Direct Consultant Supervision Research Articles

SP2.1.7Navigating surgical training: a game of trust

Abstract Introduction One premise of the Improved Surgical Training (IST) pilot is delivery of better quality of early years surgical training. However, the quality of the trainee-trainer relationship can positively or negatively impact trainees’ experiences of the specialty. Trust is a key determinant of the relationship, which is influenced by trainers’ level of risk aversion and trainees’ motivation. Game theory provides a framework to understand cooperation amongst rational ‘players’. This study explores how trainee-trainer relationships impact trainees’ experiences through the IST curricular reform. Methods Using a qualitative case study approach, data were obtained from interviews with core surgical trainees across Scotland. Data coding and inductive thematic analysis were undertaken. Results Forty-six trainees participated. Trainees and trainers regularly interacting in clinical activities demonstrated growing levels of trust, aided by: specialty rotations of 6 months or more duration, working at junior registrar level with structured weekly clinical activities and direct consultant supervision, individual goal-setting and regular progress check, and meaningful and timely feedback. Cooperative relationships led to individual fulfilment, growth, and trainee autonomy. Factors hindering development of trust included: temporal and/or geographical distance between trainee-trainer, poor communication and understanding of expectations and training needs, and lack of interest and enthusiasm from either party. Conclusion Cohesive trainee-trainer relationships demonstrated cooperative equilibrium; both trainees and trainers met each other’s expectations and positively impacted on trainees’ experiences. On the contrary, ‘players’ in relationships deficient in trust achieved the minimum to ensure trainee progression. Addressing factors fostering a cooperative trainee-trainer relationship positively impacts trainees’ experiences.

A retrospective analysis of case-load and supervision from a large anaesthetic logbook database.

The recent development of electronic logbooks with secure off-device data storage provides a rich resource for research. We present the largest analysis of anaesthetic logbooks to date, with data from 494,235 cases logged by 964 anaesthetists over a 4-year period. Our analysis describes and compares the annual case-load and supervision levels of different grades of anaesthetists across the UK and Republic of Ireland. We calculated the number of cases undertaken per year by grade (median (IQR [range]) core trainees=388 (252-512 [52-1204]); specialist trainees=344 (228-480 [52-1144]); and consultants=328 (204-500 [52-1316]). Overall, the proportion of cases undertaken with direct consultant supervision was 56.7% and 41.6% for core trainees and specialist trainees, respectively. The proportion of supervised cases reduced out-of-hours, for both core trainees (day 93.5%, evening 86.3%, night 78.6%) and specialist trainees (day 81.0%, evening 67.7%, night 56.4%).

'Modern' distal femoral locking plates allow safe, early weight-bearing with a high rate of union and low rate of failure: five-year experience from a United Kingdom major trauma centre.

Fractures of the distal femur can be challenging to manage and are on the increase in the elderly osteoporotic population. Management with casting or bracing can unacceptably limit a patient's ability to bear weight, but historically, operative fixation has been associated with a high rate of re-operation. In this study, we describe the outcomes of fixation using modern implants within a strategy of early return to function. All patients treated at our centre with lateral distal femoral locking plates (LDFLP) between 2009 and 2014 were identified. Fracture classification and operative information including weight-bearing status, rates of union, re-operation, failure of implants and mortality rate, were recorded. A total of 127 fractures were identified in 122 patients. The mean age was 72.8 years (16 to 101) and 92 of the patients (75%) were female. A consultant performed the operation in 85 of the cases, (67%) with the remainder performed under direct consultant supervision. In total 107 patients (84%) were allowed to bear full weight immediately. The rate of clinical and radiological union was 81/85 (95%) and only four fractures of 127 (3%) fractures required re-operation for failure of surgery. The 30-day, three- and 12-month mortality rates were 6 (5%), 17 (15%) and 25 (22%), respectively. Our study suggests an exponential increase in the incidence of a fracture of the distal femur with age, analogous to the population suffering from a proximal femoral fracture. Allowing immediate unrestricted weight-bearing after LDFLP fixation in these elderly patients was not associated with failure of fixation. There was a high rate of union and low rate of re-operation. Cite this article: Bone Joint J 2017;99-B:951-7.

