A Comparative Study of Contrasting Surgical Residency Programs

Quality Metrics and Indicators for Surgical Training: A Scoping Review

BACKGROUND

Surgical training quality is critical to ensure that trainees receive adequate preparation to perform surgical procedures independently and that patients receive safe, effective, and high-quality care. Numerous surgical training quality indicators have been proposed, investigated and implemented. However, the existing evidence base for these indicators is limited, with most studies originating from English-speaking, high-income countries.

OBJECTIVES

This scoping review aimed to identify the range of quality indicators that have been proposed and evaluated in the literature, and to critically evaluate the existing evidence base for these indicators.

METHODS

A systematic literature search was conducted using MEDLINE and Embase databases to identify studies reporting on surgical training quality indicators. A total of 68 articles were included in the review.

RESULTS

Operative volume is the most commonly cited indicator and has been investigated for its effects on trainee exam performance and career progression. Other indicators include operative diversity, workplace-based assessments, regular evaluation and feedback, academic achievements, formal teaching, and learning agreements, and direct observation of procedural skills. However, these indicators are largely based on qualitative analyses and expert opinions and have not been validated quantitatively using clear outcome measures for trainees and patients.

CONCLUSIONS

Future research is necessary to establish evidence-based indicators of high-quality surgical training, including in low-resource settings. Quantitative and qualitative studies are required to validate existing indicators and to identify new indicators that are relevant to diverse surgical training environments. Lastly, any approach to surgical training quality must prioritize the benefit to both trainees and patients, ensuring training success, career progression, and patient safety.

Tutorial Assistance for Board Certification in Surgery: Frequency, Associated Time and Cost

BACKGROUND

Tutorial assistance is related to extra time and cost, and the hospitals' financial compensation for this activity is under debate. We therefore aimed at quantifying the extra time and resulting cost required to train one surgical resident in the operating theatre for board certification in Switzerland as an example of a training curriculum involving several surgical subspecialties. Additionally, we intended to quantify the percentage of tutorial assistance.

METHODS

We analysed 200,700 operations carried out between 2008 and 2012. Median duration of procedure categories was calculated according to four different seniority levels. The extra time if the procedure was performed by residents, and resulting cost were analysed. The percentage of procedures carried out by residents as compared to more experienced surgeons was assessed over time.

RESULTS

On average, residents performed about a third of all operations including typical teaching procedures like appendectomies. An increase in duration and cost of well-defined procedures categories, e.g. cholecystectomies was demonstrated if a resident performed the procedure. In less well-defined categories, residents seemed to perform less difficult procedures than senior consultants resulting in shorter durations of surgery.

CONCLUSIONS

The financial impact of tutorial assistance is important, and solutions need to be found to compensate for this activity. The low percentage of procedures performed by trainees may make it difficult to fulfil requirements for board certification within a reasonable period of time. This should be addressed within the training curriculum.

Beliefs and values about intra-operative teaching and learning: a case study of surgical teachers and trainees

Surgeons require advanced psychomotor skills, critical decision-making and teamwork skills. Much of surgical skills training involve progressive trainee participation in supervised operations where case variability, operating team interaction and environment affect learning, while surgical teachers face the key challenge of ensuring patient safety. Using a theoretical framework of situated learning including cognitive apprenticeship, we explored teachers' and trainees' beliefs and values about intra-operative training and reasons for any differences. A qualitative case study method was used where five teacher-trainee pairs participating in an observed teaching operation were separately interviewed about the same operation. Thematic analysis of transcribed interviews and observations was performed with iterative refinement and a reflexive approach was adopted throughout the study. We found that in all cases, teachers and trainees had shared recognition of learning about technical skills whereas they differed in three cases regarding non-technical skills such as surgical reasoning and team management. Factors contributing to teacher and trainee satisfaction with the process were successful trainee completion of operation without need for surgeon take-over, a positive learning environment and learning new things. Teaching-learning behaviours observed and discussed were modeling, coaching and scaffolding, while exploration, reflection and articulation were less common. Our study reveals differing teacher and trainee perspectives of some aspects of intra-operative training and surfaces new reasons other than amount of feedback and autonomy given. Factors contributing to different perspectives include teacher and trainee abilities, values and situational influences. Targeted teaching-learning strategies could enhance intra-operative learning.

Systematic review with meta-analysis of the impact of surgical fellowship training on patient outcomes

Background

The number of surgeons entering fellowship training before independent practice is increasing. This may have a negative impact on surgeons in training. The impact of fellowship training on patient outcomes is not yet known. This review aimed to investigate the impact of fellowship training in surgery on patient outcomes.

Methods

A systematic review of the literature was conducted to identify studies exploring the structural and surgeon-specific characteristics of fellowship training on patient outcomes. Data from these studies were extracted, synthesized and reported qualitatively, or quantitatively through meta-analysis.

Results

Twenty-three studies were included. The mortality rate for patients in centres with an affiliated fellowship programme was lower than that for centres without (odds ratio 0·86, 95 per cent c.i. 0·84 to 0·88), as was the rate of complications (odds ratio 0·90, 0·78 to 1·02). Surgeons without fellowship training converted more laparoscopic operations to open surgery than those with fellowship training (risk ratio (RR) 1·04, 95 per cent c.i. 1·03 to 1·05). Comparison of outcomes for senior surgeons versus current fellows showed no differences in rates of mortality (RR 1·00, 1·00 to 1·01), complications (RR 1·03, 0·98 to 1·08) or conversion to open surgery (RR 1·01, 1·00 to 1·01).

Conclusion

Fellowship training appears to have a positive impact on patient outcomes.