Registrar operating experience over a 15-year period: more, less or more or less the same?

Have changes in colorectal surgery training impacted on mortality in cancer patients? A retrospective cohort study of 51,562 procedures

INTRODUCTION

The aim of this study was to explore whether there were any differences in consultant colorectal surgeon training and adjusted 90-day postoperative colorectal cancer mortality rates (AMR).

METHODS

We undertook a retrospective analysis of outcomes data published on the Association of Coloproctology of Great Britain and Ireland (ACPGBI) website. A total of 51,562 procedures for patients in England diagnosed with large bowel cancer between 2010 and 2015, registered under 551 consultants were included. Consultants were split into two cohorts. The first group were the pre-Calman Trained Consultants (pre-CTr), who completed their training before 1998. The second group-the post-Calman Trained Consultants (post-CTr)-included those who received their Certificate of Completion of Training (CCT) under the Calman Training Principles (CTC, 1998-2007) and the Modernising Medical Careers Curriculum (MMC, 2008 and onwards). The outcome measure was an AMR.

RESULTS

The pre-CTr cohort (n=84) consisted of 3.6% female colorectal consultants (n=3/84), whereas the post-CTr cohort (n=467) consisted of 14.3% female colorectal consultants (n=67/467) (p=0.006). In this cross-sectional analysis over 5 years, the average pre-CTr undertook a greater number of colorectal resections than their post-CTr peers: median procedures (interquartile range, IQR): 104 (59) vs 89 (57) respectively, p=0.008. The median AMR was significantly greater among pre-CTrs compared with post-CTrs, median AMR (IQR): 2.7% (2.0) vs 2.1% (2.9), p=0.022.

CONCLUSIONS

These data indicate that the implementation of the MMC and Calman training principles for colorectal training is associated with a statistically lower AMR compared with other historical training periods. This merits further exploration.

Comparison of Educational and Academic Quality of Laparoscopic Distal Pancreatectomy Videos on WebSurg® and YouTube® Platforms

BACKGROUND

The aim of this study was to compare the educational and academic quality of laparoscopic distal pancreatectomy (LDP) videos on YouTube® and WebSurg® platforms.

MATERIAL AND METHODS

YouTube and WebSurg platforms were searched with the keyword "laparoscopic distal pancreatectomy". According to the exclusion criteria, 12 videos were found on WebSurg. To ensure a 1:1 ratio, the first 12 videos that met the criteria on YouTube were also analyzed. Journal of American Medical Association (JAMA) benchmark criteria were used to evaluate the reliability of the videos. The non-educational quality of the videos was calculated using the Global Quality Score (GQS), the educational and academic quality of videos was calculated using Laparoscopic Distal Pancreatectomy-specific score (LDP-SS) and Laparoscopic Surgery Video Educational Guidelines scoring system (LAP-VEGaS).

RESULTS

The mean JAMA score was 1.58 on YouTube and 2.83 on WebSurg (P < .001). The median GQS was 2 on YouTube and 5 on WebSurg (P < .001). The median LAP-VEGaS score was 8 on YouTube and 14.5 on WebSurg (P < .001). The median LDP-SS score was 6 on YouTube and 9.5 on WebSurg (P = .001). According to the LAP-VEGaS, eleven (91.7%) of the WebSurg videos had a high score of 11 or more (P = .04). According to Spearman correlation analysis, there was a statistically significant positive correlation between LDP-SS and JAMA, GQS and LAP-VEGaS (r: .589, P = .002; r: .648, P = .001; r: .848, P < .001 respectively).

CONCLUSIONS

The WebSurg is superior to the YouTube in terms of educational and academic value, quality, accuracy, reliability and usability in scientific meetings for LDP videos.

Differences in progression by surgical specialty: a national cohort study

The aim of surgical training across the 10 surgical specialties is to produce competent day 1 consultants. Progression through training in the UK is assessed by the Annual Review of Competency Progression (ARCP).

OBJECTIVE

This study aimed to examine variation in ARCP outcomes within surgical training and identify differences in outcomes between specialties.

