Surgical training: an objective assessment of recent changes for a single health board
BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7084.891 (Published 22 March 1997) Cite this as: BMJ 1997;314:891
- T J Crofts, consultant surgeona,
- J M T Griffiths, consultant surgeona,
- S Sharma, specialty registrara,
- J Wygrala, surgical senior house officera,
- R J Aitken, consultant surgeona
- Correspondence to: Mr Crofts
- Accepted 31 December 1996
Abstract
The reduction in doctors' hours and the introduction of specialist training have reduced general surgical training by 60%. This study assessed the implications for a single health board. A questionnaire listing 13 representative operations was sent to 44 trainees and 52 trainers to determine the number of operations a trainee should perform. The total number of operations required for training was compared against the total actually performed across the health board. Operating times for five representative operations were audited prospectively. Trainers and trainees recommended a similar and conservative number of operations. The total number of operations available for training (4913) was 38% less than the number recommended (7946). Trainees required 50-75% more operating time than consultants. To increase the proportion of operations undertaken by trainees from the current 30% to 70% would require an extra 270 theatre days (or £1.3m) yearly. The minimum number of operations required for training must be defined and the proportion of supervised operations undertaken by trainees substantially increased. Service and financial implications will have to be addressed. Action is needed urgently, as the first trainees will become consultants in less than five years.
Introduction
During the past decade many official reports reorganising the National Health Service have combined to reduce the level of general surgical training. Achieving a Balance: Plan for Action proposed an increase in the number of NHS consultants and a proportionate decrease in the number of trainees.1 To a large extent its proposals have not been fulfilled. The confidential enquiry into perioperative deaths2 recommended greater consultant participation in emergency surgery. The “new deal” for junior doctors' hours3 and the introduction of specialist training4 have reduced surgical training time by around two thirds.5 There will be a further reduction in experience if “hard pressed” specialties are limited to 56 hours a week or if the European Commission imposes a limit of 48 hours a week. Other changes such as the increasing trend to day case surgery, waiting list initiatives, and the use of staff grade surgeons, nurses, and surgeon assistants will all remove ideal training cases from trainees.
In order to provide trainees with the necessary practical experience the intensity of surgical training will have to be increased. The practical implications of providing this intensive training do not seem to have been fully considered. We conducted an objective assessment of whether current general surgical practice within a single health board can satisfactorily accommodate the requirements of the proposed shortened general surgical training programme.
Methods
The study was carried out in three stages.
Stage 1
A postal questionnaire was sent to every general surgical consultant (trainer), senior house officer, and specialist registrar (trainees) in the south east Scotland general surgical training scheme. Subjects included trainers and trainees in district general and teaching hospitals who were working in both general surgery and specialist units. They were presented with a range of general surgical operations (indicator operations) and asked to state the ideal number of supervised and unsupervised operations that trainees should be expected to undertake during three periods of surgical training (senior house officer and specialist registrar in years 1-3 and 4-6). The mean number of indicator operations considered ideal for training was calculated.
The distribution of trainees throughout Lothian before and after the introduction of the present training programme was obtained from the chairmen of the training schemes. In the present scheme there were 35 trainees (17 senior house officers, 18 specialist registrars), an overall increase of 25%. Previously there had been 28 trainees (12 senior house officers, seven registrars, nine senior registrars).
The total number of indicator operations required in Lothian to provide the ideal training was the product of the mean number of recommended training operations and the number of trainees. Because some general surgery in Lothian is undertaken only in specialist units it was assumed that trainees could receive training only appropriate to the unit in which they worked. For example, training in breast surgery was not expected in the vascular unit. Surgical trainees based in the transplant and intensive care units and three staff grade surgeons were excluded from the calculations.
Stage 2
General surgical activity within Lothian was obtained from the Lothian Surgical Audit database.6 This provided the total number of general surgical operations, including indicator operations, actually undertaken in Lothian during 1994. This was compared against the ideal number of indicator operations recommended by the trainers and trainees and any difference calculated.
Stage 3
A prospective study of skin to skin operating times for five indicator operations was conducted at the Eastern General Hospital. As the aim was to compare skin to skin times for various combinations of trainees and trainers, the patients selected were simple cases with a similar degree of complexity. For example, recurrent operations and obese patients were excluded, as they would not normally be suitable for training. The total skin to skin time required to perform each timed indicator operation was then calculated for each combination of surgeons. The additional time required for training could then be estimated. This calculation could be repeated after changing the proportion of operations undertaken by trainees and whether or not the operations were supervised.
