Training for the future NHS: training junior doctors in the United Kingdom within the 48-hour European working time directive

The Benefits of Promoting Junior Trainees in Vascular Surgery

Introduction United Kingdom surgical training consists of a two-year core surgical training (CST) followed by a six-year higher speciality training (ST). There is a significant step up in responsibility and operative skills when transitioning from core to higher training. One-way trainees can bridge this gap is to "act up" to registrar level "CST-R." The CST "steps up" to the role of ST typically in the latter part of their core training and gains exposure at being the "reg of the week," primary assistant in theatre, managing MDTs, and taking speciality referrals. This can be an excellent training opportunity. This study aims to demonstrate a quantitative improvement in trainee operation as a result of stepping up. Methods This study compares the operative experience of one vascular surgery-themed trainee during six months as a CST and six months acting up as a CST-R. The trainee's eLogbook was searched for all operations between August 3, 2022, and January 31, 2023, and between February 1, 2023, and August 1, 2023. The number of cases performed and the role played in each were analyzed. The number of low complexity cases conducted in each block was used as a baseline to ensure the progression seen was because of increasingly complex ST operating rather than the increase in CST level operating expected throughout CST. An abscess incision and drainage were used as the reference low-complexity case. Results The number of cases the trainee performed independently increased from 13% to 25%, while the number where they were simply assisting decreased from 43% to 35%. The number of cases where the trainer remained scrubbed decreased nonsignificantly from 43% to 39%. The number of low-complexity cases performed remained unchanged for each six-month block. Conclusion As a CST-R, the trainee played a more prominent operative role in a greater number of cases. The CST-R does require a supportive department and consultant body. It also enables other STs to gain more surgical exposure because of their reduced frequency of being the "reg of the week." If a trainee can remain in a post for two six-month blocks, then there is much to be gained from a formalised acting-up program, and consideration should be given to formally incorporating this into core surgical programs.

Evaluating the perceptions of workplace-based assessments in surgical training: a systematic review

INTRODUCTION

Workplace-based assessments (WBAs) are intended to maximise learning opportunities in surgical training. There is speculation as to whether mandatory assessments in this form contribute to a tick-box culture. The objective of this review was to investigate surgical trainees' attitudes towards WBAs.

METHODS

This systematic review of qualitative studies was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. The literature was searched on the Medline®, Embase™, PubMed and Web of Science™ databases on 22 March 2022.

RESULTS

Sixteen studies were included in the review, mostly carried out on users of the Intercollegiate Surgical Curriculum Programme portfolio in the UK. Trainees felt that WBAs were educationally useful, providing opportunity for feedback, but this was overshadowed by a pressure to reach a set annual quota for WBAs and achieve high scores. Other themes included inaccurate recording of WBAs, the role of WBAs as formative or summative assessments, engagement and accessibility of trainers, and lack of time to complete WBAs.

CONCLUSIONS

Negative perceptions about WBAs were widespread among surgical trainees despite a recognition of their capacity to facilitate learning. This review supports the recent removal of the annual quota for WBAs in UK surgical training programmes.

Surgical care practitioners: an audit across the surgical specialties

INTRODUCTION

The Royal College of Surgeons of England (RCS), when devising their curriculum for surgical care practitioners (SCPs), aimed to provide a level of training to produce a practitioner able to work across the surgical patient's journey, providing care to, arguably, an advanced level. This audit planned to examine the reality of this.

METHOD

SCPs from a closed group, on the Facebook social media platform were invited to complete an online questionnaire about their role as an SCP.

RESULTS

A total of 92 responses were gathered from across the surgical specialty SCP community and from around the UK. Data were collected on the breakdown of the SCP's role and working practices.

CONCLUSION

The data collected demonstrated the multifunctional nature of the SCP and their ability to work at a level as envisioned by the RCS curriculum.

Evaluation of the impact of teaching on delineation variation during a virtual stereotactic ablative radiotherapy contouring workshop

Introduction:

Variation in delineation of target volumes/organs at risk (OARs) is well recognised in radiotherapy and may be reduced by several methods including teaching. We evaluated the impact of teaching on contouring variation for thoracic/pelvic stereotactic ablative radiotherapy (SABR) during a virtual contouring workshop.

Materials and methods:

Target volume/OAR contours produced by workshop participants for three cases were evaluated against reference contours using DICE similarity coefficient (DSC) and line domain error (LDE) metrics. Pre- and post-workshop DSC results were compared using Wilcoxon signed ranks test to determine the impact of teaching during the workshop.

