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Frequently Asked Questions

The subsections here tell you what we do, what process makes an Orthopaedic Foot and Ankle surgeon, the difference between us and Chiropodists and Podiatrists.

What do Orthopaedic Foot & Ankle surgeons do ?

Foot and ankle surgeons offer comprehensive surgical care for a wide variety of problems, including:

  • arthritis in the foot and ankle
  • sports injuries, especially in the ankle
  • fractures in the foot and ankle
  • foot problems in people with diabetes
  • birth deformities and other foot problems in children
  • heel pain
  • high-arched and flat feet
  • bunions
  • problems with the small toes

Not all foot surgeons do all of the above work. It depends on what other services are available in the hospital: for instance, children with foot problems may be cared for by a surgeon with a special interest in children's orthopaedics.

Most foot and ankle surgeons also do other orthopaedic and fracture work.

Orthopaedic foot and ankle surgeons work as part of a team, including nurses, podiatrists, orthotists, plaster technicians, secretaries and experts in information technology. They also work closely with other medical specialists in diabetes care, arthritis, vascular and plastic surgery. They may work in either the National Health Service or the private sector, or in both.

Most foot and ankle surgeons are involved in the training of junior doctors and often of medical students, passing on their knowledge and experience to future surgeons. They conduct research in both basic science and the clinical care of patients.

Are you the same as Chiropodists or Podiatrists ?

No. Orthopaedic foot and ankle surgeons are fully trained doctors, who have then undergone further post-graduate training in orthopaedic and trauma surgery. In the course of this training they have been trained in foot and ankle surgery. Many have undertaken some specialised training in foot and ankle surgery over and above their main orthopaedic training.

Chiropodists have trained for a diploma or usually nowadays, a degree, in the care of foot problems. While they study some general medical principles, they have not been trained in the diagnosis and treatment of general medical and surgical conditions. They have studied the structure and function of the foot in some detail and have considerable expertise in its special conditions. If they suspect general medical or surgical conditions such as diabetes or poor circulation, they refer the patient back to their own general practitioner.

Chiropodists will generally offer treatment for problems of the skin and nails of the feet, and some are trained in the production of special insoles to improve foot function and comfort.

Basic chiropody training includes only very simple surgery, such as to the toenails. Some chiropodists, or podiatrists, study surgical techniques further and may offer surgical treatment for various conditions. The place of this type of service has not yet been established.

The Society of Chiropodists and Podiatrists is the professional body for chiropodists and podiatrists in the UK.

What Makes an Orthopaedic Foot and Ankle Surgeon?

Surgeons need to be able to perform in differing conditions and circumstances and respond to the unpredictable. They have to make decisions under pressure. They use professional judgment, experience, insight and leadership in everyday practice working in multidisciplinary teams. Surgical conduct is guided by professional standards and values against which the surgeon is judged and his/her decisions and outcomes are evaluated.

Orthopaedic foot and ankle surgeons are medically qualified and their standards of practice are defined by the General Medical Council (GMC). Since April 2010, the GMC has assumed statutory responsibility for all stages of medical education. Prior to this the Postgraduate Medical Education Training Board (PMETB) was the regulator of specialist training. Thus the GMC is the regulator for medically qualified foot and ankle surgeons, through all stages of their training and practice.

The GMC break down medical education into four stages;

1.    Undergraduate medical education

2.    Foundation years

3.    Specialty training

4.    Consultant practice with continuing professional development (CPD), which includes ensuring through revalidation, that doctors remain up to date and fit to practice.

With these processes the GMC aims to protect the public and patients as well as ensuring that medical education and training reflects the needs of patients, the doctor and the service. The documents that cover this extensive area of information are freely available within the public domain.

In this document we outline the progression through undergraduate training to ongoing revalidation for an orthopedically trained foot and ankle surgeon. 

Undergraduate Education

Fundamental to the mission of each UK medical school is the preparation of doctors competent to start work on the Foundation programmes.  Diversity of curriculum is encouraged in medical schools. Medical students need to prove themselves as scientists, scholars, practitioners and professionals. Subjects covered include Physiology, Biochemistry, Anatomy, Pharmacology, Psychology, Sociology and Reproductive Biology. The importance of this broad education is not only to understand the human body and it's response to illness but also the patient as a whole, including the psychological and social aspects of illness.

Each medical school has a responsibility to ensure that the outcomes specified in the GMC’s document “Tomorrows Doctors 2009”1 are met by students on graduation. The graduates must also meet the requirements of the EU Medical Directive. Article 24 of this Directive states that the period of basic medical training must be at least five years, or 5,500 hours, of theoretical and practical training provided by, and under the supervision of, a university.