DESIGN

A national cohort study using data from the UK Medical Education Database was performed. ARCP outcome was the primary outcome measure. Multilevel ordinal regression analyses were performed, with ARCP outcomes nested within trainees.

PARTICIPANTS

Higher surgical trainees (ST3-ST8) from nine UK surgical specialties were included (vascular surgery was excluded due to insufficient data). All surgical trainees across the UK with an ARCP outcome between 2010 and 2017 were included.

RESULTS

Eight thousand two hundred and twenty trainees with an ARCP outcome awarded between 2010 and 2017 were included, comprising 31 788 ARCP outcomes. There was substantial variation in the proportion of non-standard outcomes recorded across specialties with general surgery trainees having the highest proportion of non-standard outcomes (22.5%) and urology trainees the fewest (12.4%). After adjustment, general surgery trainees were 1.3 times more likely to receive a non-standard ARCP outcome compared with trainees in trauma and orthopaedics (T&O) (OR 1.33, 95% CI 1.21 to 1.45, p=0.001). Urology trainees were 36% less likely to receive a non-standard outcome compared with T&O trainees (OR 0.64, 95% CI 0.54 to 0.75, p<0.001). Female trainees and older age were associated with non-standard outcomes (OR 1.11, 95% CI 1.02 to 1.22, p=0.020; OR 1.04, 95% CI 1.03 to 1.05, p<0.001).

CONCLUSION

There is wide variation in the training outcome assessments across surgical specialties. General surgery has higher rates of non-standard outcomes compared with other surgical specialties. Across all specialties, female sex and older age were associated with non-standard outcomes.

Emergency psychiatric assessments: implications for senior house officer training

Aims and Method

In order to examine the opportunities for senior house officers (SHOs) to undertake emergency psychiatric assessments we conducted a retrospective cohort study of such assessments in a district general hospital.

Results

Senior house officers conducted few assessments for self-harm compared with psychiatric liaison nurses (P< 0.001), and were involved in only 40% of emergency referrals where psychiatric opinion was requested. Senior house officers continue to undertake more assessments out of hours than any other group (P< 0.01).

Clinical Implications

Although the introduction of psychiatric liaison nurses has improved capacity and reduced waiting times for emergency assessment, the opportunity for SHOs to undertake emergency assessments has been reduced, particularly with regard to assessment of suicidal risk following self-harm. These results suggest the need for better monitoring of SHO experience, particularly in the light of service developments that have an impact on psychiatric training.

A EWTD Compliant Rotation Schedule Which Protects Elective Training Opportunities Is Safe and Provides Sufficient Exposure to Emergency General Surgery: A Prospective Study

Introduction. Training opportunities have decreased dramatically since the introduction of the European Working Time Directive (EWTD). In order to maximise training we introduced a rotation schedule in which registrars do not work night shifts and elective training opportunities are protected. We aimed to determine the safety and effectiveness of this EWTD compliant rotation schedule in achieving exposure of trainees to acute general surgical admissions and operations. Methods. A prospective study of consecutive emergency surgical admissions over a 6-month period. Exposure to acute admissions and operative procedures and patient outcomes during day and night shifts was compared. Results. There were 1156 emergency admissions covering a broad range of acute conditions. Significantly more patients were admitted during the day shift and almost all emergency procedures were performed during the day shift (2.1 versus 0.3, p < 0.001). A registrar was the primary operating surgeon in 49% of cases and was directly involved in over 65%. There were no significant differences between patients admitted during the day and night shifts in mortality rate, length of stay, admission to ICU, requirement for surgery, or readmission rates. Conclusion. A EWTD compliant rotation schedule that protects elective training opportunities is safe for patients and provides adequate exposure to training opportunities in emergency surgery.