Results:

Of 50 workshop participants, paired pre- and post-workshop contours were available for 21 (42%), 20 (40%) and 22 (44%) participants for primary lung cancer, pelvic bone metastasis and pelvic node metastasis cases, respectively. Statistically significant improvements post-workshop in median DSC and LDE results were observed for 6 (50%) and 7 (58%) of 12 structures, respectively, although the magnitude of DSC/LDE improvement was modest in most cases. An increase in median DSC post-workshop ≥0·05 was only observed for GTVbone, IGTVlung and SacralPlex, and reduction in median LDE > 1 mm was only observed for GTVbone, CTVbone and SacralPlex. Post-workshop, median DSC values were >0·7 for 75% of structures. For 92% of the structures, post-workshop contours were considered to be acceptable or within acceptable variation following review by the workshop faculty.

Conclusions:

This study has demonstrated that virtual SABR contouring training is feasible and was associated with some improvements in contouring variation for multiple target volumes/OARs.

EANS Basic Brain Course (ABC): combining simulation to cadaver lab for a new concept of neurosurgical training

BACKGROUND

Neurosurgical training has traditionally been based on an apprenticeship model that requires considerable time and exposure to surgeries. Unfortunately, nowadays these requirements are hampered by several limitations (e.g., decreased caseload, worktime restrictions). Furthermore, teaching methods vary among residency programs due to cultural differences, monetary restrictions, and infrastructure conditions, with the possible consequence of jeopardizing residents' training.

METHODS

The EANS Basic Brain Course originated from a collaboration between the Besta NeuroSim Center in Milano and the Swiss Foundation for Innovation and Training in Surgery in Geneva. It was held for 5 neurosurgical residents (PGY1-3) who participated to this first pilot experience in January 2019. The main goal was to cover the very basic aspects of cranial surgery, including both technical and non-technical skills. The course was developed in modules, starting from the diagnostic paths and communication with patients (played by professional actors), then moving to practical simulation sessions, rapid theoretical lessons, and discussions based on real cases and critical ethical aspects. At the end, the candidates had cadaver lab sessions in which they practiced basic emergency procedures and craniotomies. The interaction between the participants and the faculties was created and maintained using role plays that smoothly improved the cooperation during debriefs and discussions, thus making the sessions exceedingly involving.

RESULTS

At the end of the course, every trainee was able to complete the course curriculum and all the participants expressed their appreciation for this innovative format, with a particular emphasis on the time spent learning non-technical skills, confirming that they feel this to be a fundamental aspect of a comprehensive training in neurosurgery.

CONCLUSIONS

It is possible that this combined concept of training on technical and non-technical skills, using emerging technologies along with pedagogic techniques and cadaver dissection, may become the state-of-the-art for European Neurosurgical training programs in the next future.

Perseverance, faith and stoicism: a qualitative study of medical student perspectives on managing fatigue

CONTEXT

Fatigue risk management (FRM) strategies offer a potential solution to the widespread problem of fatigued trainees in the clinical workplace. These strategies assume a shared perception that fatigue is hazardous. Despite the growing body of evidence suggesting that fatigue leads to burnout and medical errors, previous research suggests that residents perceive fatigue as a personal, surmountable burden rather than an occupational hazard. Before we can implement FRM, we need a better understanding of when and how such problematic notions of fatigue are adopted by medical trainees. Thus, we sought to explore how third-year medical students understand and manage the workplace fatigue they experience during their first year of clinical rotations.

METHODS

A total of 22 third-year medical students participated in semi-structured interviews exploring their perspectives of workplace fatigue. Data collection and analysis occurred iteratively in keeping with constructivist grounded theory methodology and were informed by theoretical sampling to sufficiency.

RESULTS

Our participants described unprecedented levels of sleep deprivation combined with uncertainty and confusion that led to significant fatigue during training. Drawing on their workplace experience, trainees believed that fatigue posed three distinct threats, which evoked different coping strategies: (i) threat to personal health, managed by perseverance; (ii) threat to patients, managed by faith in the system, and (iii) threat to professional reputation, managed by stoicism.

CONCLUSIONS

Our findings highlight how senior medical students grapple with fatigue, as they understand it, within a training context in which they are expected to deny the impact of their fatigue on patients and themselves. Despite empirical evidence to the contrary, the prevailing assumption amongst our participants is that an ability to withstand sleep deprivation without impairment will develop naturally over time. Efforts to implement FRM strategies will need to address this assumption if these strategies are to be successfully taken up and effective.

