Rotation History

 

New PictureThe History of the Percivall Pott Club

In the early days of the National Health Service, in the decade or two following the Second World War, surgical training and indeed postgraduate training in general, was extremely haphazard. The apprenticeship system still largely prevailed. The aspiring surgeon worked exclusively with an individual Consultant, or perhaps two Consultants on a “firm” for the whole of what would now be called Higher Surgical or Specialist Training. After completing pre-registration posts, which became compulsory around about the early 1950’s, and perhaps one or two more junior appointments, the trainee would compete for a Senior Registrar post almost exclusively in a teaching hospital, and remain there until appointed to a suitable Consultant vacancy when considered ready to assume Consultant responsibility!

Curious as it may seem, Registrar posts were technically service posts and not regarded officially as training posts and were by and large in the District General Hospitals. They were regarded as providing the holder with general professional experience before settling into General Practice or another speciality. Frequently they were occupied by overseas graduates wanting to gain good paid experience before setting up practice in their homelands. There were no Registrars in General Surgery at Barts until quite recently and the Senior Registrars retained the title Chief Assistant.

With increasing specialisation within the various branches of surgery and the demise of the true generalist, it became apparent that the surgeons of the future needed to work with more than one master and furthermore, valuable experience was to be found in many of the non-teaching hospitals where most of those in training would eventually work.

Movement between firms in the teaching hospitals, usually on an ad-hoc basis, started and then straight exchanges between trainees in the teaching and non-teaching hospitals occurred, but there were no formal rotations. Perhaps the training at the RNOH came nearest to a rotational programme where both Registrars and Senior Registrars moved every six months to another firm within the RNOH or one of four hospitals outside. The moves, however, were not pre-planned and of course there was no formal link between Registrar and Senior Registrar posts, some Registrars leaving for Senior Registrar posts elsewhere, and Registrars from elsewhere coming into Senior Registrar posts in the RNOH. Even this relatively regulated system was neither comprehensive nor planned and the experience gained was often quite repetitious, trainees often repeating the experience as Senior Registrars that they had gained as a Registrar and at the same time missing out on several branches of Orthopaedics.

Clearly this type of arrangement, which was far from typical, was unsatisfactory. Galvanised by Professor Frank Holdsworth [later Sir Frank], a member of the Council of the Royal College of Surgeons, the four Surgical Colleges of the British Isles established the Joint Committee for Higher Surgical Training [JCHST] and the Specialist Advisory Committees [SAC’s] in the major surgical specialities, which in 1968 recommended to the Colleges the introduction of formal programmes of higher surgical training.

The Specialist Associations had been a party to the preliminary discussions and the late Charles Manning, a Consultant Orthopaedic Surgeon at Barts, was Secretary of the BOA at this time and so had inside knowledge of the proposals. Specialist training in Orthopaedics would occupy a minimum of four years, of which two could be spent in recognised Registrar posts, and two in Senior Registrar posts. 50% of the time should be spent in posts with a predominantly emergency workload and 50% in posts dealing with elective Orthopaedics. Paediatric Orthopaedics and hand surgery were mandatory requirements, not necessarily as separate individual posts, but as a significant part of the overall training programme.St_Bartholomews_Hospital-300x200

With this knowledge we set about devising a programme which would meet the requirements of the SAC. There was no shortage of hospitals wishing to join us at Barts when they learned of our quest for partners but as is so often the case, decisions rest on personal contacts and connections. Geoffrey Fisk at Harlow was an eminent hand surgeon and both he and his colleague Henry Poirier were Barts men. Furthermore, the Princess Alexandra Hospital was in a new town with a young population, not burdened with the geriatric Orthopaedics commonly found in the inner cities.

Old-N-and-N-300x187The Norfolk & Norwich Hospital, although renowned for hip replacement, had a predominantly emergency workload, and major trauma at that. Furthermore, Ken McKee was another Barts man. The Queen Elizabeth Hospital in Hackney had recently been administratively linked with Great Ormond Street, where I was working as a long-term locum, and so children’s Orthopaedics would be adequately covered and both Charles Manning and I had appointments at the Royal National Orthopaedic Hospital to facilitate postings to a prestigious postgraduate centre for exposure to the more specialised aspects of Orthopaedics.

