Medical Training Review Panel: thirteenth report
Royal Australian College of Surgeons
Training ProgramThe Royal Australasian College of Surgeons (RACS) Surgical Education and Training (SET) program requires five to six years of specialist surgical training in one of nine specialty training areas.
Surgical training is primarily a 'hands on' learning experience. The training programs are similar to an apprenticeship system, with a trainee progressing through an incremental learning structure that peaks at the point of the award of fellowship. The trainee’s hospital rotations are closely monitored by supervisors to ensure that sufficient and competent experience is obtained in specified surgical procedures.
The college's vocational training programs are designed to provide progressive, supervised training and experience in all aspects of clinical assessment, decision making and patient management, including preoperative care, postoperative care, postoperative follow up and operating room responsibility. The trainee is expected to assume increasing responsibilities in each of these areas as he/she progresses through the program. As the operative skills of a trainee increase over the period of the training program, there is a commensurate decrease in supervision.
The training program in each specialty is designed to allow the surgical trainee to achieve competency in the domains of medical and technical expertise, clinical judgement, communication, collaboration, management and leadership, health advocacy, scholar and teacher, and professionalism, leading to competent, independent practice as a specialist surgeon.
Surgical trainees choose from the nine specialty areas described below.
General SurgeryGeneral surgery, despite its name, is the surgical specialty that focuses on surgical treatment of abdominal organs, and often include endocrine surgery, breast surgery and hernia surgery. Training includes delegated operating responsibility commensurate with developing skills and experience.
Cardiothoracic SurgeryCardiothoracic surgery requires two years of training in 'surgery in general' prior to cardiothoracic training to provide the trainee with broad experience in general surgical procedures. Trainees are then directed to particular positions to ensure that adequate experience in all designated areas of cardiothoracic surgery, that is, surgical treatment of diseases of the heart and lungs, is achieved.
NeurosurgeryThroughout their training, trainees are concerned with management of all aspects of the central and peripheral nervous system. Trainees are also expected to have some experience in the management of trauma. During neurosurgical training, responsibilities for clinical and operative work are steadily increased. Later in the program, trainees are expected to gain experience in
Orthopaedic SurgeryTraining in orthopaedic surgery is designed to provide progressive experience in operating responsibility, as well as ensuring adequate training in clinical assessment, investigations and non-surgical management of orthopaedic problems, that is, problems of the musculo-skeletal system, whether they are congenital conditions or caused by trauma or degeneration.
Otolaryngology, Head and Neck SurgeryAt the conclusion of the program, it is expected that trainees will be familiar with all aspects of medicine and surgery involving the main subdivisions of the specialty, namely otology, rhinology, laryngology and head and neck surgery. Experience is expected to include a balance of inpatient and outpatient, adult and paediatric cases. Trainees are expected to become competent otorhinolaryngologists. Trainees should remain no longer than one year in any one approved training post.
Paediatric SurgeryTraining in paediatric surgery encompasses anomalies and disease processes involving most body systems in infants and children of all ages with surgical disorders. Paediatric surgeons diagnose, treat, and manage children’s surgical needs, including: surgical repair of birth defects, serious injures in children, childhood solid tumours, conditions requiring endoscopy and minimally
invasive procedures, and all other surgical procedures in children including ambulatory surgery.
Plastic and Reconstructive SurgeryThis surgical specialty encompasses both cosmetic and reconstructive surgery of the face and all areas of the body. Reconstructive surgery is used to improve or correct areas of the body damaged by congenital defects, developmental abnormalities, trauma or injury, infection, tumours or disease. Clinical training is the fundamental component of the training program; these experiences are supported by course lectures and tutorials in each phase of the program.
UrologyUrologists are surgeons who treat men, women and children with problems involving the kidney, bladder, prostate and male reproductive organs. These conditions include cancer, stones, infection, incontinence, sexual dysfunction and pelvic floor problems.
Vascular SurgeryDuring training in vascular surgery, trainees become familiar with all aspects of the specialty, including the assessment of patients and operative surgery. Completion of the vascular surgery modules is a compulsory component of the training program. Experience in the techniques used in vascular laboratories is also required. This specialty focuses on the diseases that affect all parts of the vascular system, except the heart and brain; with emphasis on management by medical therapy, minimally invasive procedures and surgical reconstruction.
Trainee SelectionTrainees are selected, from the beginning of their training, directly into one of the nine specialty training programs. The earliest point at which application can be made for the first year of training (SET1) is during PGY2 with entry for successful trainees in PGY3.
Any person wishing to apply for selection into one or more of the surgical specialties must fulfil all of the generic eligibility criteria, plus the eligibility criteria for the specific specialty or specialties.