Advancing spinal fellowship training: an international multi-centre educational perspective

PURPOSE

The purpose of this article is to review the importance of contemporary spine surgery fellowships and educational strategies to assist with fellowship design and delivery.

METHODS

Spine surgery fellowship includes trainees from orthopaedic and neurosurgical backgrounds and is increasingly indicated for individuals wishing to pursue spine surgery as a career, recognizing how spinal surgery evolved significantly in scope and complexity. We combine expert opinion with a review of the literature and international experience to expound spine fellowship training.

RESULTS

Contemporary learning techniques include boot camps at the start of fellowship which may reinforce previous clinical learning and help prepare fellows for their new clinical roles. There is good evidence that surgical specialty training boot camps improve clinical skills, knowledge and trainee confidence prior to embarking upon new clinical roles with increasing levels of responsibility. Furthermore, as simulation techniques and technologies take on an increasing role in medical and surgical training, we found evidence that trainees' operative skills and knowledge can improve with simulated operations, even if just carried out briefly. Finally, we found evidence to suggest a role for establishing competence-based objectives for training in specific operative and technical procedures. Competence-based objectives are helpful for trainees and trainers to highlight gaps in a trainee's skill set that may then be addressed during training.

CONCLUSIONS

Spinal fellowships may benefit from certain contemporary strategies that assist design and delivery of training in a safe environment. Interpersonal factors that promote healthy teamwork may contribute to an environment conducive to learning. These slides can be retrieved under Electronic Supplementary Material.

The clinical learning environment

Learning in a clinical context is foundational in the training of health professionals; there is simply no alternative. The subject of the clinical learning environment (CLE) is at the forefront of discussions. In this introduction to a themed issue on the CLE, we present an expanded conceptual model that approaches the CLE through six different lenses, termed "avenues:" architectural, digital, diversity and inclusion, education, psychological, and sociocultural, with each avenue represented by a paper. The aim is to facilitate dialog around the contributions of different academic disciplines to research on the CLE. Collectively the papers highlight the overlap between the various "avenues" in how they influence each other, and how they collectively have shaped the work to understand and improve the CLE. The expectation is that the various avenues can add to existing knowledge and create new ideas for interventions to improve the clinical learning environment across nations for learners and teachers with the ultimate aim of improving patient care. Research and efforts to improve the CLE are critical to learning, professional socialization and well-being for trainees as they learn and participate in patient care, and to the quality of care they will deliver over decades of practice after graduation.

Filling the gap between the OR and virtual simulation: a European study on a basic neurosurgical procedure

BACKGROUND

Currently available simulators are supposed to allow young neurosurgeons to hone their technical skills in a safe environment, without causing any unnecessary harm to their patients caused by their inexperience. For this training method to be largely accepted in neurosurgery, it is necessary to prove simulation efficacy by means of large-scale clinical validation studies.

METHODS

We correlated and analysed the performance at a simulator and the actual operative skills of different neurosurgeons (construct validity). We conducted a study involving 92 residents and attending neurosurgeons from different European Centres; each participant had to perform a virtual task, namely the placement of an external ventricular drain (EVD) at a neurosurgical simulator (ImmersiveTouch). The number of attempts needed to reach the ventricles and the accuracy in positioning the catheter were assessed.

RESULTS

Data suggests a positive correlation between subjects who placed more EVDs in the previous year and those who get better scores at the simulator (p = .008) (fewer attempts and better surgical accuracy). The number of attempts to reach the ventricle was also analysed; senior residents needed fewer attempts (mean = 2.26; SD = 1.11) than junior residents (mean = 3.12; SD = 1.05) (p = .007) and staff neurosurgeons (mean = 2.89, SD = 1.23). Scoring results were compared by using the Fisher's test, for the analysis of the variances, and the Student's T test. Surprisingly, having a wider surgical experience overall does not correlate with the best performance at the simulator.

CONCLUSION

The performance of an EVD placement on a simulator correlates with the density of the neurosurgical experience for that specific task performed in the OR, suggesting that simulators are able to differentiate neurosurgeons according to their surgical ability. Namely this suggests that the simulation performance reflects the surgeons' consistency in placing EVDs in the last year.

