Surgical Training Experience Research Articles

The Impact of an Independent Sector Treatment Centre on Basic Surgical Training

The reorganisation of postgraduate medical training in the UK as a result of Calman reforms, the New Deal and the implementation of the European workingTime regulations (EwTr) has led to a substantial reduction in working hours and a fall in operative experience for surgical trainees. The move of large volumes of minor and intermediate NHS surgical caseload into independently run hospitals and specialist centres (of which the Southampton NHS Treatment Centre, an independent sector treatment centre (ISTC) is a well-established example) has also radically altered the basic surgical training environment. The Southampton ISTC is run on contract by Care UK and is medically staffed by a mix of full-time Care UK employees from the UK and abroad as well as by visiting consultants from University Hospital Southampton NHS foundationTrust (UHSFT).

Worlds apart: training in rural South Africa

Reforms in the delivery of surgical and anaesthetic services in the UK have reduced the opportunity for trainees to acquire 'hands-on' training. These problems are seen in other European countries and in North America. Surgical and anaesthetic services within developed health care systems tend to be specialised, and are often consultant led. In rural South Africa there is a shortage of surgeons and anaesthetists to service the population, and the public health care system is vastly over-burdened. Trauma accounts for a large percentage of the surgical and anaesthetic workload. This report compares the anaesthetic and surgical training experience of two first-year registrars during a 6-month training period in rural South Africa and a 6-month training period in the UK. Surgical and anaesthetic trainees from countries such as the UK can spend an out-of-programme training period in rural South Africa, thereby broadening their experience and exposure to trauma. They have the opportunity to take on a higher level of responsibility at an earlier stage of training, gaining 'hands-on' experience. Similarly, South African anaesthetic and surgical trainees can spend an out-of-programme training period in the UK, where they can learn the specialist procedures needed in their home country.

The United Kingdom and Ireland Trauma & Orthopaedic eLogbook—An evidence base for enhancing training

The United Kingdom and Ireland Trauma and Orthopaedic (T&O) eLogbook was originally conceived over ten years ago in order to provide individual surgeon support and allow national analysis of surgical training experience. Since 2003 every trainee in T&O has been required to submit data recording their operative experience throughout the six years of higher specialist training. We describe how orthopaedic surgeons are using the evidence from the eLogbook to improve training, set operative standards and support consultant (post-specialist registration) revalidation.

Creating a Virtual Surgical Atlas of Craniofacial Procedures: Part II. Surgical Animations

Craniofacial surgery can be challenging to teach and learn. To augment the intraoperative learning experience for surgical trainees and to provide a resource for practicing craniofacial surgeons to review uncommonly performed procedures before entering the operating room, a series of three-dimensional animations were created encompassing the most commonly performed craniofacial procedures. Previously created three-dimensional craniofacial digital models were used to create digital animations of craniofacial surgical procedures using Maya 8.5. Digital models were altered systematically within Maya to recreate the ordered steps of each craniofacial procedure. Surgical tools were imported into Maya for use in the animations using computer-aided manufacturing files obtained directly from the manufacturer. Nine craniofacial procedures were animated: genioplasty, bilateral sagittal split osteotomy, intraoral vertical ramus osteotomy, Le Fort I osteotomy, unifocal mandibular distraction, mandibular transport distraction, fronto-orbital advancement with cranial vault remodeling, Le Fort III advancement/distraction, and monobloc advancement/distraction. All major surgical steps are demonstrated, including exposure, execution of the osteotomy, displacement of the bone composite, and the predicted morphologic changes to the craniofacial contour. Throughout the surgical animation, the view of the surgeon in the operating room is incorporated to reproduce the vantage of the surgeon, and the overlying tissue is rendered transparent to illustrate critical underlying anatomical relationships. The first virtual surgical atlas of craniofacial procedures is presented. These animations should serve as a resource for trainees and practicing surgeons in preparation for craniofacial surgical procedures.

The Impact of Duty Hours on Surgical Resident Education: Are Operative Logs Appropriate Surrogates for Surgical Competence?