Operative Exposure of a Surgical Trainee at a Tertiary Hospital in Kenya

Background. Psychomotor domain training requires repetitive exposure in order to develop proficiency in skills. This depends on many training factors in any training institution. Objective. This study sought to look at the operative exposure of surgical trainees in a tertiary hospital in a developing country. Design and Setting. This was a six-month retrospective study performed in one surgical firm at Kenyatta National Hospital. Patients and Methods. The files of all patients admitted to the unit at that time were retrieved. The demographics, diagnosis at admission, need for surgery, and cadre of operating surgeon among others were recorded. Scientific Package for Social Sciences (SPSS) version 17.0 was used for data entry and analysis. Results. The study cohort was 402 patients of the 757 patients admitted in the study period. The average age was 36.7 years, a female to male ratio of 1 : 2.5. The majority (69.7%) of patients required surgery. Trauma was the most common reason for admission (44.5%). Year 2 residents received the most clinical exposure. Consultant was available in only 34.5% of the cases. Conclusion. The junior residents performed the vast majority of procedures with an unsatisfactory amount of supervision from the senior residents and faculty.

Is current surgical training efficient? A national survey

OBJECTIVES

Evaluation of surgical training in Denmark is competency based with no requirement for a specific number of procedures. This may affect monitoring of surgical progress adversely and cause an underestimation of the time needed to acquire surgical competencies. We investigated the number of common surgical procedures performed by trainees. Trainees' and consultants' expectations from the training program were also investigated.

DESIGN AND PARTICIPANTS

A questionnaire was sent to all 115 surgical trainees in Denmark. We asked how many common surgical procedures the trainees had performed during their postgraduate training, whether self-reported procedural confidence was achieved during their training, and whether their training expectations were met. Another questionnaire dealt with the consultants' expectations of the surgical training.

RESULTS

The total number of common surgical procedures (Lichtenstein hernia repair, appendectomy, laparoscopic appendectomy, and laparoscopic cholecystectomy) that were performed varied between trainees. One group performed few common procedures during training. A low number in 1 procedure correlated with a similar pattern in other procedures. Approximately one-third did not perform common elective procedures independently until their fifth year. Consultants and trainees viewed training differently.

CONCLUSIONS

Our study reveals no common trend in the numbers and types of procedures performed during training. The number of procedures seems to reflect the individual trainee and a local tradition rather than the particular training program. An informal competency-based assessment system with lack of quantitative requirements evidently involves a risk of skewness in training.

The impact of shortened postgraduate surgical training on colorectal cancer outcome

BACKGROUND

Shortened postgraduate surgical training reforms, known as Calman, have altered delivery of surgical training in the UK with reduced working hours and training time aiming to produce a more subspecialised workforce.

AIMS

This study aims to compare rectal cancer surgical outcomes of Calman-trained consultants in a single institution to published data. Additionally, the study compared colorectal cancer surgical outcome between Calman-trained consultants (CTCs) and non-Calman consultants (NCTCs) in a national dataset.

METHODS

Local dataset Clinicopathological outcome of rectal cancer resection undertaken by CTCs in a single institution (2006-2010) were compared against NCTC counterparts. National dataset All elective colorectal cancer resections between 2004 and 2008 in English NHS hospitals were included. CTCs (present from 2004 onwards) were compared to NCTCs (present prior to 2004). Outcome measures included 30-day in-hospital mortality, reoperation and readmission rates.

RESULTS

Local dataset One hundred thirteen patients were operated under five CTC. The 30-day in-hospital mortality for CTCs (1%) was favourable compared to published rates (3-5%). Local recurrence rate (4.4%) was comparable to NCTC (3.6%). National dataset Between 2004 and 2008, 44,106 patients underwent elective colorectal resection. Multiple regression demonstrated CTC patients had a reduced length of stay and reduced reoperation rate. No difference in mortality and unplanned readmission rates were seen.

CONCLUSION

CTCs have similar safety outcome to NCTCs for colorectal cancer resection procedures. Further work is needed to assess the impact of further training reductions on clinical outcome.

Higher surgical training opportunities in the general hospital setting; getting the balance right

BACKGROUND

The general hospital can play an important role in training of higher surgical trainees (HSTs) in Ireland and abroad. Training opportunities in such a setting have not been closely analysed to date.

