Should oesophagectomies be performed by trainees? The experience from a single teaching centre under the supervision of one surgeon

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Does staged surgical training for minimally invasive esophagectomy have an impact on short-term outcomes?

BACKGROUND

sophageal cancer has a low incidence, and the anatomy is difficult to understand during esophagectomy. This necessitates a precise and lengthy operation. Therefore, the establishment of a training system in esophageal surgery is of critical importance. In this study, we compared the short-term outcomes of minimally invasive esophagectomy (MIE) performed by consultants versus trainees and explored the factors that impacted the thoracic operation time for each group.

METHODS

We have introduced standardized MIE surgical techniques to our trainees in 2016. Our procedure consists of a laparoscopic phase and a thoracoscopic phase and is systematically designed to be learned in a step-by-step manner in each phase. We retrospectively identified 308 patients who underwent MIE from April 2016 to April 2018. The patients were divided into those who underwent MIE by consultants and those who underwent MIE by trainees. The preoperative background factors, operation-related factors, and postoperative complications were compared between the two groups. We also assessed the association between a prolonged thoracic operation time and tumor-and patient-related factors in each of the consults and trainees.

RESULTS

Significantly more patients had stage ≥ III cancer in the consultant than trainee group. However, the postoperative complications were comparable, specifically pneumonia (11% vs. 18%), anastomotic leakage (11% vs. 13%), and mortality (0.6% vs. 1.3%). There was no significant difference in the lymph node yield (20 vs. 17) or R0 resection rate (94% vs. 91%) between the two groups. However, the trainees had a significantly longer thoracic operation time (143 ± 34 vs. 190 ± 28 min) and significantly greater blood loss (93 vs. 183 ml). Oncological factors were correlated with a prolonged thoracic operation time in the consultants, but not in the trainees.

CONCLUSIONS

Under standardized surgical management using a stepwise educational program, performance of MIE by trainees has no impact on short-term outcomes.

Impact of trainee involvement in esophagectomy on clinical outcomes: a narrative systematic review of the literature

Changes in the structure of surgical training have affected trainees' operative experience. Performing an esophagectomy is being increasingly viewed as a complex technical skill attained after completion of the routine training pathway. This systematic review aimed to identify all studies analyzing the impact of trainee involvement in esophagectomy on clinical outcomes. A search of the major reference databases (Cochrane Library, MEDLINE, EMBASE) was performed with no time limits up to the date of the search (November 2017). Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and study quality assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Four studies that included a total of 42 trainees and 16 consultants were identified, which assessed trainee involvement in open esophagogastric resectional surgery. A total of 1109 patients underwent upper gastrointestinal procedures, of whom 904 patients underwent an esophagectomy. Preoperative characteristics, histology, neoadjuvant treatment, and overall length of hospital stay were comparable between groups. One study found higher rates of anastomotic leaks in procedures primarily performed by trainees as compared to consultants (P < 0.01)-this did not affect overall morbidity or survival; however, overall anastomotic leak rates from the published data were 10.4% (trainee) versus 6.3% (trainer) (P = 0.10). A meta-analysis could not be performed due to the heterogeneity of data. The median MINORS score for the included studies was 13 (range 11-15). This study demonstrates that training can be achieved with excellent results in high-volume centers. This has important implications on the consent process and training delivered, as patients wish to be aware of the risks involved with surgery and can be reassured that appropriately supervised trainee involvement will not adversely affect outcomes.

Effect of publishing surgeon-specific outcomes on surgical training

Background

Over the past 10 years, the National Health Service in England has started to publish surgeon-specific outcomes publicly. The aim of this study was to investigate how this has affected training case exposure for surgeons in training.

Methods

Anonymized data were collected from the Intercollegiate Surgical Curriculum Programme database for operations in each specialty with published surgeon outcomes, involving surgical trainees on an approved training programme between 1 January 2011 and 31 December 2016. Trainee and supervisor involvement in operations before and after the start of publication of surgeon-specific outcomes were compared using mixed-effects models.

Results

A total of 163 076 recorded operative procedures were included. A statistically significant improvement in exposure to training procedures was observed for anterior resection of rectum, carotid endarterectomy, gastrectomy, meningioma excision, prostatectomy and thyroidectomy following the introduction of publication of surgeon outcomes. In coronary artery bypass grafting (CABG) and total hip replacement (THR), however, there was a reduction in involvement in training procedures. This was apparent for both trainee and supervisor involvement in CABG, and for trainee involvement in THR.

Conclusion

Exposure to training procedures has improved rather than declined in the UK in the majority of surgical specialties, since the publication of surgeon-specific outcomes.

