Cent Of Consultants Research Articles

Trainee-trainer outcomes in mastoid surgery: a comparative study.

Mastoid exploration remains an advanced, mainstay operation within ENT, in which the surgical trainees' role has been debated. This audit compares mastoid exploration outcomes between trainees and consultants. Cortical mastoidectomy, atticotomy, atticoantrostomy, modified radical mastoidectomy, combined-approach tympanoplasty and revision mastoidectomy operations performed between 2009 and 2020 were reviewed. Complications assessed were: facial palsy, labyrinth injury, dead ear, disease recurrence and time to recurrence. The chi-square test was used to determine significant associations. A total of 118 operations were surveyed. Thirty-five per cent of procedures (n = 41) were performed by trainees under supervision, and 65 per cent (n = 77) were carried out solely by consultants. Patients from 5 per cent of trainees' operations (n = 2) developed recurrence, compared with 7.8 per cent of consultants' (n = 6) (p = 0.55). No other complications developed in either group. The results corroborate those of other studies, indicating no significant increase in complication rate from consultants to trainees. Trainees likely completed less complicated cases. The stepwise incorporation of trainees did not compromise patient safety.

Eustachian tube balloon dilatation: a cross-sectional, survey-based study of 137 UK consultants.

To explore the opinions of the UK consultant body on endoscopic Eustachian tube balloon dilatation in the context of Eustachian tube dysfunction. A 10-question online survey was distributed to ENT consultants currently practising in the UK (July-September 2018). A total of 137 ENT consultants responded. Twenty-three per cent reported experience of Eustachian tube balloon dilatation, with a further 10 per cent planning to start performing the procedure. Of those performing the procedure, 16 per cent had more than two years' experience. Thirty-two per cent were performing zero to five procedures a year. Eustachian tube balloon dilatation was primarily conducted to treat Eustachian tube dysfunction symptoms, as well as retraction pockets, baro-challenge-induced Eustachian tube dysfunction and otitis media with effusion. The most common reason for not undertaking Eustachian tube balloon dilatation was insufficient evidence of efficacy (65 per cent). Seventy-two per cent of consultants thought that creating a national database for audit and monitoring purposes would benefit the specialty. The majority of UK ENT consultants do not practise Eustachian tube balloon dilatation, citing a lack of high-level evidence to support its use. A national database for auditing and research could facilitate the creation of guidelines.

The National Bowel Cancer Audit Project: what do trusts think of the National Bowel Cancer Audit and how can it be improved?

The National Bowel Cancer Audit Project (NBOCAP) collects data from hospitals in the UK and aims to improve surgical outcomes and quality of care for patients. The aims of this study were to understand why trusts were/were not participating in the NBOCAP and how to improve the quality of data collected and feedback. This was a prospective e-survey on colorectal surgeons' attitudes towards and opinions of the NBOCAP, within trusts in the UK. A questionnaire was emailed to members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI). Of the 171 trusts contacted by email, 66% of trusts (n = 117) had at least 1 consultant respond. Of the 117 trusts that responded, 60 (51.2%) had submitted data to the NBOCAP. A total of 549 consultants received the questionnaire, and 159 (29.0%) consultants responded. Fifty-one per cent (n = 60) of the trusts had submitted data to the NBOCAP. Reasons for data submission included the following: comparison of a units' data with national data (56.8%), a national audit improves outcomes (45.9%) and generation of information for use at a local level (42.6%). The main reasons for non-submission were as follows: lack of technical support (23.6%), lack of funding (19.6%) and lack of dedicated audit time (18.9%). Ninety-six (60.4%) consultants felt that the audit report should identify individual trust results. Fifty-three per cent of consultants (n = 87) rated their trusts' resources for audit as being very poor or poor. Consultant members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) within hospital trusts in the UK feel participation in the National Bowel Cancer Audit improves patients' quality of care and surgical outcomes. Increased awareness of the benefits of the NBOCAP and improved allocation of resources from hospital trusts could improve participation.

Naseptin® and peanut oil: a survey of practitioners' awareness in the UK

The aim of this study was to determine how aware ENT practitioners are that Naseptin (Alliance), widely used in ENT practice, contains peanut oil and to what extent this is conveyed to patients. A questionnaire was sent out to all ENT practitioners registered with the British Association of Otolaryngologists. Analysis of the data confirmed that Naseptin cream is widely used in ENT practice and showed that although most practitioners are aware that Naseptin cream contains refined peanut oil (arachis oil) (74.3 per cent of consultants and 93.6 per cent of registrars) not all ask their patients whether they are allergic to peanuts (62.6 per cent of consultants and 87.3 per cent of registrars). The results suggest that more should be done to raise awareness amongst practitioners that Naseptin cream contains peanut oil and should be avoided in patients with a peanut allergy, as recommended by national guidelines. The use of Naseptin cream when contraindicated may have medicolegal implications.