Using the Lothian Surgical Audit database we estimated the total skin to skin operating time (the product of the total number of operations and the mean recorded time) for these five timed indicator operations across the whole of Lothian. The five timed indicator operations represented 32% of the workload and 36% of the caseload for all general surgical operations in Lothian.7 We therefore assumed that these timed indicator operations represented one third of the total general surgical activity across Lothian. The total skin to skin operating time for all general surgery across Lothian could then be estimated. This calculation could be repeated after adjusting the proportion of operations performed by trainees. Thus an estimate of the total number of additional days required for training could then be calculated (seven skin to skin hours being taken as representing one theatre day).
Results
Questionnaires were sent to 52 trainers and 44 trainees; 27 (52%) and 15 (34%) respectively responded. The mean numbers of indicator operations recommended by the trainers and the trainees were very similar, so only data for trainers were used. Table 1) shows the mean numbers of indicator operations recommended by the trainers. Table 2) gives the actual numbers of indicator operations performed in Lothian. Table 2) also shows the differences between the numbers of operations required for training and the actual numbers performed.
Mean numbers of operations that trainers recommended that individual trainees should undertake each year
Yearly numbers of operations estimated to provide adequate training at each stage and differences between total numbers of training operations required and actual numbers of operations undertaken each year
Mean and range of operating times (minutes) for five indicator operations and various combinations and grades of surgeon and assistant. Registrar includes both experienced overseas trainee and previously appointed senior registrar
Table 3 shows the mean skin to skin operating times for various combinations of trainer and trainee undertaking the five indicator operations. At this hospital each 10% increase in the proportion of operations undertaken by trainees would require an extra 23 theatre days a year. If the proportion of general surgical operations undertaken by trainees in Lothian was increased from one in three to two in three an extra 270 theatre days a year would be required.
Discussion
This study suggests that Lothian hospitals (serving a population of around 750 000) will not be able to provide the level of general surgical training that trainers and trainees believe is required. So far as we know this is the first objective study assessing the implications of the recent changes to surgical training across a region. Indeed, it is unlikely that a similar study could be undertaken elsewhere in the United Kingdom because the Lothian Surgical Audit database is a unique regional record of surgical activity.6 8 However, there is no reason to think that the training opportunities in other health boards or surgical specialties will be any different.
The numbers of training operations proposed for individual trainees were not unrealistic. Many people might consider them a conservative estimate. However, the larger number of trainees and the shorter training period meant that the total number of training operations required across the region greatly exceeded the number available. Laparoscopic cholecystectomy can be used as an example. During the first year of surgical training a senior house officer would perform six of these operations under supervision and none independently. During each of the first three years a specialty registrar would perform a further 13 under supervision and six independently. In each of the second three years these figures would be 10 and 18 respectively.
Despite these very modest individual requirements the regional need as assessed by the trainers was for 1409 laparoscopic cholecystectomies. However, only 598 were actually undertaken, a shortfall of 811. These figures assume that 60% of laparoscopic cholecystectomies are undertaken by trainees. The reality is that in 1995 only 30% were performed by trainees. Even if consultants and staff grade surgeons did not perform a single laparoscopic cholecystectomy there would still be a 50% shortfall in the number required for training. If the proportion of laparoscopic cholecystectomies undertaken by trainees was increased from 30% to 70% an additional 92 theatre days would be required in Lothian. This does not include the extra time required for anaesthetic training or setting up the theatre.
Loss of training opportunities
The true situation is almost certainly substantially worse. In future senior house officers will undertake only six months and not 12 months of general surgery, and as this will be their first surgical experience they are likely to undertake proportionately fewer cases than in the full year assumed for this study. The questionnaire also assumed that trainees would receive training in each operation every year. This will not be so. Trainees will have to rotate through units that offer little or no experience in some types of surgery. These calculations also assume that every operation is suitable for training, which will not be the case. Realistically, trainees might be expected to receive 50-70% of the training assumed in this study.
More difficult to assess is the loss of training opportunities that have undoubtedly occurred from more subtle changes in surgical practice. For example, attachments will be for shorter periods and training opportunities will be lost at each rotation while the consultant assesses the new trainee.9 10 Increasing calls for senior staff to be responsible for day cases and waiting list initiatives will deny trainees access to ideal training operations. The increasing use of staff grade surgeons, theatre assistants, and nurses will further deprive trainees of cases that are typically ideal for training. In future, contracts should insist that a minimum proportion of day case and waiting list operations are undertaken by both supervised and unsupervised trainees.