The Accreditation Council for Graduate Medical Education mandated residency training programs to institute restricted duty hours July 1, 2003. Since that time, much has been written regarding the impact on surgical residents' training experiences and quality of life, as well as the ultimate effect on patient safety and care. A major concern of both residents and faculty was the assumption that this restriction would impact different specialties in unique ways. Specifically, surgeons feared that this would decrease the residents' operative experience and have a detrimental impact on technical skills.

Validity of using Fundamentals of Laparoscopic Surgery (FLS) program to assess laparoscopic competence for gynecologists

This study was designed to investigate the validity of using the Fundamentals of Laparoscopic Surgery (FLS) program to assess laparoscopic competence among gynecologists. A total of 42 gynecologists with variable surgical training and laparoscopic experience were enrolled for FLS testing which includes a computer-based cognitive examination to assess one's knowledge and a psychomotor portion for manual skills assessment. Prior to testing, participants were surveyed to document their level of surgical training and caseload for common laparoscopic procedures. Participants were required to self-evaluate their confidence in conducting laparoscopic procedures. Upon completion of the FLS test, feedback was collected regarding the use of the FLS program for training and assessing laparoscopic skills of gynecologists. Gynecologists with advanced levels of surgical training achieved higher scores in the FLS manual skills test than those with lower levels of training (P = 0.009). The cognitive test, however, failed to show an increased score with greater levels of surgical training (P = 0.457). Regression analyses revealed that a participant's laparoscopic expertise contributed significantly to one's FLS manual skills scores (P = 0.008) beyond surgical training level alone. In contrast, laparoscopic expertise did not reflect changes in the FLS cognitive scores significantly (P = 0.628). Self-reported confidence scores correlated well with FLS manual skills test scores (r = 0.54) but not with the cognitive scores (r = 0.16). The manual skills test of the FLS program appropriately measures the level of a gynecologist's psychomotor skills. The FLS cognitive test does not discriminate between advanced and novice surgeons. Modifications of questions used in the cognitive test are necessary to allow better adaptability when applying the FLS program to gynecologists.

Uneven Operative Experience in Surgical Training

Uneven Operative Experience in Surgical Training

Effect of work-hour restriction on operative experience in cardiothoracic surgical residency training

Resident work-hour regulations were instituted to improve patient care during resident training. Although initial data have not shown the intended benefit of limiting resident work hours, concern has developed as to whether resident operative experience has significantly decreased since instituting the work-hour restrictions. Resident operative logs were reviewed for 3 training institutions in the western United States for residents graduating in the years 1999-2007. Residents were divided into pre-work-hour restriction (1999-2002) and post-work-hour restriction (2003-2007) groups. Thoracic, cardiac, and all combined cases were reviewed separately for all residents at yearly intervals. Statistical analysis was subsequently conducted. A total of 37 residents were identified from 3 different programs over the study period. Thoracic cases were lower during the first year of training but increased in the second and third years of training after work-hour restrictions (78 vs 42, 65 vs 72, and 102 vs 138; P = .17, P = .59, and P = .11, respectively). Cardiac cases were substantially lower during each year of training after work-hour restrictions (190 vs 153, 154 vs 108, and 116 vs 76; P = 0.15, P < .0001, and P = .001, respectively). Overall total cases were also lower over all years of residency after work-hour restrictions (251 vs 195, 219 vs 187, and 234 vs 214; P = .03, P = .049, and P = .59, respectively). The overall volume of thoracic surgery cases was not significantly different after the implementation of the 80-hour work-week restriction. The total number of cardiac cases logged was substantially less during the same time period, and therefore as a result, the total number of cases performed after the implementation of the work-hour restrictions was also reduced. Although recent data have not shown an improvement in patient outcomes after restriction of resident work hours, we speculate that in a time of increasingly complex cases, reduction in resident case volumes caused by work-hour restrictions and decreasing cardiac cases might lead to inadequate operative experience.

