people to interact someone like the ST3 is sitting in there thinking, well, actually I really want to have a go at this case, but this is going to be recorded and put on the rotation website for the next 15 years. I'm not sure I want to say anything.
I think again, there's almost that division of actually there's the interactive teaching that's in-house and private. [00:24:00] And then actually there's also a role for getting experts nationally of actually, can you give a 15 minute noninteractive session that could be recorded and archived and it's held by the BOA or whoever it is. And then people can just access that when theyre, you know, actually the lists gone down because of COVID so I'm going to go and watch some of those really great screencasts and catch up on a couple of things that I've been really struggling to think about.
Academic wise, I think that I completely agreed. I think that the collaborative research.streams - this causes great debates in the TPD world. And I think some people have perceived this as oh it's the easy way out. You know, you're just a bit part in a huge project.
I would argue this should be the direction of travel. That from a personal perspective, I would much rather one of our trainees contribute to a national project that recruits a thousand patients naturally answers a question, publishes yet another case series of 40 patients and [00:25:00] concludes further research is needed in this area, having spent how many hours writing a paper.
I think, yes, it's really impressive hard work, but if we haven't actually answered a question, is it useful work?
Sarah: I think, it's interesting that it's taken this to kind of get a real consensus, as you say, of a direction of travel towards that, because I think it's sort of increased academic activity and definitely more collaborative work is really a theme that's come out of this, and that is sort of an unseen positive in COVID.
James, as a TPD, do you think there's opportunity for us to be able to share this innovative practice that's going on across the UK?
James: Yeah, I think Tom's example was a really good one and I suspect there's lots of really innovative things going on all around the UK at the moment within orthopedics, in terms of trying to maximize trading opportunities. And I think if BOTA and The BOA were interested I [00:26:00] think both of those national meetings next year would be a really good forum to try and share some of those ideas and think about, as we've tried to look at how we can improve patient care, how could we improve training as well with lessons from COVID and try and see some of the positives from what's been a really difficult time.
Sarah: I think that's a great point. It's something I think we're always looking to do in orthopedics is sort of innovate. And I think something we're maybe less good at is not trying to reinvent the wheel sometimes. And I think actually sharing practice across the UK and seeing what other people have done really well is a really good idea.
Well, on that note, on that call to the BOA and Bota and maybe the faculty of surgical trainers, then I will say thank you very much for panel members. That's Tom Harding from the East of Scotland, and James Tomlinson from your Yorkshire. Guys, thanks so much again for giving up your time and joining us this evening.
Tom: Thank you for the invite.
James: Thank you. Thanks for the invite.
Sarah: I'm going to wrap it up there [00:27:00] guys cause I think we're probably hitting the end of people's commute or their walk at the weekend or whatever to listen to this. But I think we've covered a lot of ground there. And I think in terms of the trainers, you know, we're really asking the trainers to sort of discuss and plan cohesively to identify learning opportunities for trainees going forward and predict gaps in their training from this COVID period and facilitate how we can cover those gaps in future. And for the trainees, I think Tom, your examples have been really illustrative and James, I think you're absolutely right in that the trainees have been very proactive in terms of both their sort of giving to service. And their educational activities. And I think it is an opportunity for trainees to see this as an opportunity and a challenge rather than a negative. Update your CV, see where you've got points to be gained and where there are opportunity for academic gains.
So Tom Harding from the East of Scotland and James Tomlinson from [00:28:00] Yorkshire. Thank you very much for having us. Thank you. Bye-bye.