AIMS

The aim of this study was to quantify operative exposure for HSTs over a 5-year period in a single institution.

METHODS

Analysis of electronic training logbooks (over a 5-year period, 2007-2012) was performed for general surgery trainees on the higher surgical training programme in Ireland. The most commonly performed adult and paediatric procedures per trainee, per year were analysed.

RESULTS

Standard general surgery operations such as herniae (average 58, range 32-86) and cholecystectomy (average 60, range 49-72) ranked highly in each logbook. The most frequently performed emergency operations were appendicectomy (average 45, range 33-53) and laparotomy for acute abdomen (average 48, range 10-79). Paediatric surgical experience included appendicectomy, circumcision, orchidopexy and hernia/hydrocoele repair. Overall, the procedure most commonly performed in the adult setting was endoscopy, with each trainee recording an average of 116 (range 98-132) oesophagogastroduodenoscopies and 284 (range 227-354) colonoscopies.

CONCLUSIONS

General hospitals continue to play a major role in the training of higher surgical trainees. Analysis of the electronic logbooks over a 5-year period reveals the high volume of procedures available to trainees in a non-specialist centre. Such training opportunities are invaluable in the context of changing work practices and limited resources.

Expert practical operative skills teaching in Trauma and Orthopaedics at a nominal cost

BACKGROUND AND PURPOSE

The AO Foundation Operative Fracture Management course is the gold standard in training courses currently available for trainees at ST3 level. We have devised a low cost operative skills course comprising instructional lectures, demonstrations and practical dry bone workshops. To assess the quality of teaching, candidates' feedback was analysed in two cohorts for the running of the course over two consecutive years: 2008 and 2009.

METHODS

Trainees were given short instructional lectures by consultant surgeons followed by workshops, with a trainer to candidate ratio of 1:4. A trauma inventory was provided by Stryker Trauma UK, ensuring a nominal fee for each candidate (£50). Feedback was anonymously collected according to a Likert scale and analysed using non-parametric methods appropriate for ranked data.

MAIN FINDINGS

Twenty one of 22 (95%) candidates gave feedback in 2008 and 18 out of 18 candidates (100%) in 2009. The teaching provided was highly rated consistently for both years, apart from an informal session on theatre tips and tricks in 2008. This was not repeated in 2009 to allow more practical time. Only one session, an intramedullary nailing lecture, had a significant difference in scores between the 2 years (p = 0.044) because of improved scores in 2009.

CONCLUSIONS

Due to changes in training, trainees have reduced exposure in theatre and this has implications for the early stages of acquiring practical operative skills. As an adjunct to the AO course, practical skills teaching by consultants in the format of a low cost skills workshop outside of a theatre environment can be achieved with support from a trauma implant supplier.

A modern approach to teaching pancreatic surgery: stepwise pancreatoduodenectomy for trainees

INTRODUCTION

Pancreatoduodenectomy (PD) has always been regarded as one of the most technically demanding abdominal procedures, even when carried out in high-volume centers by experienced surgeons. The reduction in higher surgical trainees working hours has led to reduced exposure, and consequently less experience in operative procedures. Furthermore, trainees have also become victims as health care systems striving for operating room efficiency, have attempted to reduce procedure duration by encouraging consultant led procedures at the expense of training. A strategy therefore needs to be developed to match the ability of the trainee with the complexity of the surgical procedure. As a PD can be deconstructed into a number of different steps, it may indeed be an ideal training operation for varying levels of ability.

METHODS

We describe our technique for PD and break it down to nine steps of varying technical ability making it suitable for many different stages of surgical training.

RESULTS

The complexity and variety of steps required to perform a PD makes it an ideal training operation from the junior surgical trainee to the most senior fellow, allowing the development of a wide range of skill sets.