QS327. Assessment of Teleconferenced Lectures in a Surgical Residency Program

Background: Many surgical residency programs, whether community or university based, utilize multiple facilities to educate their residents. One of the challenges of surgical education in this model is to provide a standardized didactic curriculum that can be universally utilized among all integrated teaching hospitals. Methods: At our institution a series of core conferences, which includes weekly morbidity and mortality conferences, basic and clinical science, and surgical grand, rounds are required for all residents whether they are on site or at an integrated institution. To decrease time spent away from clinical duties and to limit transit time to and from hospitals, these core conferences are teleconferenced live from our main institution. The average number of teaching staff and residents attending grand rounds by teleconference for the 2006-2007 academic year was calculated. Additionally, travel time was also recorded. Results: On average 3.64 teaching staff and 2 residents attending surgery grand rounds by teleconference. Although the distance between the institutions is only a little over 16 miles, travel time one way is forty-five minutes with the heavy traffic and parking. This leads to a total of an hour and a half of time saved per each teaching staff and resident at the other institution by teleconferencing the conference. Conclusion: Within the framework of an 80 hour work week, no amount of time can be underutilized without a loss in educational exposure. Conferences in out institution are typically held in the morning prior to the start of the first case. With operative exposure playing a primary role in surgical education, lengthy transit times to and from conferences can limit the quantity of actual training. As such, our ability to incorporate teleconferencing into our academic schedule can only serve to enhance the quality and degree of our surgical training experience.

Building an efficient surgical team using a bench model simulation: construct validity of the Legacy Inanimate System for Endoscopic Team Training (LISETT)

Complex laparoscopic tasks require collaboration of surgeons as a surgical team. Conventionally, surgical teams are formed shortly before the start of the surgery, and team skills are built during the surgery. There is a need to establish a training simulation to improve surgical team skills without jeopardizing the safety of surgery. The Legacy Inanimate System for Laparoscopic Team Training (LISETT) is a bench simulation designed to enhance surgical team skills. The reported project tested the construct validity of LISETT. The research question was whether the LISETT scores show progressive improvement correlating with the level of surgical training and laparoscopic team experience or not. With LISETT, two surgeons are required to work closely to perform two laparoscopic tasks: peg transportation and suturing. A total of 44 surgical dyad teams were recruited, composed of medical students, residents, laparoscopic fellows, and experienced surgeons. The LISETT scores were calculated according to the speed and accuracy of the movements. The LISETT scores were positively correlated with surgical experience, and the results can be generalized confidently to surgical teams (Pearson's coefficient, 0.73; p = 0.001). To analyze the influences of individual skill and team dynamics on LISETT performance, team quality was rated by team members using communication and cooperation characters after each practice. The LISETT scores are positively correlated with self-rated team quality scores (Pearson's coefficient, 0.39; p = 0.008). The findings proved LISETT to be a valid system for assessing cooperative skills of a surgical team. By increasing practice time, LISETT provides an opportunity to build surgical team skills, which include effective communication and cooperation.

International Experience, Electives, and Volunteerism in Surgical Training: A Survey of Resident Interest

Sustainable international surgery expertise is more frequently being discussed in the US surgical community. At the resident level, there is discussion about incorporating international experience into residency training, but current opportunities for residents are limited and often require personal funding and use of vacation time. This study analyzed resident interest in acquiring international experience. A structured questionnaire was administered anonymously to all New York University general surgery residents. The questionnaire elicited demographic information and information about interest in an international surgery elective and future volunteerism. Descriptive statistics and chi-square analyses were performed for the completed data. Fifty-two of 63 residents (82.5%) completed surveys. Fifty-one residents (98%) were interested in an international elective, and 38 residents (73%) would prioritize such an elective over all other electives. Twenty-three (44%) and 25 (48%) residents would be willing to use vacation and finance the elective, respectively. The most frequent expectations of international training were acquiring technical and clinical skills (94% of residents) and cultural skills (88%). Residents believed financial difficulties and scheduling conflicts were the most significant barriers to international training (82% and 53%, respectively). Thirty-two residents (62%) planned to incorporate volunteer work into their future practice. Chi-square analyses revealed a significant relationship between residents who would prioritize international training and those who planned to incorporate volunteerism into their future practice (p<0.01). International training represents an opportunity for US surgical education to provide residents with broader clinical expertise and increased cultural awareness. Our data suggest that surgical residents at NYU are strongly interested in acquiring this experience and that international training may provide an opportunity to encourage lifelong volunteerism. National study of US residents and faculty is warranted to further investigate these conclusions.

