Training of Surgeons?

Training of Surgeons – Feedback Survey

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This information is being collected in order to establish whether initial concerns regarding the training programme have been addressed and whether the committee has formed an outline for the proposal for training of surgeons which the members would broadly support at this stage.

This feedback is designed to elicit a general response on the initial proposal format and to generate comment and suggestion. It does not constitute a bid for any final approval. To help us further we would be grateful if you could also respond to the following points by posting a reply on the forum. To do this click on the “Post reply” box and enter your responses to the numbered points followed by any additional comments or feedback.

1) If you were assured that the training and competency testing would be carried out to the highest standard and external impartial examiners would carry out examining/testing would you support this programme?
Yes Unsure No

2) If you were assured the those not deemed competent would be restricted by their professional body from practicing ultrasound, would that give you confidence that the training will not lead to the inappropriate use of ultrasound ?
Yes Unsure No

3) Would you be interested in providing training at your centre?
Yes No

4) Additional comments and feedback. This might include –
• What you feel are the main restrictions to providing training eg: time, money, staffing levels, time available to SpRs to commit to training etc;
• How many hours of classroom teaching and clinical contact you feel it should take to train surgeons to the standard outlined in the newsletter;
• Comments on the proposed tests for inclusion in training and suggestions for any other tests that might be included that would be of benefit to patients;


Training in Vascular Ultrasound for Vascular Surgeons

Further to the discussion at the AGM in November 2007, the executive committee has put together an update on the status of the initial discussion between the SVT and Vascular Society (VS) that took place in January 2008.

Background information
The society was approached by the VS to look at setting up a training module for the surgeons before the AGM.
WHY ARE THE SURGEONS KEEN TO TRAIN?
The availability of portable ultrasound machines and their marketing by the companies has brought the prospect of an important diagnostic tool for the vascular surgeons, many of whom already use hand-held Doppler, in the management of their patients. Furthermore the remit of vascular surgery is changing to encompass various endovascular procedures that seem to be the future trend in both arterial and venous disease management. On top of this the 18-week target means that there is a lot of pressure to ensure quick and effective diagnosis and management decisions for patients when they are seen in OPDs.
Already ultrasound is used in this way by cardiologists, and in gynaecology and obstetrics but it does not mean that the consultants and registrars do a full ultrasound list every week.

The SVT committee are aware of the differences of opinion that exist with regard to this topic and are very concerned that we ensure that the opinions of the members are heard and acted upon.

Please read the following information and take time to give us your response:

The committee wants to know and understand what the current thoughts and opinions are of the membership regarding this issue before the SVT moves things forward with this challenge. The reality is that following the example of surgeons in other parts of the world, the UK surgeons have decided that they require some limited ultrasounds skills and they need to obtain training to do so. It is much better for the SVT and our members if we are leading this training and ensure that it’s targets are realistic, achievable and, above all, safe for patients. This issue is very important and we all have to decide how to proceed. The committee has listened to the feedback at the AGM and has attempted to address the initial concerns raised by the membership. The committee believes that the proposed format is achievable, practical and in the interests of quality care for our patients, so please do not discard this article without giving us your thoughts on the subject.

The Facts
• An initial meeting was held in January between the SVT and VS.
• Nothing has been agreed pending feedback from the membership.
• The SVT proposes that training will be limited to basic exams, focusing on the use of ultrasound in the OPD, emergency or out of hours settings when full ultrasound scans are not available.
• At the initial meeting the VS agreed to this limited scanning proposal.
• The SVT proposes starting with a pilot scheme for ten specialist registrars.
• Any training beyond the pilot scheme will require full funding by the Royal College/VS or hospital trusts.
• Consultants and SPR’s would be required to take the course in order to be considered competent in basic limited ultrasound exams.
• The training would involve theory and practical training and would comprise both written and practical exams. A minimum number of ultrasound exams and logbook will be required to be considered competent.
• The SVT would receive backing of the VS and Royal College of Surgeons to fail individuals if they did not pass the course and were not deemed competent following training. The Royal College of Surgeons would not support or endorse the use of ultrasound by any surgeon not considered competent.
• The programme the SVT are proposing will protect patient safety and may in fact lead to improved patient care in the out of hours setting as limited ultrasound exams would be available when the daily service is closed.
• Any surgeon undertaking ultrasound training will be required to maintain their practice and CPD.
• Any centre unable to carry out this training due to resources would not be ‘forced’ to provide training. Training centres may be established on a regional basis and those willing to undertake this training will be encouraged and supported financially.

