The impact of surgical care practitioners on surgical training
Authors: C A Bruce, I A Bruce, L Williams
Journal: Journal of the Royal Society of Medicine (2006)

The emergence of surgical care practitioners over recent years is considered to be a ‘mixed blessing’ by the majority of specialist registrars. In the National Curriculum Framework for Surgical Care Practitioners document,1 a surgical care practitioner is defined as:


'... a non-medical practitioner, working in clinical practice as a member of the extended surgical team, who performs surgical intervention, pre-operative and post-operative care under the direction and supervision of a consultant surgeon'.


Most trainees understand that the work load of surgical teams will continue to rise in the face of falling numbers of specialist registrars and other junior doctors, and that steps must be taken to address any associated deficiency in service provision. Properly trained, suitably experienced surgical care practitioners could have an important role to play as part of the ‘modern’ surgical team. Surgical care practitioners would be drawn from the existing pool of nurses, operating department practitioners and allied health professionals. It is envisaged that they would have a significant role in the pre-operative assessment, examination and preparation of patients for theatre, as directed by agreed guidelines and protocols.1 For example, the preparation by a nurse practitioner of patients for diagnostic cardiac catheterization has been demonstrated to be safe, in a randomized controlled trial, compared with the established system of preparation by a member of the junior medical staff.2 Surgical care practitioners would also perform certain technical and operative procedures, in addition to acting as assistant to the operative surgeon.1 The use of an appropriately trained nurse, as first assistant to an operating consultant, has not been demonstrated to compromise results in low-risk cardiac surgery cases.3 They would be expected to play an active role in postoperative care and they would also practice within the normal out-patient department, including assessing patients.1 The successful use of a nurse practitioner, in what amounted to a semi-independent follow-up breast clinic, has been presented in a previous issue of this journal.4

However, from a surgical trainee's perspective, several concerns persist, demanding attention prior to the expansion of the surgical care practitioner grade. First, surgical care practitioners should have a positive impact upon service, without diluting the already much reduced surgical exposure available to trainees. In addition, the restraints forced upon surgical training by the European Working Time Directive and the impact of Modernising Medical Careers will further truncate surgical exposure. Steps must be taken to ensure that the role does not further limit possible theatre experience. The curriculum framework document states that surgical training will not be compromised.1 However, we have reservations that the proposed use of surgical care practitioners to support junior surgeon training sessions, or their being used to provide delegated care of patients during consultant-led training sessions, would make a significant impact on training opportunities. It is commendable that the general public insist on an increased level of surgical quality, but that is far from guaranteed if the next generation of surgeons must compete for surgical experience with other healthcare professionals. For example, it is likely that surgical care practitioners and junior surgical trainees will be trained in the same basic surgical procedures; skills that the surgical trainee will be expected to master quickly in the face of reduced surgical training. Consultant delivered training of individual surgical trainees will also suffer if consultants are made responsible for the training and subsequent supervision of surgical care practitioners. A shorter length of surgical training must be matched by an increase in quality and intensity, but a dilution of training seems the inevitable result of such competition for consultant time.

In line with medical practice, individual performances should also be scrutinized in a standardized manner. Specialist registrars are regularly assessed within the record of in-training assessment (RITA) framework to assess satisfactory progress and competence. Consultants are required to undertake continued professional development, in addition to appraisal and revalidation. The curriculum framework document1 provides limited information concerning what will be expected, in terms of continuing professional development, and the ongoing assessment of performance, following the completion of surgical care practitioner training. If such practitioners are also to operate on patients alongside surgeons, then their ongoing professional assessments should be similarly standardized and vigorous. Perhaps such assessments should be undertaken by the same professional body.

The level of supervision under which surgical care practitioners are to work also requires clarification. It is now no longer considered acceptable for junior surgeons to operate in adjoining theatres to consultants, performing ‘parallel lists’. Surely, it is therefore contradictory, and unacceptable, for surgical care practitioners with comparable or, as will often be the case, less surgical experience to operate under such a level of supervision. We feel further clarification of levels of supervision is essential.

Up to this point the concerns raised concentrate upon the perceived impact upon surgical training and performance assessment. Of equal importance is the assurance that the patients will be informed exactly who is to operate on them, as part of the process of informed consent. They should be made aware that, although properly trained to an accepted standard, surgical care practitioners are not medically qualified. Patients should be enabled to express a preference to be operated upon by a medically qualified person, without the implied perception that their subsequent care will be prejudiced, or significantly delayed.

Surgical care practitioners could have a positive impact upon various aspects of the efficiency of the surgical team. As detailed by the curriculum framework document,1 their role could include the preoperative assessment and preparation of the patient for theatre. In addition, the organization and liaison skills of an experienced healthcare professional could ensure the smooth running of the surgical unit, with the expected benefit of enhancing the patients' perception of the service provided. 5-7 Such positive impact on service would also, in part, compensate for the removal of experienced surgical nurses from the often undervalued role of the traditional ward nurse.

On a more general note, the proposed title of those undertaking such a role is also a potentially controversial issue. The British Medical Association has noted that the term ‘practitioner’ (particularly when prefixed by surgical) could lead to the patient misconception that the post holder is medically qualified. They suggested that the term ‘surgical assistant’ should be adopted instead, in keeping with practice overseas.8

Although, undoubtedly, there is much careful discussion and clarification still to be done, we believe that surgical care practitioners have a potentially valuable role to play in the surgical team. Not as independent, or semi-independent, specialists performing routine operations in order to shorten waiting lists, but as healthcare professionals who can bring experience from their unique backgrounds to a well-defined role within the surgical team. Their role should not compete with established surgical practice and training: rather it should improve the patient's experience, whilst making the service more efficient.