Graduation is followed by provisional registration with the GMC.  All doctors need to be aware of and follow the GMC’s Fitness to Practice guidelines in their professional practice and conduct.

Foundation Years

Foundation year one (FY1):  After qualification the provisionally registered doctor enters Foundation year one. This allows the newly qualified doctor to commence practice within a learning environment.  At the end of this year the doctor is placed onto the full Medical Register, subject to the necessary competencies being completed.

Foundation year two (FY2): In this year the registered doctor obtains further experience in a broad range of specialties, in advance of choosing the specialty of their choice.

Specialty Training

The prospective Orthopaedic foot and ankle surgeon would be required to gain surgical experience at the FY2 stage and beyond. Trainees will undertake between two and four years of Core training in various surgical specialties. Core is 2 years and is at CT1/CT2 level for most trainees; ST1/ST2 (or run through) occurs in Scotland .Academic trainees are also on run through these posts are for 3 years. The MRCS examination is taken at the end of this period and is deemed essential to entering into Trauma and Orthopaedic specialty training at the ST3 level.

Entry into a Training Programme at ST3 level is a competitive process. This process is now centralised nationally to ensure fairness and transparency.

Trauma and Orthopaedic Surgery is a specialty dealing with trauma, congenital and acquired disorders of the bones, joints and their associated soft tissues, including ligaments, nerves and muscles. A programme of training in Trauma and Orthopaedic Surgery is currently 6 years in duration and this in turn is in two phases.

ST3-6: This period of training takes the trainee to an intermediate level, usually involving six-month specialist attachments in the sub specialist areas. The trainee is expected to acquire the level of knowledge, skills and professionalism expected of a consultant surgeon practising in the generality of orthopaedics.

ST7-8: This stage entails a further period of focused training and experience in one or more sub-specialist areas as well as trauma care at an advanced level.

The Curriculum

The orthopaedic surgical curriculum has been designed around four broad areas (content/syllabus, teaching and learning, assessment, systems and resources) to provide high quality and safe surgical care for patients. This curriculum maps to the GMC’s principals of good medical practice and is regulated by summative and formative assessments.

The British Orthopaedic Association (BOA) in 2007 published a competency Based Curriculum2 for specialist training in trauma and orthopaedics, which was approved by the then regulator, PMETB. The present version of the T&O Curriculum approved by GMC is the 2010 version. A complete revision was submitted at the end of 2012 and should be approved to be operational by August 2013.

Assessment

The GMC remains responsible for standards of training but delegates this responsibility to local Deaneries with the Royal Surgical Colleges providing support and externality. The curriculum is competency based and its focus is on the trainee’s ability to demonstrate knowledge, skills and professional behaviours. Trainees are assessed annually by the Deanery. A representative of the Specialty Advisory Committee (SAC) provides externality to this assessment. The assessment of the trainees is via learning agreements; work place based assessments and the trainee’s logbook of operative cases. The standards at each stage of training are laid down by the GMC. Educational and clinical supervisors’ reports are also used in this assessment.

Throughout all phases the trainee must demonstrated a range of generic medical skills including team-working, communication, management skills, teaching, research and evidence of competence in the general practice of orthopaedic and trauma surgery.

There are various examinations taken whilst the doctor is in this phase of specialty training. As part of the training process annual evaluation by the UKITE examination form a yardstick to evaluate core knowledge of a trainee. Some deaneries go further and stipulate that their trainees sit the American assessment examination, the Orthopaedic In training Examination (OITE).

The FRCS(Tr &Orth)Examination 3 is a high stakes assessment undertaken towards the end of training.  The Joint Intercollegiate Board, which is an independent body accountable to the GMC, runs these examinations. This examination is usually taken after 4 years specialty training. The standard required to pass is that of a day one consultant practicing the generality of orthopaedics and trauma in a general hospital setting.

The Certificate of Completion of Training (CCT) is awarded at the end of training and. It is a prerequisite for awarding the CCT that the trainee has passed the FRCS (Tr &Orth) exam, has sufficient specified logbook activity, including appropriate performance in key procedures at a level to allow independent practice. Evidence of academic activity, with a minimum of two peer reviewed publications, is a requirement for the award of the CCT.

Although assessment is competency based indicative numbers are used to guide the training process. It is expected that the individual will have undertaken a total of 1,800 surgical procedures, either supervised or as the primary surgeon during their ST years. In general trainees will have between 10,000 to 15,000 hours of training in their ST programme.

