RG3 Appendix G: Examples

Examples of current difficulties in optimally meeting curricular objectives

A specific general surgery example

The specific areas where a general surgical trainee's training is lacking in public hospitals in NSW are:

• Consulting on new referrals and follow up cases. There are only a few units that have consultant supervised out patients where a trainee sees new referrals and does regular follow up reviews in a supervised fashion. The majority of terms have no consultant supervised clinics.
  
  
• Out patient proctology: Most out patient proctology is done in private rooms. Therefore the trainees have very limited exposure to training in the assessment of common conditions that present with rectal bleeding.
  
  
• Barastatic surgery: Currently the only area that has barastatic surgery in the public is John Hunter. This is a growing area of general surgery with virtually no or very limited access for trainees in the public hospitals.
  
  
• Minor operative procedures: Minor procedures such as removal of skin lesions, in grown toe nail surgery, sebaceous cysts are really done in larger public hospitals. These are good operations for the most junior of surgical trainees to develop their elementary technical skills.
  
  
• Endoscopy: Currently it is very difficult for trainees to complete their endoscopy training numbers in NSW. This is particularly for gastroscopy, but colonoscopy is becoming more difficult. The training numbers are determined by the conjoint committee for endoscopy training

A specific orthopaedic surgery example

Below is a list of common procedures provided by a specialist trainee in orthopaedic surgery of which they believe that they have not seen/done adequate numbers of during their training. This is not an exhaustive list, nor is it necessarily representative of their colleagues (as they may have had different experiences); it provides an example of one trainee’s experience:

• Anterior cruciate ligament reconstruction- especially different techniques
• Posterior cruciate ligament reconstruction
• Arthroscopic shoulder stabilisation
• Arthroscopic rotator cuff repair
• Tennis elbow release
• Foot surgery-eg:
  • bunion procedures
  • hammer/curly toe correction
  • subtalar arthrodesis
  • ankle arthrodesis
  • plantar fascia release
  • ankle arthroscopy
• Hand surgery-eg:
  • trauma
  • Dupuytren's release
  • MCP/IP arthroplasty
  • reconstructive procedures for rheumatoid hand
  • de Quervains release

There are some areas that are specialised and the trainee would not expect to have seen much of them. That said, they have seen little or none of the following:

• Elbow arthroscopy
• Elbow arthoplasty
• Ankle arthroplasty
• Wrist arthroscopy
• Hip arthroscopy

Remembering that over 50% of surgery is now done in the private sector, even if some of the above surgery is done on the public sector there is no doubt that there is plenty of scope for exposure to these cases in private.

A specific rheumatology example

Most accredited rheumatology advanced training sites in Australia offer a well supervised program of training. It is recognised that no one unit has the expertise to comprehensively cover the complete spectrum of rheumatic disease. Accordingly it is compulsory for all advanced trainees to spend part of their core training at more than one site.

Even with this caveat it has become apparent that there are some areas of core curriculum that are not well covered at teaching hospital public clinics or in the in-patient service. Each advanced trainee is required to submit an audit of 2 months of their clinical exposure each year. Over 50% of the patients have inflammatory rheumatic disease. There is an under-representation of patients with osteoarthritis, soft tissue rheumatism (eg tennis elbow and frozen shoulder), chronic pain syndromes and sports medicine.

By contrast, in most private rheumatology consultant practices there is a far greater proportion of patients with osteoarthritis, soft tissue rheumatism and chronic pain syndromes. Most advanced trainees in rheumatology will ultimately become private practice consultants. To provide them with a more comprehensive training program, which includes soft tissue rheumatology, as required in the curriculum, it would be advantageous if advanced trainees could spend some of their training in private practice. Furthermore this would provide an opportunity for them to be exposed to the work environment in which they are likely to practise when they become private consultants.