Role of ITU experience in surgical training

Traditionally, patients in the intensive treatment unit (ITU) have been looked after mainly by anaesthetists, and intensive care medicine has been considered an essential part of anaesthetic training. But now things are changing. Having worked in ITU as part of my surgical training, I would like to share my experiences. I think it would have been better if I had worked in ITU as a house officer. Generally speaking, it teaches you how to manage critically ill patients. A job in ITU is beneficial to junior doctors from all specialties. With the new foundation programmes, more junior doctors will have the opportunity to get ITU experience and improve their skills. Here are some of the ways it helped me. Physiology —It improves your understanding of applied physiology, for example cardiac function, respiratory function, renal function. The best part of it is that you learn things in real time. In other words, you can see the effects of any intervention, for example how increasing intravenous fluids affects central venous pressure, increasing oxygen concentration …

The influence of training level and surgical experience on survival in colorectal cancer

The effect of surgical training level, experience, and operation volume on complications and survival in colorectal cancer during a 10-year period in a medium-volume university hospital was retrospectively studied. Four hundred and fifty-six patients were resected for primary colorectal adenocarcinoma during the 10-year period of 1981-1990, and of these, 387 patients underwent resection with curative intent. The surgeons were divided into three groups according to training level and volume: group 1, surgeons in training and other surgeons operating annually on only 1-4 patients; group 2, surgeons specializing in gastrointestinal surgery (average annual volume 4-13 operations); group 3, specialists in gastrointestinal surgery (average annual volume 3-8 operations). Postoperative morbidity and mortality rates, as well as long-term survival rates, were analysed, and comparisons were made between the patients in the three groups. There were no statistically significant differences between the three groups in postoperative morbidity or mortality. Cancer-specific 5-year survival rate of all patients was 57%, and that of those resected in the aforementioned three groups was 51%, 63%, and 55%, respectively, P=0.087. The 5-year survival rates for colon cancer were 59% (total), 52%, 69%, and 58%, respectively, P=0.067, and for rectal cancer were 51% (total), 42%, 53%, and 52%, respectively, P=0.585. There were no significant differences in the rates of postoperative mortality, morbidity, and long-term overall survival between the volume groups. However, in patients with colon cancer, there was a trend for better survival for those operated on by the surgeons specializing in gastrointestinal surgery, and in rectal cancer patients, a tendency of fewer local recurrences in those operated on by the specialist surgeons.

Colorectal Operative Experience in General Surgical Training at King Faisal Specialist Hospital and Research Centre

Colorectal Operative Experience in General Surgical Training at King Faisal Specialist Hospital and Research Centre

Colorectal operative experience in general surgical training.

Surgical trainees often feel that their operative training is inadequate--trainers usually do not share this view. The distribution of colorectal operative surgical workloads between consultants and trainees was examined over a 15-year period in the Colorectal Service at the Wellington School of Medicine. Consultants performed 947 operations and trainees performed 1012 operations. The average age of patients operated on by trainees was lower than that of those operated on by consultants. Trainees performed more emergency surgery. Anorectal surgery, except fistula surgery, was more commonly performed by trainees, whereas abdominal colorectal surgery was more commonly performed by consultants. Trainees had lower postoperative morbidity and mortality rates. The diseases predominantly treated by consultants and trainees differed. Twenty-four percent of patients with colorectal cancers and 25% of patients with diverticular disease were managed operatively by trainees. Yearly trainee workloads for minor anorectal conditions were similar to those of trainees in the USA. Although this small colorectal audit provides some information about trainees' operative experience, until all surgical procedures performed by all surgical trainees are accurately audited and criteria for adequacy of operative training are clearly stated, it will not be possible to say whether our training programs provide adequate operative training or not.

Vascular ultrasound: yet another casualty?

Vascular ultrasound is now ¢rmly established as the¢rst line and inmanycases theonly required imaging in the investigationandmanagementofpatients presenting with symptoms of peripheral or cerebrovasculardisease.Highquality, colourDopplerultrasound (CDUS), performed by trained operators backed up with audit and quality assurance, has enabled vascular radiologists and surgeons to make management decisions and perform complex endovascular surgery with no need for diagnostic arteriography [1]. As a consequence, vascular ``laboratories'' have developed in many hospitals. In general, these are run not by radiologists but by vascular surgeons and staied by vascular technologists without any radiological involvement. The reason for this (r)evolution is that radiologists have consistentlyfailed toprovideanorganized,accurate, audited, vascular ultrasound service. This has motivated vascular surgeons to divert resources and create theirown imagingdepartmentswhichprovide hands on experience for surgical trainees, who are then su¤ciently trained to establish further laboratories in the many hospitals where the radiology department cannot orwill not provide an equivalent service. To assess the eiect of this surgical domination, it is important to have a clear understanding of the pivotal role of modern vascular ultrasound and my commentarywill attempt to provide this.