Consultant assisting at laparoscopic cholecystectomy
ANTONIA REEVE
Senior surgical registrars in the United Kingdom were traditionally appointed as fully trained “stand alone” consultants. As matters stand now the first of the present specialty registrars will be expected to discharge the same responsibilities when they become consultants in less than five years. There is no doubt specialty registrars will have neither the depth nor breadth of experience that their predecessors had. It is essential that all concerned recognise that this potential problem will become a real problem in less than five years.
Possible solutions
A return to the past, when trainees were stated to have been overexperienced but undertrained,11 would not be appropriate or acceptable to trainees, politicians, or patients. No single solution will solve this problem but the following possibilities should be considered.
Purchasers, providers, and educational authorities must agree that teaching and training are in every way of equivalent valueto clinical work. Until there is this commitment training will alwaysbe subjugated to service requirements.
This means that the number and proportion of both supervised and unsupervised operations undertaken by trainees will have to be substantially increased. This would require absolute numbers to be defined and includedin the contracting process. This is implied in the Department of Health guide to specialist registrartraining, which states that assessment should “measure progress against defined criteria” and that trainees “have to meet an agreed standard.”12 However, to date neither the Royal Colleges of Surgeons nor the postgraduate deans have been prepared to define these criteria. As a result consultants are trapped betweenmanagers who wish to see service activity increased and training bodies that wish to see training increased. In large part these objectives are incompatible andconsultants will become the pawn in the middle. This can only contribute further to consultantdisillusionment.
To accept that trainees will not receive enough training before becoming consultants and will complete their training after taking up their consultant appointment. In the early years a junior consultant may frequently require assistance from senior colleagues. This has obvious service implications.
A natural extension of this concept would be to plan the introduction of a subconsultant grade. This has not previously been considered an attractive option by the surgical community but would seem to be the inevitable consequence of the current arrangements.
To provide additional funding to selected trainees, who would then undertake “specialist fellowships” and assume responsibility for major and complex cases.
To recognise that narrow specialisation is the way of the future and to rotate trainees only to those units which offer the relevant training in their chosen specialty. This would have important future logistical implications for many district general hospitals.
To accept that the recent 60% reduction in trainees' overall training is excessive. Two options would be to increase the basic surgical training period by an additional year of general surgery and to permit a limited increase in the number of hours on call.
For trainers and educational authorities to agree that the immediate priority is to preserve and increase training. Managers and politicians should be left to sort out the inevitable growth in waiting lists.
The government's stated aim is to increase the number of consultants1 but thus far expansion has been limited. Failure to increase the number of consultants lies at the heart of the present problem. However, additional consultants are an expensive investment and many trusts will not create new posts without increased funding. At present there are unfilled consultant vacancies because of an acute shortage of trainees and so expansion is not possible. This is unlikely to be resolved before the first of the current (undertrained) specialist registrars become consultants.
Additional operating time for trainees
Though it is self evident that trainees require more time than consultants to perform operations, no previous report has studied the additional requirements in detail. One retrospective study reviewed overall activity for a mixture of cases but did not undertake a detailed analysis of specific training operations.13 In that study it was possible to determine whether the trainee was the surgeon but not whether he or she was supervised. In this study trainees required 50-75% more time than the consultants to undertake simple operations. This may be an optimistic assessment because by current standards all the trainees were comparatively experienced. The three senior house officers in this study were at the end of their first year whereas future senior house officers will be in post for only six months. One specialist registrar in this study was an experienced overseas registrar and the other an experienced senior registrar converted from a career grade registrar post.
Notably, only the specialist vascular and breast units could provide the trainees with the required number of operations. This was partly because the operations were more concentrated but also because the ratio of trainees to trainers was typically one to one whereas it was nearer one to two in the other units.
At an average theatre expenditure of £700 an hour the extra 270 days required would cost Lothian Health an extra £1.3m for general surgery alone. There is no reason to believe that the situation in other surgical specialties will be substantially different. Hence the increased cost of surgical training to Lothian Health will be considerable. An independent study has estimated the increased cost of the specialist training proposals as 6% of trust income.14
In conclusion, this study has shown that the present proposals for general surgical training will not provide trainees with enough experience. This problem needs to be addressed urgently, as the first specialist registrars will become consultants in less than five years.
Acknowledgments
We thank the Royal College of Surgeons of Edinburgh and LothianSurgical Audit for their help.
Footnotes
-
Funding None.
-
Conflict of interest None.