At the completion of training the orthopaedic surgeon will be able to receive and manage patients as an emergency, review patients in clinics and initiate management and appropriate diagnostic tests based on a reasonable differential diagnosis.  The individual will be able to manage the patients in the perioperative period and recognise and treat the common complications.

Completion of the CCT does not imply that sub-specialist training is complete. Periods of further “fellowship” training, for one to two years are undertaken. Within the basic training period foot and ankle surgery will be undertaken both in the elective and emergency environment (fractures, diabetic foot care). Following this it is usual to undertake a period of specialist training in a foot and ankle surgery unit, often abroad. This period, in the majority of cases, is for one to two years. Trainees accumulate further advanced competencies, including experience of up-to 2000 surgical  foot and ankle cases. Following this the individual will apply for a consultant post in an NHS hospital.

Consultant Practice

Consultant Appointment process Consultants are appointed by an Appointments Advisory Committee (AAC), which has a specified membership and includes a representative from the AAC panel of the Royal College of Surgeons to ensure quality, probity and competence in the appointments system.

Consultant practice Consultants are appointed to Hospital Trusts to work within multidisciplinary team structures. Consultant job plans will include time for clinical governance and appraisal, which make up the bulk of Continuing Professional Development (CPD). The consultant is accountable to their Trust’s Medical Director and Chief Executive for maintaining their CPD.

Medical Revalidation: Licensed doctors are appraised annually. As from the end of 2012 this appraisal will form the basis of medical revalidation. Revalidation will be undertaken every five years to maintain medical registration. The GMC document  “Good Medical Practice Framework”4 sets out broad areas that should be covered in medical appraisal, upon which recommendations to revalidate doctors will be based. The revalidation process is made up of four domains:

         - Knowledge, skills and performance: It is necessary to maintain professional performance, knowledge and skills. This includes keeping up to date, by participating in professional development and educational activities as well as taking part in and responding constructively to the outcome of systematic quality improvement activities, such as audit, appraisals and performance reviews.  The doctor must recognise and work within the limits of his or her competence. All NHS Hospital Trusts have guidelines to allow the introduction of new competencies to which practitioners must adhere to if they wish to introduce techniques in to practice.

         - Safety and quality: The doctor should take part in systems of quality assurance and quality improvement in order to protect patients. It is also necessary to comply with risk management and clinical governance. All of these various parameters have stipulated and validated guidelines created by the GMC and other organisations, including the Royal Colleges and the British Orthopaedic Association.

         - Communication, partnership and teamwork: The doctor must communicate effectively, listening to patients and respecting their views. Patients should be given the information they need in order to make decisions about their care in a way they can understand. It is important to work constructively with colleagues and delegate effectively. It is also important for orthopaedic surgeons to work closely with allied health professionals including physiotherapists, podiatrists and the nursing profession as also other medical experts including anaesthetists, rheumatologists, diabetologists, intensivists, general practitioners, vascular surgeons, radiologists and others in order to implement the holistic treatment of patients.

         - Maintaining trust: The doctor should show respect for patients, treat patients and colleagues fairly and without discrimination, as well as acting with honesty and integrity.

This activity is largely grounded locally within the NHS Trust employing the consultant. In a wider context The Academy of Medical Royal Colleges is responsible for facilitating the Royal Colleges, faculties and surgical specialist associations in developing revalidation. There is a strong accent on collaboration and team working.

The BOA has taken the lead in supporting orthopaedic surgeons with revalidation and the British Foot and Ankle Society (BOFAS) works in partnership with the BOA on foot and ankle surgery.

References:

1. Tomorrow’s Doctors Outcomes and standards for undergraduate medical education. General Medical Council 2009. http://www.gmc-uk.org/education/undergraduate/tomorrows_doctors_2009.asp

2. Pitts D, Rowley DI, Marx C, Sher L, Banks T, Murray A. Specialist training in Trauma and Orthopaedics: A competency Based Curriculum 2007, British Orthopaedic Association. https://www.iscp.ac.uk/static/orthocurriculum/Content/15350_Whole_Doc_19.pdf

3. Secretariat of the Intercollegiate Specialty Board in Trauma & Orthopaedic Regulations Relating to the Intercollegiate Specialty  Examination In Trauma & Orthopaedic Surgery. http://www.intercollegiate.org.uk/Content/content.aspx?ID=20

4. General Medical Council (2011) Good Medical Practice Framework for appraisal and revalidation London, General Medical Council. http://www.gmc-uk.org/doctors/revalidation/revalidation_gmp_ framework.asp

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