Consultant outcomes publication and surgical training: Consensus recommendations by the association of surgeons in training

Consultant Outcomes Publication (COP) has the longest history in cardiothoracic surgery, where it was introduced in 2005. Subsequently COP has been broadened to include all surgical specialties in NHS England in 2013-14. The Association of Surgeons in Training (ASiT) fully supports efforts to improve patient care and trust in the profession and is keen to overcome potential unintended adverse effects of COP. Identification of these adverse effects is the first step in this process: Firstly, there is a risk that COP may lead to reluctance by consultants to provide trainees with the necessary appropriate primary operator experience to become skilled consultant surgeons for the future. Secondly, COP may lead to inappropriately cautious case selection. This adjusted case mix affects both patients who are denied operations, and also limits the complexity of the case mix to which surgical trainees are exposed. Thirdly, COP undermines efforts to train surgical trainees in non-technical skills and human factors, simply obliterating the critical role of the multidisciplinary team and organisational processes in determining outcomes. This tunnel vision masks opportunities to improve patient care and outcomes at a unit level. It also misinforms the public as to the root causes of adverse events by failing to identify care process deficiencies. Finally, for safe surgical care, graduate retention and morale is important - COP may lead to high calibre trainees opting out of surgical careers, or opting to work abroad. The negative effects of COP on surgical training and trainees must be addressed as high quality surgical training and retention of high calibre graduates is essential for excellent patient care.

Provision of care by medical residents and the impact on quality

The quality of care received by patients is a basic element of modern medicine. Medical residents or interns are essential within the healthcare system, but their lack of experience can raise concerns about the quality of care given. A registrar or specialist has greater knowledge and skills, while a resident has greater motivation and enthusiasm. The aim of training programs is to prepare residents to provide high quality care. This requires close supervision that seems to be lacking, with the consequent impact on both healthcare quality and academic results. The so-called "July effect" refers to the diminished quality of care during the summer months when resident physicians switch over. The results of studies analysing this effect vary widely, but the loss of efficacy during these months does seem to be real. Pulmonology is one of medical specialties that generates the least demand for internships and residencies, but it is impossible to determine if this affects the quality of care. The high prevalence of respiratory diseases and the latest diagnostic and therapeutic advances may mean that this situation will change in coming years.

Publication of surgeon specific outcome data: a review of implementation, controversies and the potential impact on surgical training

Government-mandated publication of named surgeon-specific outcome data (SSD) has recently been introduced across nine surgical speciality areas in England. This move is the first time that such national data has been released in any country, and it promises to provide a significant advancement in health service transparency. Data is derived from nine preexisting national surgical audit databases. However, eight of these were not originally designed for this purpose, and there is considerable controversy surrounding data quality, risk adjustment, patient use and interpretation, and surgeons' subsequent case selection. Concerns also surround the degree to which these results truly reflect the individual consultant, or the wider hospital team and accompanying resources. The potential impact on surgical training has largely been overlooked. This paper investigated the background to SSD publication and controversies surrounding this, the potential impact on surgical training and the response to these concerns from medical and surgical leaders. As SSD collection continues to be refined, the most appropriate outcomes measurements need to be established, and risk adjustment requires ongoing improvement and validation. Prospective evaluation of changes in surgical training should be undertaken, as any degradation of will have both short and long-term consequences for patients and surgeons alike. It is important that the literature supporting the safety of supervised trainee practice is also promoted in order to counterbalance any potential concerns that might detract from trainee operating opportunities. Finally, it is important that outcomes data is communicated to patients in the most meaningful way in order to facilitate their understanding and interpretation given the complexities of the data and analysis involved.

A systematic review of the effects of residency training on patient outcomes

BACKGROUND

Residents are vital to the clinical workforce of today and tomorrow. Although in training to become specialists, they also provide much of the daily patient care. Residency training aims to prepare residents to provide a high quality of care. It is essential to assess the patient outcome aspects of residency training, to evaluate the effect or impact of global investments made in training programs. Therefore, we conducted a systematic review to evaluate the effects of relevant aspects of residency training on patient outcomes.

METHODS

The literature was searched from December 2004 to February 2011 using MEDLINE, Cochrane, Embase and the Education Resources Information Center databases with terms related to residency training and (post) graduate medical education and patient outcomes, including mortality, morbidity, complications, length of stay and patient satisfaction. Included studies evaluated the impact of residency training on patient outcomes.

RESULTS

Ninety-seven articles were included from 182 full-text articles of the initial 2,001 hits. All studies were of average or good quality and the majority had an observational study design. Ninety-six studies provided insight into the effect of 'the level of experience of residents' on patient outcomes during residency training. Within these studies, the start of the academic year was not without risk (five out of 19 studies), but individual progression of residents (seven studies) as well as progression through residency training (nine out of 10 studies) had a positive effect on patient outcomes. Compared with faculty, residents' care resulted mostly in similar patient outcomes when dedicated supervision and additional operation time were arranged for (34 out of 43 studies). After new, modified or improved training programs, patient outcomes remained unchanged or improved (16 out of 17 studies). Only one study focused on physicians' prior training site when assessing the quality of patient care. In this study, training programs were ranked by complication rates of their graduates, thus linking patient outcomes back to where physicians were trained.

CONCLUSIONS

The majority of studies included in this systematic review drew attention to the fact that patient care appears safe and of equal quality when delivered by residents. A minority of results pointed to some negative patient outcomes from the involvement of residents. Adequate supervision, room for extra operation time, and evaluation of and attention to the individual competence of residents throughout residency training could positively serve patient outcomes. Limited evidence is available on the effect of residency training on later practice. Both qualitative and quantitative research designs are needed to clarify which aspects of residency training best prepare doctors to deliver high quality care.