What shape do UK trainees want their training to be? Results of a cross-sectional study

Temporal Trends in the Investigation, Management and Outcomes of Acute Appendicitis over 15 Years in the North of England: A Retrospective Cohort Study

BACKGROUND

Acute appendicitis is a common surgical emergency with an estimated lifetime prevalence of 8.6% for males and 6.7% for females. Despite the frequency of presentation, considerable variation in clinical practice exists. Our study aimed to explore temporal trends in the investigation, treatment and outcomes for patients with appendicitis between 2002 and 2016.

METHODS

Data collected included all patients aged ≥16 years across the NHS trusts in Northern England between 01/01/2002 and 31/12/2016 diagnosed with appendicitis. Patient demographics, co-morbidity and management strategies were included. Outcomes of interest were length of stay and inpatient mortality.

RESULTS

Over a 15 years period, 22,137 patients were admitted with acute appendicitis. A consistent male preponderance (n = 11,952, 54%) was observed, and median age increased over time (2002-2006: 36.4 vs. 2012-2016: 39.5, p < 0.001). Comorbidity of patients also increased (p < 0.001) in recent years. Computed tomography (CT) use increased from 0.8 to 21.9% (p < 0.001) over the study period. Following CT scanning, there was a longer time to theatre (1.22 vs. 0.70 days, p < 0.001), and patients were more frequently managed non-operatively (23.8% vs. 5.7%, p < 0.001). The utilisation of laparoscopic approaches significantly increased from 4.1 to 70.4% (p < 0.001). Laparoscopic patients had a shorter median length of stay (2.97 days) when compared with open surgery (4.44 days) or non-operative (6.19 days) patients. The 30-day mortality rate was 0.33% overall and decreased with time (p = 0.004).

CONCLUSIONS

CT and laparoscopic surgery are increasingly utilised in the management of appendicitis. Along with other advances in clinical practice, they have led to reduced lengths of stay and mortality.

Factors affecting the UK junior doctor workforce retention crisis: an integrative review

OBJECTIVES

To determine the factors contributing to the junior doctor workforce retention crisis in the UK using evidence collected directly from junior doctors, and to develop recommendations for changes to address the issue.

DESIGN

Integrative review.

DATA SOURCES

Searches were conducted on Ovid Medline and HMIC to locate evidence published between January 2016 and April 2021. This was supplemented by publications from relevant national organisations.

ELIGIBILITY CRITERIA

English-language papers relating to UK junior doctor retention, well-being or satisfaction which contained data collected directly from junior doctors were included. Papers focusing solely on the pandemic, factors specific to one medical specialty, evaluation of interventions, or numerical data with no evidence relating to causation were excluded. Review papers were excluded.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and coded on NVivo by FKL, then thematic analysis was conducted.

RESULTS

47 papers were included, consisting of academic (qualitative, quantitative, mixed and commentary) and grey literature. Key themes identified were working conditions, support and relationships, and learning and development, with an overarching theme of lack of flexibility. The outcomes of these factors are doctors not feeling valued, lacking autonomy, having a poor work-life balance, and providing compromised patient care. This results in need for a break from medical training.

CONCLUSION

This review builds on findings of related literature regarding working environments, isolation, stigma, and desire for autonomy, and highlights additional issues around learning and training, flexibility, feeling valued, and patient care. It goes on to present recommendations for tackling poor retention of UK junior doctors, highlighting that the complex problem requires evidence-based solutions and a bottom-up approach in which junior doctors are regarded as core stakeholders during the planning of interventions.

Defining performance levels in undergraduate otolaryngology education

OBJECTIVES

This study seeks the opinions of qualified doctors on what they feel medical students should learn about otolaryngology. It aims to identify both the content deemed relevant and the performance levels for medical students in otolaryngology.

METHODS

A national survey developed from a content analysis of undergraduate otolaryngology curricula from the UK was undertaken, accompanied by a review of the literature and input from an expert group. Data were collected from a wide range of doctors.

RESULTS

Participants felt that graduating students should be able to: recognise, assess and initiate management for common and life-threatening acute conditions; take an appropriate patient history; and perform an appropriate examination for the majority of otolaryngology clinical conditions but manage only a select few.

CONCLUSION

This study reports performance levels for otolaryngology topics at an undergraduate level. Participating doctors felt that a higher level of performance should be expected of students treating life-threatening, acute and common otolaryngology conditions.

Removing Educational Achievement Points From the Foundation Programme Application System: Is This the Right Decision?