Over the course of about a year posts at these hospitals were assimilated into the Barts training programme, unique at that time in establishing a formal rotation through a sequence of posts with increasing responsibility, rather than the straight exchanges which were customary at that time. For example, Chang Chen, who was already a Senior Registrar in Norwich, was incorporated into the programme to provide a vacancy there and a vacancy at the RNOH was created by incorporating David Dandy into the programme. Howard Smith had already been appointed a Registrar at Barts and so it was a question of appointing him to a Senior Registrar post through a formal Advisory Appointments Committee. The posts at Harlow and at the Queen Elizabeth Hospital proved to be no problem because they were new posts, which were created specifically by the Department of Health as rotational posts. It was indeed planned progressive and continuous training [PPC], by coincidence the initials of the Percivall Pott Club. There was, however, one further stumbling block to planning a comprehensive programme, namely the promotion from Registrar to Senior Registrar. Senior Registrars, unlike Registrars, were appointed by a statutorily constituted Advisory Appointments Committee, after due advertisement in the medical journals. Registrars were appointed by internal hospital committees, an arrangement which continued until the recent introduction of seamless training by the former Chief Medical Officer, Sir Kenneth Calman.

The problem was overcome by exploiting a loophole in the regulations, aided and abetted by Dennis Ellison-Nash, the North-East Thames Postgraduate Dean and a General Surgeon at Barts, [President of the Pott Club in the mid-1980s]. Although appointed to Registrar posts, the trainees entering the Barts training programme were appointed by a properly constituted Senior Registrar Appointments Committee which enabled the trainee to be upgraded to Senior Registrar when a vacancy occurred, without further interview, subject of course to satisfactory progress. To this end, six-monthly assessments, albeit less complicated than those currently in use, were introduced, another revolutionary innovation which is now universal.

The programme was established by 1969 and was, I believe, the third to be recognised by the SAC, Edinburgh being the first, it being no coincidence that the first Chairman of the SAC was Professor J.I.P. James, the Professor of Orthopaedics in Edinburgh! There were eight posts, each of six months’ duration and by another coincidence the current President of the Percivall Pott Club, Howard Smith, was the first trainee to complete the whole cycle. For the rotation to succeed, two trainees were required to leave the programme every year and this sometimes caused problems which were solved in a variety of ways.

As the trainees left the programme to take up Consultant appointments, such was the camaraderie that had developed between them, that they decided they would like to maintain the friendships that had developed during their training. It is against the background of the far-reaching changes in surgical training which took place in the late 1960’s that the Percivall Pott Club came into being and held its inaugural meeting at Barts on 3rd November, 1973. It seemed appropriate to adopt that name, for Pott’s contributions to Orthopaedics are well known and surprisingly there was no other club or organisation at Barts perpetuating his name.

Initially, the only full members were those who had completed the Barts training programme, or a substantial part of it. Others, such as the trainers, were honorary members. The members would elect the President for the year, someone associated with Barts or the training programme, whose only duty would be to deliver a presidential address and to preside at the ensuing dinner.

A meeting would be held each year at Barts on a Friday afternoon in the autumn, largely given over to presentations by the trainees after a brief business meeting. The meetings would be organised by the Senior Registrar in post at Barts at the time, with the object of giving the trainees experience in presenting their research, either completed or in progress, before perhaps presentation at major meetings or publication. At the same time, it would bring the senior members up to date, and as time passed would also give the junior members of our speciality the opportunity of meeting some of the well-known up and coming Orthopaedic Surgeons. It is worthy of comment that the current President of the BOA, the President Elect, the Secretary, the Assistant Secretary, and the Chairman of the SAC, are all members of the Percivall Pott Club. The BOA President and the President Elect are also elected members of the Council of the Royal College of Surgeons. Another member of the club is a member of the Court of Examiners. Let us hope that the current and future members of the club show comparable commitment to Orthopaedics in particular and surgery and the profession in general.

A biennial summer orthopaedic meeting was established at Harlow independently of the Percivall Pott Club and probably before its inception, and this has become incorporated in an informal way into the Pott Club calendar, alternating with a summer meeting at Norwich in which trainees particularly are given the opportunity to emphasise their achievements.

The Percivall Pott Club was primarily formed to provide an opportunity for past and present trainees to meet together socially and professionally and for their mutual benefit and I believe the founding members are owed a debt of gratitude by all those who followed. It is incumbent upon the present trainees to maintain the traditions and standards of the past, not least by their contributions and presence at the meetings.

Alan Lettin

(2011)