A novel 3D-printed hybrid simulation model for robotic-assisted kidney transplantation (RAKT)

Robotic-assisted kidney transplantation (RAKT) offers key benefits for patients that have been demonstrated in several studies. A barrier to the wider uptake of RAKT is surgical skill acquisition. This is exacerbated by the challenges of modern surgery with reduced surgical training time, patient safety concerns and financial pressures. Simulation is a well-established method of developing surgical skill in a safe and controlled environment away from the patient. We have developed a 3D printed simulation model for the key step of the kidney transplant operation which is the vascular anastomosis. The model is anatomically accurate, based on the CT scans of patients and it incorporates deceased donor vascular tissue. Crucially, it was developed to be used in the robotic operating theatre with the operating robot to enhance its fidelity. It is portable and relatively inexpensive when compared with other forms of simulation such as virtual reality or animal lab training. It thus has the potential of being more accessible as a training tool for the safe acquisition of RAKT specific skills. We demonstrate this model here.

Satisfaction of doctors with their training: evidence from UK

Background

This study considers the primary training environment factors affecting the satisfaction of doctors in training with their training.

Methods

An OLS multiple regression analysis was performed on responses given by doctors in training (trainees) to General Medical Council (UK) National Trainee Survey annually from 2012 to 2015. Two different research models investigate the determinant of trainee doctor satisfaction. The first model includes clinical supervision, feedback, workload, and gender as explanatory variables. The second model adds supportive environment to the first model.

Results

The GMC survey response rate is 97%. Our analysis shows the key factors that determine trainee satisfaction are strong clinical supervision, frequent and useful feedback meetings, an adequate workload and a supportive environment.

Conclusions

It is suggested focus on clinical supervision, feedback, workload and supportive environment would increase trainee satisfaction, improve the quality of training and morale, and hopefully, therefore, the quality of care patients receive.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2792-0) contains supplementary material, which is available to authorized users.

Fatigue in Residency Education: Understanding the Influence of Work Hours Regulations in Europe

PURPOSE

Although one proposed solution to the problem of fatigued medical trainees is the implementation of work hours regulations, concerns about the effectiveness of these regulations are growing. Canada remains one of the few Western jurisdictions without legislated regulation. Recent research suggests that fatigue is a complex social construct, rather than simply a lack of sleep; thus, the authors explored how regulations and fatigue are understood in countries with established work hours frameworks to better inform other jurisdictions looking to address trainee fatigue.

METHOD

Using constructivist grounded theory methodology, the authors conducted individual, semistructured interviews in 2015-2016 with 13 postgraduate medical trainees from four European countries with established work hours regulations. Data collection and analysis proceeded iteratively, and the authors used a constant comparative approach to analysis.

RESULTS

Trainees reported that they were commonly fatigued and that they violated the work hours restrictions for various reasons, including educational pursuits. Although they understood the regulations were legislated specifically to ensure safe patient care and optimize trainee well-being, they also described implicit meanings (e.g., monitoring for trainee efficiency) and unintended consequences (e.g., losing a sense of vocation).

CONCLUSIONS

Work hours regulations carry multiple, conflicting meanings for trainees that are captured by three predominant rhetorics: the rhetoric of patient safety, of well-being, and of efficiency. Tensions within each of those rhetorics reveal that managing fatigue within clinical training environments is complex. These findings suggest that straightforward solutions are unlikely to solve the problem of fatigue, assure patient safety, and improve trainee well-being.

Foundation year one training in neurosurgery: achieving competency a 5-year review

INTRODUCTION

F1 doctors are a rare breed in Neurosurgery, featuring in only 4 out of 40 UK centres. It is widely perceived that Neurosurgery would only provide a highly specialised experience for F1s, limiting the opportunity to achieve the core practical and clinical competencies as highlighted by the United Kingdom Foundation Programme (UKFPO). Additionally, Health Education England have increased the number of community placements such as General Practice and Psychiatry further limiting F1 placements offered in specialities like Neurosurgery.

AIMS

We sought to acquire the views, experiences and true perspectives of training from F1 doctors in our neurosurgery centre. Importantly, we wanted to determine whether Neurosurgery provides sufficient opportunities to achieve mandatory core foundation competencies.

METHODS

We invited all F1s (27) to complete a secure-web based online questionnaire comprising nine domains of training. Responses: We had an overall response rate of 96%. Ninety-six per cent of our F1s valued this placement, gaining skills that could be transferred to other specialities. Eighty-eight per cent found the post to be of similar or greater value in comparison to their other F1 posts and 66% would recommend this post to others. Ninety-two per cent of F1s felt they were adequately supervised and regular informal feedback was offered in order to ensure acquisition of core competences. Fourty-four per cent of F1s were involved in post-graduate academia. All trainees attended their mandatory F1 teaching although attendance to additional departmental teaching was limited.