DISCUSSION

Since the introduction of reduced working hours (48 h per week in Europe and 80 h per week in the USA) the "apprenticeship" model of surgical training has shifted towards a time-limited program with greater emphasis on supervision. Due to the complexity of surgery, and the perception of diminished levels of trainees' competency, a PD is often viewed as a consultant level operation. We believe that PD is an excellent model as it provides opportunities for trainees with varying levels of operative experience so that a PD could be considered the ideal "teaching case". Breaking down PD into a number of different steps may help building up surgical expertise more quickly while maintaining patients' safety and allowing the surgery to be expedited in a timely manner.

Opening the black box: the patient mix of GP trainees

BACKGROUND

The variety of health problems (patient mix) that medical trainees encounter is presumed to be sufficient to master the required competencies.

AIM

To describe the patient mix of GP trainees, to study differences in patient mix between first-year and third-year GP trainees, and to investigate differences in exposure to sex-specific diseases between male and female trainees.

DESIGN AND SETTING

Prospective cohort study in Dutch primary care.

METHOD

During a 6-month period, aggregated data about International Classification of Primary Care diagnosis codes, and data on the sex and age of all contacts were collected from the electronic patient record (EPR) system.

RESULTS

Seventy-three trainees participated in this study. The mean coding percentage was 86% and the mean number of face-to-face consultations per trimester was 450.0 in the first year and 485.4 in the third year, indicating greater variance in the number of patient contacts among third-year trainees. Diseases seen most frequently were: musculoskeletal (mean per trimester = 89.2 in the first year/91.0 in the third year), respiratory (98.2/92.7) and skin diseases (89.5/96.0). Least often seen were diseases of the blood and blood-forming organs (5.3/7.2), male genital disorders (6.1/7.1), and social problems (4.3/4.2). The mean number of chronic diseases seen per trimester was 48.0 for first-year trainees and 62.4 for third-year trainees. Female trainees saw an average of 39.8 female conditions per trimester--twice as many as male trainees (mean = 21.3).

CONCLUSION

Considerable variation exists trainees in the number of patient contacts. Differences in patient mix between first- and third-year trainees seem at least partly related to year-specific learning objectives. The use of an EPR-derived educational instrument provides insight into the trainees' patient mix at both the group and the individual level. This offers opportunities for GP trainers, trainees, and curriculum designers to optimise learning when exposure may be low.

Analysing the operative experience of basic surgical trainees in Ireland using a web-based logbook

BACKGROUND

There is concern about the adequacy of operative exposure in surgical training programmes, in the context of changing work practices. We aimed to quantify the operative exposure of all trainees on the National Basic Surgical Training (BST) programme in Ireland and compare the results with arbitrary training targets.

METHODS

Retrospective analysis of data obtained from a web-based logbook (http://www.elogbook.org) for all general surgery and orthopaedic training posts between July 2007 and June 2009.

RESULTS

104 trainees recorded 23,918 operations between two 6-month general surgery posts. The most common general surgery operation performed was simple skin excision with trainees performing an average of 19.7 (± 9.9) over the 2-year training programme. Trainees most frequently assisted with cholecystectomy with an average of 16.0 (± 11.0) per trainee. Comparison of trainee operative experience to arbitrary training targets found that 2-38% of trainees achieved the targets for 9 emergency index operations and 24-90% of trainees achieved the targets for 8 index elective operations. 72 trainees also completed a 6-month post in orthopaedics and recorded 7,551 operations. The most common orthopaedic operation that trainees performed was removal of metal, with an average of 2.90 (± 3.27) per trainee. The most common orthopaedic operation that trainees assisted with was total hip replacement, with an average of 10.46 (± 6.21) per trainee.

CONCLUSIONS

A centralised web-based logbook provides valuable data to analyse training programme performance. Analysis of logbooks raises concerns about operative experience at junior trainee level. The provision of adequate operative exposure for trainees should be a key performance indicator for training programmes.

Is gynaecological surgical training a cause for concern?: a questionnaire survey of trainees and trainers

BACKGROUND

Concerns have been raised as to whether the current postgraduate training programme for gynaecological surgery is being detrimentally affected by changes in working practices, in particular the European Working Time Directive (EWTD). The purpose of this study was to investigate the surgical activity of obstetrics and gynaecology trainees and to explore trainees' and trainers' opinions on the current barriers and potential solutions to surgical training.