There are five general eligibility criteria which apply across all nine specialties. The trainee must:
- have permanent residency or citizenship status of Australia or New Zealand;
- be a graduate of a medical school recognised by the Australian or New Zealand Medical Councils;
- have unconditional registration to practise in Australia or general scope registration to practise in New Zealand;
- have satisfactorily completed PGY1 and be in PGY2 or later; and
- be willing to consent to a full criminal history check, including submission of relevant documentation on request, to enable this to be undertaken.
Trainee AssessmentSET trainees complete rotations in approved surgical training hospitals. In addition, all trainees must complete the Australian and New Zealand Surgical Skills Education and Training (ASSET) course, the Early Management of Severe Trauma (EMST) course, and the Care of the Critically Ill Surgical Patient (CCrISP) course. Early assessment requirements include generic and specialtyspecific basic sciences examinations and generic clinical examinations.
Trainees in SET1 are appointed by the employing hospital at the level that the hospital deems appropriate. The trainees perform clinical rotations in units designated by the specialty in which they are selected as providing career aligned requirements. During this period, there is an increased focus on workplace competency assessment and in-training assessment.
Throughout SET2-6, there are some variations in the assessment requirements between specialties. However, all trainees are required to achieve satisfactory performance in every six-month clinical rotation and must successfully complete the fellowship examination before being awarded fellowship of the college.
Overseas Trained SpecialistsThe processes for assessing the suitability of overseas trained doctors for practice as surgeons in Australia are in accordance with the principles outlined in the:
- AMC application procedures and requirements for specialist assessment;
- AMC/Committee of Presidents of Medical Colleges (CPMC)/state and territory medical boards/Australian Government Department of Health and Ageing/state and territory health departments' Assessment Process for Area of Need specialists: User’s Guide; and
- AMC/CPMC Joint Standing Committee on Overseas Trained Specialists (JSCOTS) Assessment of Overseas Trained Specialists: Template for Colleges.
The specialist assessment of the OTS focuses on education, training, quality, quantity and scope of clinical experience, level of formal assessment including specialist qualifications in surgery, recency of relevant practice and relevant professional skills and attributes in order to determine substantial comparability with Australian standards. The elements of such a test of substantial comparability are that the doctor has an acceptable overseas qualification, acceptable competency according to the RACS list of competencies and acceptable recency and currency of surgical practice.
The assessment tools include a document-based assessment of curriculum vitae, referee reports and log books, a semi-structured interview to ascertain non-clinical competencies, and a period of assessment of clinical practice by oversight or supervision.
The doctor may also be required to present for the fellowship examination. Importantly, there is no implication of equivalence of training or conforming within Australian and New Zealand surgical specialties, which gives the college scope to accept experienced surgeons whose training program may have been different.
The college assesses each international medical graduate on an individual basis, scrutinising a range of documentation supplied by the doctor that covers their education, training, qualifications and surgical experience. If this assessment determines that the applicant is not comparable to an Australian or New Zealand trained surgeon, a written assessment with recommendations is made. Where the written assessment suggests comparability, an interview is scheduled with the applicant.
As a result of the new policies implemented in 2006, assessment panels may recommend a period of assessment of clinical practice by oversight or supervision and/or a requirement to sit the fellowship examination for applicants to achieve fellowship of the college. Where an applicant is deemed not comparable to an Australian or New Zealand trained surgeon, the applicant is required to complete medical registration requirements, including the AMC examinations before applying for specialist training.
AccreditationWith the accreditation of hospital posts for SET, the specialties each accredit specific hospital positions according to the level of training they are able to offer a trainee.
Specialist surgical training is conducted in surgical training posts in which the trainees are supervised and mentored by appropriately qualified surgeons. Accreditation is based on 43 criteria grouped within seven standards as follows:
- Standard 1 - education facilities and systems required;
- Standard 2 - quality of education, training and learning;
- Standard 3 - surgical supervisors and staff;
- Standard 4 - support services for trainees;
- Standard 5 - clinical load and theatre sessions;
- Standard 6 - equipment and clinical support services; and
- Standard 7 - clinical governance, quality and safety.
Inspection teams are nominated by the specialty board and jurisdictions are invited to nominate a representative as a full member of the team. On completion of an inspection visit, the team will prepare a draft report containing the recommendation. This report is sent to the hospital for comment on factual matters. The final draft report is then prepared for review by the specialty board, which makes a recommendation on accreditation to the Board of Specialist Surgical Training.
The recommendation of the Board is incorporated into the final report and the decision communicated to the hospital.
Hospital accreditation is regularly reviewed. It is recognised that facilities at different hospitals positions will vary throughout a training program and the specialties maintain a constant vigil as to the efficacy of each position.