Topical antibiotic ototoxicity: does it influence our practice?

We hypothesised that general practitioners and ENT specialists manage discharging ears differently. This study was designed to investigate this further. Postal questionnaires were sent to all general practitioners in the Birmingham area and all UK consultants on the British Association of Otolaryngology-Head and Neck Surgery address list. In the presence of an intact tympanic membrane, 99 per cent of consultants and 90 per cent of general practitioners would use topical antibiotics. In the presence of a perforated tympanic membrane, 97 per cent of consultants would continue to use topical antibiotics, compared with only 43 per cent of general practitioners. This was attributed to a fear of ototoxicity. If a topical non-ototoxic antibiotic of proven efficacy could be made available, 93 per cent of consultants and 88 per cent of general practitioners in this study would seriously consider using it as first line treatment. The majority of general practitioners would not use topical antibiotics in the presence of a perforated tympanic membrane. Most doctors would consider using a non-ototoxic topical antibiotic as first line treatment should one be made available.

Psychological support for orthognathic patients – what do orthodontists want?

(1) To evaluate consultant orthodontist opinion on referral of orthognathic patients to a liaison psychiatrist or psychologist and (2) To investigate the value of training orthodontic specialists in recognition of patients with psychological profiles that might affect orthognathic outcome. Questionnaire-based study. A structured questionnaire was distributed to all consultant orthodontists in the UK. Approximately 40% of consultants thought that up to 10% of their orthognathic patients would benefit from psychological assessment by appropriately trained personnel. Twenty per cent of consultants were not certain what proportion of their patients would benefit from referral and over half the respondents said they do not refer any orthognathic patients for assessment. The most common reasons for referral were past/current psychiatric history (36%), unrealistic expectations (32%), 'gut instinct' (14%), no significant clinical problem (13%). Reasons not to refer were: nobody to refer to (30.5%), fear of patient reacting badly (15.8%), not sure who to refer to (14.7%), response from mental health team not useful (12.4%), waiting list too long (9.6%). The majority of clinicians felt they would benefit from training in this field (84.7%), as over 80% reported no teaching or training in psychological assessment/management. Although we have no evidence to prove that interdisciplinary care is better for patients, clinical experience and reports from clinicians working in large centres, tells us there are probable advantages. The development of a training programme for both orthodontists and mental health teams would seem to be beneficial for both clinicians and patients.

Transanal endoscopic microsurgery: a necessary requirement?

There has been a gradual introduction of transanal endoscopic microsurgery (TEM) into UK practice although the uptake remains variable. This study aimed to assess the availability, application and referral pattern of TEM amongst colorectal surgeons. A questionnaire was sent to all consultant members of the Association of Coloproctology. This considered their practice, the availability, application and referral pattern for TEM, and their views on application regarding a selection of rectal tumour scenarios. There were 142 replies representing 116 hospitals and 297 colorectal surgeons. The median catchment area was 280,000 (range 70,000-1,000,000). TEM was available in 18% of hospitals and 72% either performed or referred patents for TEM. Of 21 units performing TEM, 15 received referrals. From 305 TEM procedures performed over the previous year, 206 were referred cases. Eighty-five per cent of consultants considered TEM a necessary technique for optimum management of rectal lesions. Although 61% of consultants considered endoanal excision optimal for low benign rectal tumours, 58% said TEM was optimal for midrectal lesions and between 30% and 55% for high rectal lesions depending if the tumour position was anterior or posterior, respectively. One-third of consultants would perform TEM for a low T1 rectal carcinoma although half would proceed to anterior resection. TEM is considered to have a significant role in the optimal management of rectal lesions. The presence of the technique in a limited number of hospitals does appear to provide adequate resources although audit should continue to be centralized.

SPATIAL MARKETS FOR CONSULTANCY TO SMEs

ABSTRACTThis paper demonstrates the existence of both localised and national spatial markets for consultancy in Britain. A large survey sample of 1,208 client‐advisor links whose locations are geo‐coded is investigated using GIS software. It is expected from previous literature that search and selection effects, and the transaction costs of interaction at different distances, will influence the selection of consultants by clients. The paper shows that most client‐advisor relationships are geographically close: 61.3 per cent of links are less than 20 km in distance. But there is also a national market whereby 21.9 per cent of consultants are over 100 km and 7.9 per cent are over 200 km from the client. From these patterns, the maximum reach of market areas for different business centres can be estimated. This varies by type of consultancy assignment and size of business centre. The market area is only 30–40 km for consultancy on marketing and sales, and finance and taxation, which are sourced chiefly from local small business centres. For consultancy on business strategy and organisation, product design and quality and training/HR, regional centres and London play a more important role. The paper demonstrates something of a hierarchical structure of consultancy assignments and their spatial markets that is similar to that in retailing.