METHODS

Two questionnaire surveys were conducted, one to obstetrics and gynaecology trainees working within the West Midlands Deanery and a second to consultant gynaecologists in the West Midlands region.

RESULTS

One hundred and four trainees (64.3%) and 66 consultant gynaecologists (55.0%) responded. Sixty-six trainees (66.7%) reported attending up to one operating list per week. However, 28.1% reported attending up to one list every two weeks or less and 5 trainees stated that they had not attended a list at all over the preceding 8 weeks. Trainees working in a unit with less than 3999 deliveries attended significantly more theatre sessions compared to trainees in units with over 4000 deliveries (p = 0.007), as did senior trainees (p = 0.032) and trainees attached to consultants performing major gynaecological surgery (p = 0.022). In the previous 8 weeks, only 6 trainees reported performing a total abdominal hysterectomy independently, all were senior trainees (ST6 and above). In the trainers' survey, only two respondents (3.0%) agreed that the current program produces doctors competent in general gynaecological surgery by the end of training, compared to 48 (73.8%) respondents who disagreed.

CONCLUSIONS

Trainees' concerns over a lack of surgical training appear to be justified. The main barriers to training are perceived to be a lack of team structure and a lack of theatre time.

Who determines the patient mix of GP trainees? The role of the receptionist

BACKGROUND

During their specialty training, Dutch GP trainees work at a GP under the supervision of a GP trainer. Research suggests that the patient mix of GP trainees differs from that of their trainers. Receptionists assign patients to either the trainee or the trainer, thereby influencing the patient mix of the trainees. The decision to which doctor to assign is complex and depends on the latitude the receptionists have. Their considerations when assigning patients are unknown.

OBJECTIVE

To study receptionists' assigning behaviour.

METHODS

This was a questionnaire survey. To design the questionnaire, topics about assigning behaviour were identified in a focus group. The resulting questionnaire was sent to 478 GP training practices in the Netherlands.

RESULTS

Response rate was 68%. Of the receptionists, 95% asked for the reason for the consultation at least 'sometimes'. Most (86.3%) of the receptionists considered the patient mix of trainees and trainers to be similar. Almost all receptionists (97%) reported 'often' or 'always' assigning 'every possible problem' to the trainee and a similar picture arose regarding specific subpopulations. However, the receptionists reported that they assigned complex and new patients to the trainers more often than to trainees.

CONCLUSION

With some exceptions, receptionists try to assign trainees a varied patient mix.

Training tomorrow's military surgeons: lessons from the past and challenges for the future

The nature of conflict is evolving, with current warfare being associated with an initial "shock and awe" phase followed by protracted periods ofcounter-insurgency and peace support missions. As conflict has changed, so have the munitions deployed and the resulting patterns of injury. Improvised Explosive Devices have become the preferred weapon of the insurgent and the resultant explosive and fragmentation injuries are the hallmark of modern military wounding. These injuries pose a significant challenge to deployed medical forces, requiring a well-defined, seamless approach from injury to rehabilitation. Traditionally, military medical services demonstrate a poor 'institutional memory' in the maintenance of combat surgical skills. Numerous publications detail the re-learning of key tenets of war surgery by generations of surgeons deploying onto the field of battle. While the maintenance of military surgical capability in trained surgeons may be addressed through combat surgical courses, concern exists as to the generic competency of those currently in training and their ability to deal with the burden of injury associated with modern conflict. The training of junior doctors in the United Kingdom and further afield is in a state of flux. New curriculum development, streamlined and run-through training programmes have combined with the legal requirements of the European Working Time Directive to produce a training landscape almost unrecognisable with that of previous years. This article investigates the development of current military wounding patterns and modern surgical training programmes. It describes processes already in place to address the unique training needs of military surgeons and proposes a framework for enabling appropriate training opportunities in the future.

