Effects of the EWTD on anaesthetic training in the UK

I have undertaken a review of the training implications associated with the implementation of the European Working Time Directive (EWTD) on year 3 specialist registrars (SpRs) in my department. I have compared this with the rostered work pattern of senior registrars (SRs) in the department in 1991, as there is a general perception among more senior anaesthetists that the amount of ‘in-theatre’ training and experience has changed over this time period. Despite the different time period comparisons, some of the findings are similar to those obtained by Sim, Wrigley and Harris (Anaesthesia 2004; 59: 781–4), although there are also important differences. The data was obtained by reviewing 13 consecutive weekly rotas of an SR working in this department in 1991, and those of one of our current EWTD compliant, year 3 SpRs. Both rotas are representative of the work undertaken by trainees of similar seniority in 1991 and 2004. These figures have been used to predict their respective activity for 1 year. Six weeks of annual leave and 2 weeks’ study leave have been included for both trainees. Table 1 summarises the results obtained and shows that the EWTD-compliant SpR will have approximately one theatre session per week less than the SR working in 1991. This is an identical figure to that obtained by Sim, Wrigley and Harris, although their comparison was immediately pre- and post-implementation of EWTD compliant rotas. Table 2 gives an indication of the differences in total hours worked in 1991 and 2004. I have allocated 4.5 h for a list, with the total hours given to the nearest 50. While this is not an exact science, I think it provides a good estimate of total hours worked and it shows that 2004 EWTD-compliant SpRs work approximately 73% of the hours worked by SRs in 1991. Over a 5-year period, this equates to approximately 4000 fewer hours of training and experience which, while significantly less than the loss estimated during surgical training [1], is nevertheless a significant reduction. The greatest component of this difference is the on-call time, which provided a significant amount of clinical experience to senior trainees ‘pre-Calman’. While operating between midnight and 08.00 h was declining by 1991, following the findings of the Confidential Enquiry into Perioperative Deaths in 1987 [2], there was still more out-of-hours operating being undertaken than is currently the case. It is recognised that operating in these hours is inappropriate except for life- and limb-threatening conditions, but nevertheless, it provided good experience for senior trainees, most of whom had the necessary advanced skills to deal competently with the clinical situations that arose, with appropriate consultant back-up. The reduction in hours spent in training now is compounded further by the fact that, in this department at least, activity has decreased (from 35 000 to 25 000 cases per year between 1991 and 2004) while consultant and trainee numbers have almost doubled – I am sure this is not unique to our department. While some of this decrease is due to the increasingly complex case mix, the overall clinical experience (which I believe is an important part of senior training) is reduced. Does all this matter if Schools of Anaesthesia provide high-quality classroom teaching, better structure to training and better assessment, to compensate for reduced hands on theatre experience? Goodman stated that ‘no amount of classroom teaching can compensate for practical experience’[3], a view I support completely, while current trainees express similar concerns informally. Indeed the reduction in clinical experience associated with the 4 year SpR training programme was one of the reasons given for increasing the SpR training time to 5 years in 1999 (A proposal from the Royal College of Anaesthetists to change the SpR training in anaesthesia from 4 to 5 years. Royal College of Anaesthetists, 1998). The introduction of EWTD-compliant rotas has probably resulted in a return to levels of clinical experience closer to those obtained by those who went through the 4 year programme. The delivery of hospital services is changing and the implementation of the EWTD is one of the reasons for such change. In 1993, the Calman Report [4] provided comprehensive recommendations to ensure future medical training in the UK complied with European legislation. The recommendations have, to a large extent, been implemented in our speciality and as a result training is more in line with the rest of Europe, although it remains one of the longest periods in the world. It is envisaged that training in the future will be seamless, leading to a Certificate of Completion of Training (CCT) [5], with a greater proportion of more advanced training taking place following acquisition of a CCT [6]. Does this not imply that the CCT will lead to a permanent post that is closer to the European ‘specialist’ model than the more autonomous UK consultant post of today? I believe it does, and if this is the case, the concerns about the lack of experience at the end of training are less important as a ‘specialist’ model becomes a reality. Whatever the nature of the future specialist grade, it is essential that the speciality does not allow training time to be eroded further. The great challenge is to ensure that good models of training are developed around EWTD-compliant rotas. I do not think this is the case at present as the implementation of the EWTD has been precipitate in many instances and its effect on training has yet to be fully determined.