The UK Foundation Programme Office has announced that medical students graduating from 2023 onward will not receive Foundation Programme Application System points for additional degrees or journal publications. In this viewpoint paper, we acknowledge the reasons for this decision, such as socioeconomically advantaged students having greater access to these achievements and the promotion of intercalated degrees for the sake of point accumulation. Additionally, the predictive value of these achievements with regard to junior doctors' performance has been questioned when compared to that of other Foundation Programme Application System components. Conversely, we also highlight the drawbacks of the UK Foundation Programme Office's decision, since this might discourage medical students from completing additional degrees and attempting to publish their work, thereby resulting in clinicians with little to no academic experience or interest. Finally, we attempt to provide suggestions for future improvements in this system by analyzing different medical schools' approaches, such as the BMedSci Honors program offered at Nottingham University. Furthermore, promoting and supporting engagement with academia, especially among socioeconomically disadvantaged students, are the responsibility of all medical schools; such actions are needed in order to produce doctors who are both clinically and academically competent. We conclude that the aforementioned changes should only affect new cohorts in the interest of universities' transparency and fairness to their students.

Dimensionless squared jerk: An objective differential to assess experienced and novice probe movement in obstetric ultrasound

OBJECTIVE

Widely accepted, validated and objective measures of ultrasound competency have not been established for clinical practice. Outcomes of training curricula are often based on arbitrary thresholds, such as the number of clinical cases completed. We aimed to define metrics against which competency could be measured.

METHOD

We undertook a prospective, observational study of obstetric sonographers at a UK University Teaching Hospital. Participants were either experienced in fetal ultrasound (n = 10, >200 ultrasound examinations) or novice operators (n = 10, <25 ultrasound examinations). We recorded probe motion data during the performance of biometry on a commercially available mid-trimester phantom.

RESULTS

We report that Dimensionless squared jerk, an assessment of deliberate hand movements, independent of movement duration, extent, spurious peaks and dimension differed significantly different between groups, 19.26 (SD 3.02) for experienced and 22.08 (SD 1.05, p = 0.01) for novice operators, respectively. Experienced operator performance, was associated with a shorter time to task completion of 176.46 s (SD 47.31) compared to 666.94 s (SD 490.36, p = 0.0004) for novice operators. Probe travel was also shorter for experienced operators 521.23 mm (SD 27.41) versus 2234.82 mm (SD 188.50, p = 0.007) when compared to novice operators.

CONCLUSION

Our results represent progress toward an objective assessment of technical skill in obstetric ultrasound. Repeating this methodology in a clinical environment may develop insight into the generalisability of these findings into ultrasound education.

Virtual Patients in Health Professions Education

Health care professionals must not only have knowledge, but also be able to organise, synthesise and apply this knowledge in such a way that it promotes the development of clinical reasoning. Panels of Virtual patients (VPs) are widely being used in health professions education to facilitate the development of clinical reasoning. VPs can also be used to teach wider educational outcomes such as communication skills, resource utilisation and longitudinal patient care. This chapter will define virtual patients and examine the evidence behind their use in health professions learning and teaching. The chapter will discuss virtual patient design, such as gamification. Finally, the chapter will discuss where this pedagogical innovation is best integrated into assessment and potential barriers to implementation into existing curricula.

Surgical trainees' experience of pregnancy, maternity and paternity leave: a cross-sectional study

BACKGROUND

Internationally, supporting surgical trainees during pregnancy, maternity and paternity leave is essential for trainee well-being and for retention of high-calibre surgeons, regardless of their parental status. This study sought to determine the current experience of surgical trainees regarding pregnancy, maternity and paternity leave.

METHODS

A cross-sectional anonymised electronic voluntary survey of all surgical trainees working in the UK and Ireland was distributed via the Association of Surgeons in Training and the British Orthopaedic Trainees' Association.

RESULTS

There were 876 complete responses, of whom 61.4% (n=555) were female. 46.5% (258/555) had been pregnant during surgical training. The majority (51.9%, n=134/258) stopped night on-call shifts by 30 weeks' gestation. The most common reason for this was concerns related to tiredness and maternal health. 41% did not have rest facilities available on night shifts. 27.1% (n=70/258) of trainees did not feel supported by their department during pregnancy, and 17.1% (n=50/258) found the process of arranging maternity leave difficult or very difficult. 61% (n=118/193) of trainees felt they had returned to their normal level of working within 6 months of returning to work after maternity leave, while a significant minority took longer. 25% (n=33/135) of trainees found arranging paternity leave difficult or very difficult, and the most common source of information regarding paternity leave was other trainees.

CONCLUSION

Over a quarter of surgical trainees felt unsupported by their department during pregnancy, while a quarter of male trainees experience difficulty in arranging paternity leave. Efforts must be made to ensure support is available in pregnancy and maternity/paternity leave.

Evaluating the effects of surgical subspecialisation on patient outcomes following emergency laparotomy: A retrospective cohort study

BACKGROUND

General surgeons have become increasingly subspecialised in their elective practice. Emergency laparotomies, however, are performed by a range of subspecialists who may or may not have an interest in the affected area of gastrointestinal tract. This retrospective cohort study evaluates the impact of surgical subspecialisation on patient outcomes following emergency laparotomy.