Diagnosis of skin lesions by trainee surgeons: experience improves accuracy

INTRODUCTION

Accurate clinical diagnosis depends on the reliable recognition of signs and symptoms. This expertise comes from experience in seeing patients which has been traditionally gained over a long training period. Shortened specialist training (Modernising Medical Careers) has led to a greater reliance on structured teaching and skills transfer programmes. The accuracy of clinical diagnosis and the rate at which diagnostic skills improve during training is important for the assessment of trainees, and the delivery of care.

PATIENTS AND METHODS

This study assessed the accuracy of clinical diagnosis of skin lesions by two junior plastic surgery trainees. They were asked to diagnose 120 consecutive skin lesions seen in a pigmented skin lesion clinic in 2005, with the histological diagnosis being confirmed following subsequent excision. The process was repeated a year later in 2006 to enable the rate of correct diagnosis to be compared.

RESULTS

Initially, 53.3% of diagnoses were correct. A year later, this had risen to 65.0%. Twenty-two different skin pathologies were present in excised specimens, and skin cancers comprised 30%. The trainees demonstrated 93.8% sensitivity in their initial diagnosis of malignancy (95% CI, 79.2-99.2) and 97.4% a year later (95% CI, 86.5-99.9). However, specificity was 69.3% (95% CI, 58.6-78.7) in 2005 and 71.6% (95% CI, 60.5-71.4) in 2006.

CONCLUSIONS

Accuracy in the diagnosis of the wide range of skin conditions presenting to an out-patient clinic was shown to increase over a 1-year period. We feel that this improvement resulted from regular clinical exposure supported by a structured learning programme. The shortening of the specialist training period may affect the acquisition of diagnostic skills by trainees and impact on the confidence with which they commence consultant practice.

Impact of Calman system and recent reforms on surgical training in gynaecology

Specialist training in the UK has been affected by changes in recent years aimed at a reduction in junior doctors' working hours to comply with employment regulations and the introduction of structured training with specified duration. The Calman reforms implemented in 1996 introduced a focussed system with defined competencies and a shorter training period. The previous system was based on experience gained in an apprentice-type setting with no defined duration of training. The European Working Time Directive (EWTD) regulates the number of working hours for junior doctors and aims for a 48-h working week by 2009. In the surgical disciplines a reduction in working hours and shorter duration of training could adversely affect the acquisition of operative skills. The concern among trainees and their trainers was that surgical exposure has been reduced and therefore trainees have limited surgical experience by the time they complete training. We conducted this study in a teaching district hospital to determine the effect of recent changes on gynaecological surgical training. We found that there was a 27% reduction in surgical activity between 1995 and 2005 from 3,789 to 2,781, whereas the number of trainees had increased by 67% from 6 to 10. The proportion of operative procedures performed by trainees decreased from 55% (2,078/3,789) in 1995 to 34% (951/2,781) in 2005 (p < 0.001). The average number of procedures performed by each trainee in 2005 was 95 compared with 346 in 1995, a 73% reduction (p < 0.001). Innovative approaches to surgical training in gynaecology are required to produce a competent surgeon in a shorter time, or the risk of future consultants having limited surgical experience will increase.

Involvement of surgical trainees in surgery for colorectal cancer and their effect on outcome

OBJECTIVE

Surgical training in the UK is undergoing substantial changes. This study assessed: 1) the training opportunities available to trainees in operations for colorectal cancer, 2) the effect of colorectal specialization on training, and 3) the effect of consultant supervision on anastomotic complications, postoperative stay, operative mortality and 5-year survival.

METHOD

Unadjusted and adjusted comparisons of outcomes were made for unsupervised trainees, supervised trainees and consultants as the primary surgeon in 7411 operated patients included in the Northern Region Colorectal Cancer Audit between 1998 and 2002.