Clinical Practice 07

Aims: To assess the views of the consultant surgical community regarding the role of research in surgical training post-Calman. Methods: A postal survey of consultant members of ASGBI was performed to assess views on desirability, timing, duration and method of assessment of research in surgical training. The results were compared with a similar survey conducted pre-Calman in 1995. Results: A 50 per cent response rate was achieved compared to 71 per cent in the 1995 survey. Eight-two per cent of respondents had themselves obtained a higher degree by thesis. Overall, 89.7 per cent thought that research in training was either essential or desirable, compared to 89 per cent in the previous survey. Only 1.4 per cent felt that research should be conducted during BST (Basic Surgical Training) compared to 8 per cent previously. Forty-seven per cent indicated that research should be performed between BST and HST (Higher Surgical Training). Thirty-six per cent felt research during HST was most appropriate. Sixty-one per cent felt 1 year and 36 per cent 2 years of research was sufficient (91 and 9 per cent, respectively, in 1995). A total of 27.5 per cent thought that a thesis was the most appropriate method of assessment (33 per cent previously), while 35 per cent were supportive of an MSc (33 per cent previously). Eighty per cent of consultants with a higher degree thought research carried out as a trainee was worthwhile, both for their own education and career. There were no significant differences based on either age or specialist interest of the respondents. Conclusions: Even in the post-Calman era, 90 per cent of surgeons still regard research as either essential or desirable, although 1 year is regarded as adequate by the majority.

Current practice in the management of acute cholecystitis

AIMS: Several recent papers have advocated emergency cholecystectomy for patients with acute cholecystitis, stating that it is safe, cost effective and leads to less time off work. This study was designed to assess current practice in the management of acute cholecystitis in the UK. METHODS: A postal questionnaire was sent to 357 consultant surgeons who were thought to be involved in a general surgical on-call rota, to ascertain their current management of patients with acute cholecystitis. Replies were received from 250 consultants (70 per cent) of whom 242 (68 per cent) were involved in a general surgical take. Sixteen of these consultants, however, handed their patients with acute cholecystitis on to a different team the following day for further management. RESULTS: Twenty-seven consultants (12 per cent) routinely treat their patients by emergency cholecystectomy whenever possible, with 24 stating that they would do this within 72 h. Limiting factors to this practice were stated to be availability of surgical staff (15), theatre space (nine) and radiological investigations (four). The remaining consultants (n = 199) routinely manage their patients conservatively initially and providing they settle, either (1) book directly for cholecystectomy (n = 94, 47 per cent), (2) reassess as an outpatient (n = 65, 33 per cent), (3) either of above (n = 21; 11 per cent) or (4) refer on to a colleague (n = 19, 10 per cent). The commonest indications for acute cholecystectomy stated by consultants whose initial treatment policy is conservative are spreading peritonitis due to bile leak (93 per cent), empyema (89 per cent), unexpected space on a theatre list (28 per cent) and failure of an acute episode to settle (21 per cent). The laparoscopic method is the commonest for both elective and emergency cholecystectomy, but the percentage of consultants using an open method rises dramatically from 9 per cent in the elective situation to 48 per cent for emergency cholecystectomy. CONCLUSIONS: Despite evidence to support the increased use of emergency cholecystectomy, this practice is routinely carried out by only 12 per cent of consultants. However, of the consultants who treat their patients conservatively, 28 per cent are prepared to undertake emergency cholecystectomy if an unexpected space appears on the theatre list.

Insertion methods of the laryngeal mask airway. A survey of current practice in Wales.

The efficacy of the laryngeal mask is widely accepted, but there is a lack of consensus on the best insertion method and on the use of the mask for certain surgical procedures. We sent a questionnaire to all anaesthetists in Wales to discover the frequency of use of the laryngeal mask and the preferred insertion method. The questionnaire also enquired about the use of the laryngeal mask during anaesthesia for laparoscopic clip sterilisation. Replies were received from 125 consultants (89% of those circulated) and 122 non-consultants (69%). The insertion method described in the manufacturer's instruction manual was preferred by 30% of consultants and 34% of the others. The next most popular option was insertion of the mask with the cuff partially inflated. Twenty-three per cent of consultants and 34% of non-consultants were prepared to use the laryngeal mask during anaesthesia for laparoscopic clip sterilisation. Although the insertion technique described in the instruction manual is the most widely employed, a large number of alternative methods are frequently used.