The basic limited ultrasound scans would include;
• Detecting an aortic/popliteal aneurysm for use in out of hours situations
• Marking venous junctions before surgery, when a full diagnostic scan has already been performed
• Checking for graft patency (not a full graft scan) to exclude occlusion
• Intraoperative ultrasound guidance for endovascular procedures
• Jugular and femoral vein identification for cannulation
• Possibly limited venous exam to exclude proximal DVT
• Ankle waveforms and accurate ABPI

It would not include
• Carotid and vertebral artery duplex
• Diagnostic varicose vein or below knee DVT duplex
• Lower limb arterial duplex
• Full lower limb graft duplex

Going forward, the plan is to design a written and practical course and examination program. Following this the initial ten candidates for the pilot studies will undertake training and exams. The cost of the process will be tracked in detail to allow future planning for funding. Once we have the initial training and exam format the SVT committee will inform the membership of the details and seek further feedback at this stage.

It is important to be aware that vascular surgery and its practices are changing and already the VS has changed its name from Vascular Surgical Society to the Vascular Society. The way the services for vascular ultrasound are delivered and to whom they are delivered will also undoubtedly change but these changes should not threaten our role in the care of the vascular patient. It is our job as the executive to inform and involve our members to ensure the future development and progress of our profession through these changes and beyond.

The Executive Committee

1) Yes 2) Yes 3) No
4) My main concerns are that we are able to ensure that training only takes place in centres where there are sufficient staff of an appropriate level of experience to provide this training without any adverse effect on either clinical service provision or on the ability to provide training for vascular scientists as a first priority. How many such centres are there likely to be at a time when clinical pressures are on the increase and training of vascular scientists has never received any formalised central funding? I also feel that full funding would have to accompany any surgical trainee for these proposals to be viable and sustainable in the long-term.

Please post your feedback, suggestions and comments on the proposals the more input we get from the membership the better the end result will be. We all lots of ideas and experience of how this might work so please take some time to put them down!

1) yes 2) yes 3) not at present

My main concern is that surgeons will be able to spend the time getting the practical training, the meetings with the VS so far have assured us that it will be a priority. My hope is that this will reduce the number of surgeons using ultrasound with no appropriate training.

1)Yes 2)Yes 3)Yes but in order to do so I would probably need another member of staff and an extra room.

How will this affect surgeons who are already carrying out their own ultrasound scans? Will they be expected to go through the training/exam process before being allowed to continue practising ultrasound? I can imagine resistance to this from some surgeons. I know there are vascular surgeons (not here thankfully) who already perform carotid duplex scans. These proposals wouldn't cover them. I assume this means the Royal College of Surgeons would not 'support or endorse' them.

My thoughts on training in vascular ultrasound for vascular surgeons:
1)Yes, 2)Yes, 3)possibly
As an SVT member and accredited vascular scientist I am very grateful for being kept informed, and being asked for my opinion, on the issue of training vascular surgeons in vascular ultrasound. I think that it is fear of the unknown in this area that could lead to a defensive and over-protective attitude in the SVT. If surgeons are going to include vascular ultrasound as part of their formal training requirements, surely it would be better for the SVT exclusively to set-up and regulate a training programme for the surgeons. If the SVT refuses to co-operate we may be forcing the surgeons to turn elsewhere or self-regulate.

