Monday, 27 October 2014

Mind what you wish for!

Cardiothoracic Surgery in the UK is, as far as the General Medical Council and the Colleges of Surgery are concerned, a single specialty.
Trainees are exposed to both cardiac and thoracic surgery during their 6 to 8 years of training. In their final assessment, the exit exam for the FRCS(CTh) degree, candidates are tested in both. My specialist register entry states that I am an expert in Cardiothoracic Surgery.
In recent years, evidence of better outcomes when certain operations are performed in large numbers in individual units or by individual surgeons, has emerged. It is unsurprising therefore that a debate has arisen whether further specialisation should occur and the two halves of cardiothoracic surgical specialty should be separated.

Appointment of separate cardiac and or thoracic Consultant surgeons has taken place for many years in the UK. The decision whether to include one or other or both of the specialty responsibilities in the job description has been taken by individual hospitals depending on their needs
Over the past few years, job descriptions for posts that required both cardiac and thoracic input have not been approved by the Society for Cardiothoracic Surgery. This sadly has taken place without much debate unlike the situation in the US where the impact on trainees is being debated. This was never considered in the UK. As a consequence, pure thoracic consultant posts have remained unfilled as they have proved unpopular with many British trainees.
To compound matters, the Clinical Reference Group in Thoracic surgery has stated (?suggested) that from 2016, all cardiothoracic surgeons in England must practice only cardiac or thoracic surgery. For the uninitiated, a Clinical Reference Group is the group of clinicians who advise NHS England on commissioning for Specialist Services. There are over 70 specialist areas and a similar number of CRGs.
This suggestion for accelerated reform has angered many of the units where the majority of lung operations are performed by surgeons who perform both cardiac and thoracic. In fact more lung operations in England are performed by cardiothoracic surgeons rather than pure thoracic surgeons. The additional difficulty of organising on call rotas for both specialties has also been ignored. There are not enough doctors around for separate thoracic and cardiac consultants to be on call. Currently, in many units in England, cardiac surgeons who have not carried out any thoracic procedure for years are on call for thoracic emergencies.
The adverse effects of increasing specialisation in medicine and surgery on both training and planning of health services has been recognised. The latest review on training, entitled 'The Shape of Training' as well as speeches by Simon Stephens the new CEO of the English NHS have featured such difficulties and downside of super specialisation.
The pursuit of perfect outcomes is commendable but a full debate with consideration of all possible unintended consequences should not and cannot be avoided.