1. The Broad Context of Change Modernising Medical Careers (MMC) (reduction in time to consultant post) Government Targets for Elective Surgery European Working Time Directive (EWTD) (down to 48 hrs a week in 2009) Growth of sub-specialties Intercollegiate Surgical Curriculum Project (ISCP)

2. Effects of these changes Less time for training, both for trainees and for trainers (effect of targets and EWTD) Providing continuity of patient care with a more fragmented workforce (with limited experience of the full patient journey) Providing continuity of training when trainees and their trainers are only intermittently scheduled to be in the same place at the same time (move to a shift system)

3. Contexts for Learning Theatre for elective surgery Theatre for emergency surgery and trauma Clinics for outpatients Hospital wards Simulators, Models, Recordings Lectures, Journal clubs, Audit meetings Assessments and Portfolios

4. Key Factors for Quality time spent in each setting quality of relationships within that setting the balance between settings appropriateness of the work allocated quality and timing of advice and feedback opportunities for enhancing their understanding of surgery sustaining a sense of purpose and progression

5. Current learning status Elective surgery gets most time from ST3 on, but is retarded by lack of access and loss of training lists Emergency surgery and trauma get very little training from ST3 onwards Clinics no longer have training lists Ward-based learning is rarely planned from ST1 onwards

6. Surgical Coaching Enhanced form of work-based learning Focused on similarities and differences across cases with the same condition(s) Use of still pictures, recorded material and bits of evidence to generate understanding without having to communicate by words alone Add case information to prolong trainees, knowledge of patient pathways Makes it easier to develop more detailed learning trajectories

7. Addressing the problems A risk analysis of the current situation to increase the collective understanding of all the stakeholders Piloting new approaches to the organisation of surgical training within hospitals, with appropriate backing from the NHS Training of individual surgical trainers Training of surgical teams in all the settings discussed above

8. Risk analysis and organisational response: a case study in Trauma All deaths reviewed in open forum with a range of consultants and trainees Errors passed up for peer review group for remedial actions to be sanctioned Most changes are educational or organisational Services reorganised to create: A consultant led trauma service Dedicated wards for trauma patients A review of how they handle every single aspect of a patient’s care. Errors reduced from 9% to 1% over 3 years

9. Distributed Apprenticeship Trainees supported by more than one trainer Smooth handovers from one trainee to another Use of mediating artefacts (pictures, portfolios and recordings) related to patients to establish inter- trainer trust and understanding Engagement with and feedback from trainees Time and initiative are needed to develop sufficient coherence