DISCUSSION

Trainees found that Neurosurgery provided a generalised exposure not a specialised one. Ninety-two per cent felt Neurosurgery had provided sufficient educational opportunities to achieve their required competencies. Importantly, all trainees managed to achieve their core generic competencies. F1 placements in Neurosurgery are highly beneficial to both trainee and service. The placement provides more than sufficient educational opportunities to help meet mandatory training requirements. F1 doctors also augment the number of junior doctors supporting the neurosurgical service.

Magnitude of non-operative surgical emergency admissions; service implications for surgical and radiological practice

BACKGROUND

Financial sustainability is an area of sharp ongoing focus across the broad spectrum of the Irish Health Service. Recent attention has been drawn to the financial implications of non-operative surgical admissions, suggesting that some of these may be unnecessary.

AIMS

In this study, we aim to determine the volume of emergency surgical admissions to Mayo University Hospital (MUH), in particular, to identify the scale of non-operative admissions and to assess the wider inherent implications for acute hospital services.

METHODS

An electronic handover system for emergency surgical admissions was introduced in MUH in September 2014. All surgical admissions from September 1st 2014 to August 31st 2015 were identified from this prospectively maintained database. HIPE (Hospital Inpatient Enquiry) data were not used in this study. Theatre logbooks confirmed those patients who required operative intervention.

RESULTS

1466 patients were admitted as emergencies during the study period. 58 % (850) were male and median age was 48 years (0-100). Average length of stay was 5 days (range 1-125). 327 patients (22.3 %) required operative intervention. The most commonly performed procedure was appendicectomy (52.5 %). 48 (3.3 %) patients were transferred to other hospitals. 131 (8.9 %) admissions related to the acute urological conditions. Of the 1466 admissions, 546 underwent a CT scan, while 342 patients proceeded to ultrasound.

CONCLUSION

Almost 80 % of all surgical emergency admissions were discharged without undergoing a formal operative procedure while generating a significant workload for the radiology department. Changes in working practices and hospital network structures will be required to reduce the burden of non-operative emergency admissions.

Advanced Level Practice Education: UK Critical Care Pharmacists' Opinions in 2015

National UK standards for critical care highlight the need for clinical pharmacists to practice at an advanced level and above. The aim of this research paper was to describe the views of UK critical care pharmacists on the current provision of Advanced Level Practice (ALP) education and accreditation. It sought to identify whether there is a need for a national or regional training programme. A questionnaire was delivered electronically targeting UK critical care pharmacists. Whilst the response rate was low at 40% (166/411); the views expressed were representative of UK practitioners with the majority of responders meeting the national specifications for clinical pharmacist staffing in critical care areas. The responses highlighted work-based learning as the main resource for developing ALP and a lack of suitable training packages. The vast majority of pharmacists identified that a national or regional training programme was required for ALP. The results also identified the main barriers to undertaking ALP accreditation were lack of time, uncertainty regarding the process and its professional benefits and a lack of education and training opportunities. In conclusion, the responses clearly indicated that, for the necessary progression of critical care pharmacists to ALP, a national or regional training programme is required.

Review of 3-Dimensional Printing on Cranial Neurosurgery Simulation Training

OBJECTIVE

Shorter working times, reduced operative exposure to complex procedures, and increased subspecialization have resulted in training constraints within most surgical fields. Simulation has been suggested as a possible means of acquiring new surgical skills without exposing patients to the surgeon's operative "learning curve." Here we review the potential impact of 3-dimensional printing on simulation and training within cranial neurosurgery and its implications for the future.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a comprehensive search of PubMed, OVID MEDLINE, Embase, and the Cochrane Database of Systematic Reviews was performed.

RESULTS

In total, 31 studies relating to the use of 3-dimensional (3D) printing within neurosurgery, of which 16 were specifically related to simulation and training, were identified. The main impact of 3D printing on neurosurgical simulation training was within vascular surgery, where patient-specific replication of vascular anatomy and pathologies can aid surgeons in operative planning and clip placement for reconstruction of vascular anatomy. Models containing replicas of brain tumors have also been reconstructed and used for training purposes, with some providing realistic representations of skin, subcutaneous tissue, bone, dura, normal brain, and tumor tissue.

CONCLUSION

3D printing provides a unique means of directly replicating patient-specific pathologies. It can identify anatomic variation and provide a medium in which training models can be generated rapidly, allowing the trainee and experienced neurosurgeon to practice parts of operations preoperatively. Future studies are required to validate this technology in comparison with current simulators and show improved patient outcomes.