RESULTS

Surgery was performed in 656 (8.8%) patients by unsupervised trainees and in 1578 (21.3%) patients by supervised trainees. Unsupervised operations reduced from 182 (12.4%) in 1998 to 82 (6.1%) in 2002 (P < 0.001). Consultants with a colorectal specialist interest were more likely than nonspecialists to be present at surgical resections (OR 1.35, 1.12-1.63, P = 0.001) and to provide supervised training (OR 1.34, 1.17-1.53, P < 0.001). Patients operated on by unsupervised trainees were more often high-risk patients, however, consultant presence was not significantly associated with operative mortality (OR 0.83, 0.63-1.09, P = 0.186) or survival (HR 1.02, 0.92-1.13, P = 0.735) in risk-adjusted analysis. Supervised trainees had a case-mix similar to consultants, with shorter length of hospital stay (11.4 vs 12.4 days, P < 0.001), but similar mortality (OR 0.90, 0.71-1.16, 0.418) and survival (HR 0.96, 0.89-1.05, P = 0.378).

CONCLUSION

One third of patients were operated on by trainees, who were more likely to perform supervised resections in colorectal teams. There was no difference in anastomotic leaks rates, operative mortality or survival between unsupervised trainees, supervised trainees and consultants when case-mix adjustment was applied. This study would suggest that there is considerable underused training capacity available.

Value and face validity of objective structured assessment of technical skills (OSATS) for work based assessment of surgical skills in obstetrics and gynaecology

BACKGROUND

Changes in UK Junior Doctor working patterns, reduced training hours and increased patient expectations have resulted in less exposure of Juniors to surgical procedures. Validated methods of assessment are therefore required to assure the surgical competency of future Consultants. Objective Structured Assessment of Technical Skills (OSATS) forms are one possible tool.

AIMS

To investigate trainee and trainer perceptions of the value and validity of OSATS in the operating theatre.

METHOD

OSATS forms and feedback questionnaires.

RESULTS

38 trainees and 16 trainers provided feedback on the OSATS forms used during 60 procedures, returning 119 questionnaires in total. Value : 85% of trainee and 76% of trainer responses agreed/strongly agreed that OSATS would improve trainees' surgical skills. Face validity: 80% of trainee and 76% of trainer responses agreed/strongly agreed with OSATS ability to assess surgical skills.

APPLICATION

76% of trainee and trainer responses agreed/strongly agreed that OSATS should become part of the annual assessment process for trainees.

CONCLUSIONS

Trainees and trainers perceive OSATS to be a valuable and valid tool for the objective assessment of surgical skills in the work place. More research is required to assess their criterion-related, content, construct and predictive validity as well as their reliability in the workplace.

Current Status and Future Perspective of General Surgical Trainees in the Netherlands

BACKGROUND

The opinions of general surgical trainees about their current training program and their future career plans are important because such information can inform any redesign of surgical training programs as well as future surgical manpower planning.

METHODS

A structured questionnaire was sent to 392 general surgical trainees in the Netherlands in 2005.

RESULTS

A total of 239 (61%) questionnaires were returned by 66 (28%) women and 173 (72%) men, mean age 31.3 years. On average, trainees worked in the hospital 55 hours per week (range: 22-80 h). The mean number of operative cases performed per year was 195 (range 35-450), and this had been stable since the year 2000. The quality of the supervision by staff surgeons was rated satisfactory. The vast majority of the trainees are also satisfied with the current single year of differentiation/specialized training into one of the subspecialties, although most trainees (83%) would like to enroll in a fellowship before taking a job as a consultant. There was also a desire to take maternity/paternity leave during training. Both male and female trainees expressed the wish to work an average of 52 hours per week as a consultant, and they want these hours to occur in 4.1 days of work per week.

CONCLUSIONS

Dutch general surgery trainees are satisfied with their training. They expressed a strong wish for specialization during and after their training. All trainees favored reduced working hours and days of work per week as fully qualified surgeons in the future.

Selection, teaching and training in ophthalmology

This article examines the training requirements for ophthalmic surgical training, and the selection, assessment and training methodologies used for trainees, and also comments on the role of the surgical trainers. As an introduction to the article, a brief description of the current scheme in the UK is given.