106 New service: a cardiac physiologist managed exercise stress echo

BackgroundNational institute for health and clinical excellence (NICE) recommends functional assessment for patients presenting with chest pain of recent origin (CPRO), who have intermediate probability for coronary heart disease (CAD)....

E learning in surgery.

E learning means use of electronic media and information technologies in education. Virtual learning environment (VLE) provides learning platforms consisting of online tools, databases and managed resources. This article is a review of use of E learning in medical and surgical education including available evidence favouring this approach. E learning has been shown to be more effective, less costly and more satisfying to the students than the traditional methods. E learning cannot however replace direct consultant supervision at their place of work in surgical trainees and a combination of both called blended learning has been shown to be most useful. As an example of university-based qualification, one such programme is presented to clarify the components and the process of E learning. Increasing use of E learning and occasional face to face focussed supervision by the teacher is likely to enhance surgical training in the future.

ARE NEUROLOGY TRAINEES ADEQUATELY SUPERVISED WHEN SEEING IN–PATIENT WARD REFERRALS?

ObjectivesTo investigate–1. How neurology speciality registrars are supervised when seeing in–patient ward referrals.2. To see if supervision differs in different regions within Great Britain.3. To compare the supervision of neurology...

Anaesthetic training: not better, not worse, just different

Anaesthetic training: not better, not worse, just different

The 3-Finger Technique in Establishing Percutaneous Renal Access: A New and Simple Method for Junior Trainees

Urology trainees may lack experience in gaining renal access during percutaneous nephrolithomy (PCNL). Establishing the correct depth of initial percutaneous needle insertion is one of the major obstacles. As such, we have identified an easy technique, which can be performed, to establish correct depth adjustment allowing easier access. An initial attempt is made to insert the percutaneous needle into the desired posterior calyx in the antero-posterior (AP) plane. If the needle does not traverse into the desired calyx immediately, it is concluded that the needle track must be too shallow or too deep. The C-arm is then rotated 20 to 30 degrees from the vertical, in the axial plane, towards the operating surgeon and, using the image intensifier, very careful note is made of the end of the needle in this plane, compared with the end of the needle initially in the AP plane, to see if it has moved "medially" or "laterally." The 3-finger technique is then performed by the surgeon, to establish if the needle path is too deep or too shallow. This technique is currently being performed by trainees under direct consultant supervision with 13 successful cases so far. The 3-finger technique has been successfully used to demonstrate and teach PCNL access to urology trainees. In all 13 cases, percutaneous renal access was achieved successfully by trainees without immediate or late complications. Also, positive and encouraging feedbacks were received from those trainees, and all expressed willingness to continue using the same new technique in the future. Our new technique is cheap, safe, easy to learn and use, and of particular benefit to junior trainees who are beginning to perform PCNL access.

Echocardiography training opportunity for neonatal trainees in a tertiary neonatal unit

BackgroundHistorically, echocardiography has been provided by the paediatric cardiologist based at the regional Children's Hospital. There is now a growing need for neonatologist to develop bedside echocardiography skills for cardiac...

Electroconvulsive Therapy Training and Confidence in Administration

: As the lack of on-site electroconvulsive therapy (ECT) facilities in many psychiatric hospitals in Ireland may impact negatively on ECT training, we conducted a national survey of trainees with the aims of establishing the current standard of ECT training and to assess trainees' confidence in their abilities in ECT administration. : A national postal survey of 415 trainees was conducted in September 2008 using a self-designed 15-item questionnaire for the purpose of the study, containing no identification data and incorporating relevant questionnaire items from similar published trainee survey. Reminders were distributed to the entire study sample 4 weeks afterward within a sampling time frame of 3 months. Trainee responses were coded and converted to anonymized data, which the lead author held. : The overall response rate was 61%. Ninety-one percent of trainees had worked in ECT centers, of which 36% had given ECT on an occasion without direct consultant supervision. Overall, 12% of trainees had never administered or observed ECT, which includes 2 trainees on the national senior registrar scheme, and 19% of trainees had nil or minimal confidence in their ability to administer ECT. : Our findings indicate deficiencies in training and supervision, which is reflected in the proportion of trainees reporting nil or minimal confidence in their ability to administer ECT. Greater collaboration between training scheme coordinators, clinical tutors, and the College of Psychiatry of Ireland is essential to ensure ongoing monitoring and implementation of standards.