If the SVT undertakes this training I think it would foster co-operation between our professions (and allay fears of SVT members) if the SVT and the surgeons proceeded in agreement on the following principles:
- In order to give patients the highest standard of care vascular ultrasound scans should ideally be undertaken by sonographers who have had focussed and extended training in vascular ultrasound (dare I say AVS accredited vascular scientists), and practice vascular ultrasound as their main profession.
- However, diagnostic vascular ultrasound scans may be undertaken by a trained vascular surgeon when a scan is required as a matter of utmost clinical urgency (graft occlusion, aneurysmal disease, femoro-popliteal DVT), and this scan should be of a limited scope to enable the surgeon to make the decision which is required for immediate patient management.
- Non-diagnostic scans which require a low level of expertise due to minimal use of ultrasound controls and functions (i.e. B-Mode scans of veins for pre-operative marking or cannulation) could also be undertaken by a suitably trained vascular surgeon.

The proposal outlined by the executive committee seems to advocate the above rationale for training so I agree with the proposal at this stage. Many thanks to the executive committee for their work in taking such a difficult issue forward and many thanks also for keeping the SVT members updated.

1) Yes 2) Yes 3) unknown

I have to agree with Bridget that it's nice to be asked opinions and also it's better for us to do it than they go elswehere. However Rachel and Elaine mention the surgeons having time to do it and the vascular Labs having the nos. and the resources to fulfill their requirements. Lab efficiency is not only going to be affected by time needed for the surgeons but also for new recruits who will be needed to fulfill this training proposal. However if full funding and backing from the RCS / VS is provided I think on the whole it's a good idea -as long as it's basic and in 10 years they're not wanting to do the whole lot.

1) unsure 2) yes 3) yes

At Southmead we are already in the process of training a surgeon in haemodialysis access scanning. He is undertaking the Pg CERT in medical ultrasound at UWE. It is a part time course (run by Antonio Sassano) in which the technology aspects of ultrasound are covered along with a negiotiated set of vascular ultrasound scans. Would it not be a sensible to use the universites to provide the formal academic training and qualification whilst training the surgeons in the vascular labs. Creating a new standalone form of accreditation specifically for surgeons seems to be a case of re-inventing the wheel, some universities can already offer a bespoke postgraduate ultrasound course (UWE - negotiated speciality). Also the PG CERT is a qualification that is recognised internationally, the SVT accreditation is not (I believe this is correct)

1) yes 2) yes 3) yes (with funding!)

Whether we like it or not, surgeons will be doing more and more of their own ultrasound scanning. I think it only makes sense that we as experts in the field provide them with guidance to ensure that proper training is under taken to perform the limited scanning that is being proposed. These sorts of scans take us minutes to do, but tie up valuable slots in our workload schedules. Surgeons could easily perform these limited scans at the time of consultation to quickly get answers to questions which will facilitate patients being treated quicker. My main concern would be ensuring that they do not attempt to practice outside their scope of training and that very clear guidelines are set up AND enforced by the VSS (or appropriate body).

Of course the other issue is resources. We currently have a trainee CVS and find it difficult enough to devote the appropriate one on one training time with senior members of staff and limited machine time. Training a trainee CVS provides value for the department as the more time you spend with them the sooner they will be able to contribute to the overall workload of the department. This will not be true with surgeon training, not directly in any case. If anything it will increase waiting times and put more pressure on CVS staff. Therefore, it will be essential to have funding towards additional equipment and staffing. However, even if additional funds are made available where will we find the trained staff to fill new positions? We have trouble enough just trying to find people to fill current positions.

1). Yes 2). Yes 3). Yes (funding, staffing levels and time allowing)

Time, money and staffing levels etc have all been discussed at length but on a positive note, I feel that the knowledge we could obtain from the clinical perspective of a trainee surgeon will prove to be of more value to our current expertise. Unless, of course, you know their job fully inside out as well as your own!