METHODS

Data was collected for patients who underwent an emergency abdominal procedure on the gastrointestinal tract in the North of England from 2001 to 2016. This included demographics, co-morbidities, diagnoses and procedures undertaken. Patients were grouped according to consultants' subspecialist interest. The primary outcome of interest was 30-day postoperative mortality.

RESULTS

24,291 emergency laparotomies were performed with an associated 30-day postoperative mortality of 11.7%. Laparotomies undertaken by upper gastrointestinal (UGI) or colorectal surgeons have significantly lower mortality (10.1%) when compared with other subspecialities (13.5%). More specifically, mortality was decreased for UGI (7.9% vs. 12.9%) and colorectal procedures (10.9% vs. 14.2%) when performed by surgeons with a specialist interest in the relevant area of the gastrointestinal tract (both p < 0.001). The utilisation of laparoscopic surgery is higher, in both UGI (21.8% vs. 9.0%) and colorectal procedures (7.2% vs. 3.5%), when the causative pathology is relevant to the surgeon's subspeciality (both p < 0.001).

CONCLUSION

Mortality following emergency laparotomy is improved when performed under the care of gastrointestinal surgeons. Both UGI and colorectal emergency procedures have improved outcomes, with lower mortality and higher rates of laparoscopy, when under the care of a surgeon with a subspecialist interest in the affected area of the gastrointestinal tract.

Attracting medical students and doctors into surgical training in the UK and Ireland

AIMS

Core surgical training (CST) programmes in the UK have seen a significant reduction in competition ratios over the past five years. This study aimed to determine motivating factors and perceived barriers to pursuing a career in surgery amongst junior doctors in training and medical students attending an annual conference.

METHODS

A self-reported, electronic questionnaire was distributed to medical students, foundation year doctors, and doctors in postgraduate surgical training programmes (DIPST) who attended the Association of Surgeons in Training (ASiT) Conference in 2016. Respondents ranked factors attracting them to a career in surgery and factors that could improve perceptions of surgical careers. Chi-square test was used to test for differences between groups (a = 0.05, R Studio, V3.3.1).

RESULTS

Of 394 respondents (response rate = 50.9%), 44.9% were medical students or foundation doctors ('Pre-CST') and 55.1% were DIPST ('Peri/post-CST'). Practical application of skills (97.4%), enjoyment of the theatre environment (95.4%) and positive experiences in surgical firms (84.7%) were primary driving factors towards a surgical career. Availability of private practice (32.2%), and sustainability of consultant jobs (49.0%) had less influence. For 'Pre-CST' respondents, role models (82.8% pre-CST v 74.9% peri-post CST, p < 0.05) and defined career progression (67.2% pre-CST v 47.0% peri-post CST, p < 0.001) were particularly important. 91% of all respondents agreed that a better balance of training and service within worked hours would improve perceptions of surgery.

CONCLUSION

Addressing the motivating factors and perceived barriers to surgical careers will help bolster recruitment of the future surgical workforce.

40-4-40: educational and economic outcomes of a free, international surgical training event

PURPOSE OF STUDY

To demonstrate a model for delivery of an international surgical training event, and demonstrate its educational and economic outcomes.

STUDY DESIGN

The Association of Surgeons in Training (ASiT) ran a course series on 16 January 2016 across the UK and Ireland. A mandatory, self-reported, online questionnaire collected delegate feedback, using 5-point Likert Scales, and a NetPromoter feedback tool. Precourse and postcourse matched questionnaires were collected for 'Foundation Skills in Surgery' (FSS) courses. Paired economic analysis was performed. Statistical analysis was carried out using RStudio (V.3.1.1 Boston, Massachusetts, USA).

RESULTS

Forty courses were held across the UK and Ireland (65.0% technical, 35.0% non-technical), with 184 faculty members. Of 570 delegates, 529 fully completed the feedback survey (92.8% response rate); 56.5% were male. The median age was 26 years (range: 18-67 years). The mean overall course NetPromoter Score was 8.7 out of 10. On logistic regression high NetPromoter Score was associated with completing a Foundation Skills in Surgery course (R=0.44, OR: 1.49, p=0.025) and having clear learning outcomes (R=0.72, OR: 2.04, p=0.029) but not associated with specialty, course style or teaching style. For Foundation Skills in Surgery courses, delegates reported increased commitment to a career in surgery (p<0.001), confidence with basic surgical skills (p<0.001) and confidence with assisting in theatre (p<0.001). A comparable cost saving of £231,462.37 was calculated across the 40 courses.

CONCLUSION

The ASiT '40-4-40' event demonstrated the diversity and depth of surgical training, with 40 synchronous technical and non-technical courses, demonstrable educational benefit and a significant cost saving to surgical trainees.