The effect of trainee involvement on procedure and list times: A statistical analysis with discussion of current issues affecting orthopaedic training in UK

Training surgeons adds time to the duration of procedures and operation lists. This is not accounted for in the finance received to perform the operation by the hospital in the Payment by Results (PbR) system. To find out: 1. The effect on the duration of a procedure and the number of procedures performed on the list when a trainee is involved. 2. The percentage of orthopaedic cases with trainee involvement. 3. The effect of European working time directive (EWTD) on the trainee involvement in cases from theatre data in 2008 versus logbook data from 2004 - 2008. Data was taken from two different sources. Firstly, the Operating Room Information System (ORMIS) and patient operation notes. The second source was a consultant's logbook comprising 227 primary total knee replacements performed between 2004 and 2008. The data produced trends suggesting trainees took longer to perform procedures than consultants. In orthopaedic operations, 92% of cases had trainees present and of these 17% of cases were performed by trainees in 2008. Before the implementation of the EWTD, trainees performed more procedures when compared with current logbook data (38% versus 17% cases). Time taken by a trainee to perform the procedure under direct consultant supervision was significantly higher in comparison to procedures performed by a consultant alone (P = < 0.0001). Analysing the ORMIS and logbook data gave similar conclusions. Hospitals should be given financial recognition for training. In this debate, we should remain focused on the provision of quality training for the next generation of surgeons.

Should Oesophagectomies be Performed by Trainees? – The Experience from a Single Teaching Centre Under the Supervision of One Surgeon

Surgical training is threatened by anxieties about trainees performing major procedures. We have analysed the outcome of oesophagectomies performed by a consultant surgeon and compared these to the performance of trainees (years 4-6) operating under direct supervision. Data were collected retrospectively in a computerised database on all patients who underwent oesophagectomy at a teaching tertiary centre between December 1997 and April 2004 with a minimum 15 months' follow-up. Analysis of outcome was according to measures of technical adequacy, postoperative course, histological analysis, recurrence and survival. During the study period, 241 oesophagectomies were carried out; 157 (65.1%) of these procedures were performed by the consultant and 84 (34.9%) were performed by surgeons-in-training under direct consultant supervision. Pre-operative, technical adequacy, postoperative course, histological analysis, recurrence and survival were comparable in both groups. These data demonstrate comparable patient outcome when suitably experienced trainees are supervised in performing oesophagectomies and support its continued use in operative training.

The evolution of training in Off-Pump coronary surgery in a single institution

Background This study analyses the development of off-pump coronary artery bypass (OPCAB) surgery training at a single institution, and compares the early and midterm clinical outcomes of OPCAB and conventional coronary artery bypass grafting (CABG) procedures performed by trainees with or without direct consultant cardiothoracic surgeon supervision. Methods Analysis was undertaken on data prospectively recorded on a computer database (Patient Analysis and Tracking System). Of the 2,422 CABG operations performed between January 1999 and December 2001, 969 (40%) were carried out by trainees either off pump (422) or on pump (547). Results Although the total number of CABG operations performed by trainees remained constant, there was a significant increase in the number of OPCAB operations during the study period compared with conventional CABG, as well as an increase in the average number of grafts per patient in the OPCAB group (both p < 0.05). Furthermore, a significant trend towards using two or more arterial conduits in the OPCAB group was observed in the study period. The number of OPCAB operations performed by trainees as independent operators without direct consultant supervision also increased significantly ( p < 0.05). Early and midterm clinical outcomes were similar between patients operated by trainees on pump or off pump as independent operators versus under direct consultant supervision. Conclusions The significant increase in OPCAB operations performed by trainees as independent operators or under direct consultant supervision, as well as the increase in the number of grafts per patient and arterial conduits used for myocardial revascularization, demonstrate a progression of training in beating heart surgery for cardiothoracic trainees. Improvements in the techniques have made it safe to teach trainees off-pump multivessel coronary artery revascularization.

Direct consultant supervision of higher trainees in child and adolescent psychiatry

Higher trainees in child and adolescent psychiatry and their consultant trainers reported high levels of compliance with existing JCHPT guidelines on the structure of direct supervision. There was a consensus about the ideal content of supervision sessions but disparity about whether this is achieved in practice and over issues of responsibility for raising certain topic areas. These findings are discussed and some questions to be addressed by trainee and trainer at the outset of the supervision process are suggested.