Reduction in juniors' hours abolishes concept of continuity of care

EDITOR—The gloating editorial by Pickersgill, the chairperson of the BMA's Junior Doctors Committee, convinces me that the BMJ is now the magazine for the coffee table of the politically active lily-livered doctors who populate the NHS.1 The smile will be wiped off Pickersgill's face if ever he is unfortunate enough to need an operation.

The reduction in junior doctors' hours does not satisfy trainee surgeons' need for operative experience and abolishes the concept of continuity of care. All surgeons (trainees and consultants) understand that a patient deserves and requires continual care by the same firm for the duration of his or her admission. Pickersgill and others need to realise that trainee doctors' needs differ across the specialties and that many other professionals work long hours. It is time that the senate of the Royal Colleges of Surgeons said no to Europe's directives.

Profession needs to modernise surgical training

EDITOR—To ensure better surgical training in shorter hours1 a more structured and focused approach must be adopted. With the introduction of the new deal, Calman report, and European working time directive, the time available to train a surgeon is now reduced by more than two thirds. Further reductions in working hours threaten to jeopardise the effective continuation of patient care and compromise training, resulting in inexperienced surgeons. Fundamental reform must now take place to guarantee high surgical standard.

We must separate service provision from training and learn from the healthcare systems in the United States and Europe, where qualified physician assistants (professionally trained non-medical staff) are employed routinely to share the workload with the junior staff.

Trainers who are willing to initiate change must give a strong, enthusiastic lead in improving training, which has long been unstructured, repetitive, and at times irrelevant to the specialty ambitions of trainees.2 The standards for surgical practice should be clearly monitored and enforced, and frequent formal independent assessment, such as the record of in-training assessments and assessment by the specialist advisory committees, will help. It is essential that both trainers and trainees are assessed, with the royal colleges encouraging all consultants to improve their training abilities. Good trainers should be recognised, and bad ones should be excluded from training programmes.

The organisation of theoretical training (at local or regional level) should ensure that specific topics are taught in coordinated lectures or courses, when trainees from the same deanery are free from clinical commitments. During practical training, ward rounds and outpatient clinics should be educational. In addition, trainees must have hands-on experience in the operating theatre, with proper supervision, instruction, and practice. This may be difficult to achieve in the NHS, which is already limited in time and resources. Consequently, an increased amount of training in surgical skills has to be done with simulators (for example, latex models of organs, laparoscopic boxes), anaesthetised animals (for laparoscopic and endovascular procedures), or computer generated virtual reality (for example, laparoscopy, endoscopy).3 Such facilities must be widely available to all trainees.

Finally, the assessment of operative skill needs to become more objective and independent.4 Assessment methods (such as the objective structured assessment of technical skills or the Imperial College surgical assessment device) are already available. Detecting underperformance early would allow further training and guidance. We need to reappraise, reform, and modernise surgical training rather than blame Europe for cutting junior doctors' working hours.