A personal audit of pediatric surgical training before implementation of the calman guidelines

Purpose: The purpose of this study was to audit the surgical training experience of a Higher Surgical Trainee in the United Kingdom during the tenure of the posts of Career Registrar, Research Fellow, and Senior Registrar from August 1992 to July 1997. Although the Report of the Working Party on the UK Specialist Medical Training (the Calman report) was published during this study, the training remained the same because the author elected not to transfer to the new grade. Methods: A 39-field database was designed, and the surgical experience was entered prospectively. The data were analyzed chronologically according to age of patient, condition, level of supervision, and nature of admission (emergency, elective). Results: Two thousand two hundred ninety patients or operations are presented. Only a small number of patients underwent surgery during the research year (1994). The pattern of operating changed from one of large numbers of supervised to one of more major procedures. The numbers of neonates and younger infants who underwent surgery increased significantly, and the level of supervision changed allowing more autonomy toward the end of the training period. This trend was reversed partially during the period of overseas secondment. The results are compared with those in a recently published USA/Canadian study. Conclusion: The volume of work undertaken by the trainee ensures adequate exposure to a wide range of procedures to achieve a satisfactory level of competence. Changes that may affect this are discussed.

The relevance of research training and clinical practice

The introduction of the Specialist registrar grade in the 'Caiman' training programmes (DOH, 1993) t raises fundamental questions about the sort of training required to be a specialist doctor. When taken with the reduction of junior doctor's hours (DOH, 1991) 2 there would appear to be an inevitable squeeze on the sorts of activities previously undertaken by registrars and senior registrars. The programme is supposed to involve structured training in which the specific clinical needs of the trainee are accounted for in establishing that individual's work plan. In addition, the formative and summative assessment more formally record the experience gained by the trainee during the 5 years of the programme. Inevitably in a surgical specialty, if trainees are working less hours and take time off after being on call overnight, pressures will arise with respect to surgical training experience. This fundamental difficulty is further complicated by the inevitable increase in sub-specialization within obstetrics and gynaecology. This process is now so far developed that the real term should just be specialization. No trainee will just undertake general obstetrics and gynaecology. This means they will need to attend specialist clinics, further eroding their already full timetable. All of these pressures force the issue as to what is to be included in the trainee's training programme. One view is that research fits uneasily in this model. Trainees, after all, are learning to be practical doctors and certainly for those wishing to practise in District General Hospitals there seems to be little need of research experience. Furthermore, the type of research undertaken by most time expired senior

State of dermatology training: The residents' perspective

Changes in health care delivery necessitate modification in dermatology training. While the residents at The University of Alabama at Birmingham were planning their 1995–1996 curriculum, several questions regarding the most appropriate allocation of time and resources arose. Interest in other residency curricula prompted the development of a national survey of dermatology residents. Our purpose was to provide comprehensive data regarding the didactic, clinical, surgical, and other aspects of today's U.S. dermatology residency training from the perspective of the residents. It is hoped these data will assist dermatology residency programs with evaluation of their current curricula. A comprehensive 31-question multiplechoice survey was mailed to 631 residents in 70 U.S. dermatology residency programs. Results were tabulated and median values and percentages of responses were obtained. A Wilcoxon rank-sum test, a chi-square analysis, and logistic regression analysis were performed on survey items on the basis of residents' satisfaction with the training program. Two hundred forty-eight responses (39%) were returned with all years of training well represented. Median values and percentages obtained outlined the didactic, clinical, surgical, and other aspects of dermatology residency training. Seventeen percent of residents believed they were not being adequately trained. Satisfaction with training was noted with more didactic faculty involvement, consultations and research, and surgical procedures performed per month. Residents with enriched didactic, clinical, and surgical training experiences are more satisfied with their training programs.