A confidential comparative audit of stapedectomies: results of the Royal College of Surgeons of England Comparative Audit of ENT Surgery 1994

This paper presents the results of a national confidential comparative audit of stapedectomy: 185 operations by 28 consultants over a two-year period were retrospectively analysed. This included 10 revision procedures. Small fenestra stapedectomies accounted for 63 per cent of the total. Thirty-nine per cent of consultants operated on the second ear. Of the 168 stapedectomies in which the hearing change was known at six months, 87 per cent achieved improved hearing, eight per cent had no change and five per cent were worse. The overall complication rate was 30 per cent with a 'dead ear' rate of two per cent.

The future of stapedectomy — the Singapore problem

Concern has been expressed in the recent literature regarding the problem of a dwindling number of stapedectomy cases and an increasing number of surgeons trained to do this operation. In Singapore, the problem is made worse by the very low incidence of this disease in its main ethnic groups of Chinese and Malays who together make up more than 90 per cent of the population. We report here an audit of 47 ears that underwent stapedectomy in a teaching hospital over a six-year period. The hearing results for consultants and surgical trainees were compared. Closure of the air-bone gap to within 10 dB was obtained in 64 per cent of Consultants' cases and 68 per cent of trainees' cases. These results fall short of the 90 to 95 per cent figure reported by experts in this procedure and only comparable to the less satisfactory results of several series recorded by residents in North America. We conclude that the unsatisfactory results arise from the small number of surgical cases available for each surgeon to improve and maintain his skills in a technically demanding procedure. It is proposed that such cases be directed to those pursuing otology as a subspecialty rather than all otolaryngologists in general.

Supervision of trainees

The Royal College of Psychiatrists specifies that supervision of trainees is the single most important ingredient of training. This paper reports the results of a pre-audit survey about trainee supervision. Eighty-three per cent of consultants (n=52) and 67% of trainees (n=51) responded to a 21-item Likert questionnaire. There was unanimous agreement for seven items. A significant number of consultants and trainees were dissatisfied with the existing arrangements despite the majority being involved in weekly supervision. The minimum standards proposed served as the basis for providing guidelines against which practice may be audited.

Do the teaching hospitals of the University of Queensland really want a four‐year medical course?; A guarded yes

To gauge the measure of support among clinical teaching staff for the University of Queensland's proposals to introduce a four-year graduate entry integrated medical curriculum. The three largest teaching hospitals of the University of Queensland Faculty of Medicine. A questionnaire was sent to 565 consultants and 493 junior medical staff regarding deficiencies of the present six-year course, deficiencies in present methods of selecting students, and possible solutions. 154 (68%) full-time consultants, 174 (51%) visiting consultants and 197 (40%) junior staff replied. Ninety per cent of the consultants and 60% of the junior staff were current teachers. Respondents strongly supported the need for major change, the integration of biomedical sciences into clinical teaching and the use of problem-based learning. Regarding selection, over 80% of respondents considered graduate entry to have no advantage over undergraduate entry, but there was strong support for an external examination including sciences. There was also strong support for broadening entry criteria to include common sense, motivation and empathy. Seventy-two per cent of consultants and 82% of juniors opposed the proposals in their present form. However, 52% of consultants (but only 23% of juniors) would support the concept of a four-year integrated course if the issue of selection criteria could be resolved. A majority of consultants support the concept of a four-year integrated curriculum which uses problem-based learning methods. They do not support the proposed selection criteria based upon graduate entry, but would support a predominantly science-based selection process, not necessarily restricted to graduate applicants, but incorporating broader personal characteristics than are used at the present time.

Are you getting the message?

A questionnaire sent to 109 anaesthetists in the South West Region has revealed that there is a problem with dissemination of information relating to hazards with equipment. Thirty-four per cent of consultants, and 67% of junior anaesthetists were only slightly or not at all confident that they see the Hazard Notices and Safety Action Bulletins relating to the equipment they use. The study has also demonstrated the large amount of new equipment coming into circulation and has highlighted deficiencies in the reading of equipment manuals. Some suggestions are made as to how the current system may be improved.

Underwater medicine: a neglected area in Accident and Emergency specialist training.

We have evaluated the available medical care to sports divers by a postal questionnaire sent to consultants and senior registrars in Accident and Emergency medicine in the UK, assessing their training in underwater medicine. Replies were received from 60 of 96 consultants (63%) and 32 of 58 (55%) senior registrars. Thirty-two per cent of consultants and 50% of senior registrars had previous personal experience in managing an underwater diving accident. Thirty per cent of consultants and only 19% of senior registrars had prior formal postgraduate training in underwater medicine. Twenty-seven per cent of consultants and 13% of senior registrars replying did not know the pattern of referral for specialist advice nor where the nearest recompression chamber was to be found. We believe that more formal postgraduate training in underwater medicine is needed by A and E medical staff. Furthermore, clear guidelines about emergency management and patterns of referral for diving accidents should be displayed prominently in all A and E departments.