Effect of training on patient outcomes following lobectomy

Are there differences in cardiothoracic surgery performed by trainees versus fully trained surgeons?

OBJECTIVES

We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons.

METHODS

EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. Eight hundred and ninety-two results were obtained, 27 represented best evidence (2-meta-analyses, 1-RCT, and 24 retrospective cohort studies).

RESULTS

In all 474,160 operative outcomes were assessed for 434,535 coronary artery bypass grafting (CABG) (431,329 on-pump vs. 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital, and 4797 thoracic procedures. In all 398,058 cases were performed by trainees and 75,943 by consultants. One hundred fifty-nine cases were indeterminate. There were no statistically significant differences in the patients' preoperative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function, and reoperation cases that were undertaken by consultants. There were no differences in cardiopulmonary bypass and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the postoperative outcomes including perioperative myocardial infarction, resternotomy for bleeding, stroke, renal failure, intensive therapy unit length of stay, and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or midterm mortality out to 5-years.

DISCUSSION

Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.

A modern approach to teaching pancreatic surgery: stepwise pancreatoduodenectomy for trainees

INTRODUCTION

Pancreatoduodenectomy (PD) has always been regarded as one of the most technically demanding abdominal procedures, even when carried out in high-volume centers by experienced surgeons. The reduction in higher surgical trainees working hours has led to reduced exposure, and consequently less experience in operative procedures. Furthermore, trainees have also become victims as health care systems striving for operating room efficiency, have attempted to reduce procedure duration by encouraging consultant led procedures at the expense of training. A strategy therefore needs to be developed to match the ability of the trainee with the complexity of the surgical procedure. As a PD can be deconstructed into a number of different steps, it may indeed be an ideal training operation for varying levels of ability.

METHODS

We describe our technique for PD and break it down to nine steps of varying technical ability making it suitable for many different stages of surgical training.

RESULTS

The complexity and variety of steps required to perform a PD makes it an ideal training operation from the junior surgical trainee to the most senior fellow, allowing the development of a wide range of skill sets.

DISCUSSION

Since the introduction of reduced working hours (48 h per week in Europe and 80 h per week in the USA) the "apprenticeship" model of surgical training has shifted towards a time-limited program with greater emphasis on supervision. Due to the complexity of surgery, and the perception of diminished levels of trainees' competency, a PD is often viewed as a consultant level operation. We believe that PD is an excellent model as it provides opportunities for trainees with varying levels of operative experience so that a PD could be considered the ideal "teaching case". Breaking down PD into a number of different steps may help building up surgical expertise more quickly while maintaining patients' safety and allowing the surgery to be expedited in a timely manner.

A systematic review of the effects of residency training on patient outcomes

BACKGROUND

Residents are vital to the clinical workforce of today and tomorrow. Although in training to become specialists, they also provide much of the daily patient care. Residency training aims to prepare residents to provide a high quality of care. It is essential to assess the patient outcome aspects of residency training, to evaluate the effect or impact of global investments made in training programs. Therefore, we conducted a systematic review to evaluate the effects of relevant aspects of residency training on patient outcomes.

METHODS

The literature was searched from December 2004 to February 2011 using MEDLINE, Cochrane, Embase and the Education Resources Information Center databases with terms related to residency training and (post) graduate medical education and patient outcomes, including mortality, morbidity, complications, length of stay and patient satisfaction. Included studies evaluated the impact of residency training on patient outcomes.

RESULTS

Ninety-seven articles were included from 182 full-text articles of the initial 2,001 hits. All studies were of average or good quality and the majority had an observational study design. Ninety-six studies provided insight into the effect of 'the level of experience of residents' on patient outcomes during residency training. Within these studies, the start of the academic year was not without risk (five out of 19 studies), but individual progression of residents (seven studies) as well as progression through residency training (nine out of 10 studies) had a positive effect on patient outcomes. Compared with faculty, residents' care resulted mostly in similar patient outcomes when dedicated supervision and additional operation time were arranged for (34 out of 43 studies). After new, modified or improved training programs, patient outcomes remained unchanged or improved (16 out of 17 studies). Only one study focused on physicians' prior training site when assessing the quality of patient care. In this study, training programs were ranked by complication rates of their graduates, thus linking patient outcomes back to where physicians were trained.

CONCLUSIONS

The majority of studies included in this systematic review drew attention to the fact that patient care appears safe and of equal quality when delivered by residents. A minority of results pointed to some negative patient outcomes from the involvement of residents. Adequate supervision, room for extra operation time, and evaluation of and attention to the individual competence of residents throughout residency training could positively serve patient outcomes. Limited evidence is available on the effect of residency training on later practice. Both qualitative and quantitative research designs are needed to clarify which aspects of residency training best prepare doctors to deliver high quality care.

Early outcomes of surgery for oesophageal cancer in a thoracic regional unit. Can we maintain training without compromising results?

OBJECTIVES

Meaningful exposure to oesophageal cancer surgery during general thoracic surgical training is restricted to few centres in the United Kingdom. Our Regional Tertiary Unit remains a rare 'large-volume' oesophagectomy centre. We aimed to determine the proportion of patients operated by trainees and their perioperative outcomes.

METHODS

From January 2004 to September 2009, 323 patients (229 male and 94 female, median age of 69 (range 40-92) years) underwent oesophagectomy for carcinoma in our Thoracic Surgical Unit. Data were complete and obtained from a prospective departmental database. The preoperative characteristics, operative data and postoperative results were compared between the 120 patients (37%) operated by a trainee (group T) and the remainder 203 patients operated by a consultant (group C).

RESULTS

The overall incidence of mortality, anastomotic leak and chylothorax were 6.5%, 5.3% and 2.2%, respectively. There were no differences in terms of age, gender, tumour location, tumour staging, preoperative spirometry or use of neoadjuvant chemotherapy between the two groups. There was no significant difference between the consultant group and the trainee group in the following key outcome measures: postoperative mortality (8% vs 4%), incidence of respiratory complications (30% vs 25%), hospital stay (14 days vs 13 days) and number of lymph nodes excised (median of 16 vs 14).

CONCLUSIONS

Training in oesophageal cancer surgery can be provided in a large-volume thoracic surgical unit. It does not seem to compromise outcomes or use of resources.

Patients of surgical educational course may have a poorer outcome for pelvic organ prolapse repair and higher complication rate: a case-control study in urogynecology

INTRODUCTION AND HYPOTHESIS

To investigate the outcome of the surgical educational course setting in patients undergoing urinary incontinence (UI)/pelvic organ prolapse (POP) repair.

METHODS

A case-control study of patients who underwent surgery for UI and/or POP during educational post-graduate courses (group A) or during routine hospital work (control--group B). The primary outcome measures were changes in the incontinence rate, presence/absence of POP, and complications. For 2 x 2 tables, chi (2) test was used. Multivariate logistic regression models were developed.

RESULTS

One hundred eighty-six patients belonged to group A and 158 to group B; median follow-up was 46.7 months. Failure, complication, and re-operation rates for UI repair were not significantly different in the two groups: p = 0.162, p = 0.110, p = 0.188, respectively. The logistic regression analysis for POP repair showed that group A has higher risk for failure (OR = 2.71; 95% CI: 1.31-5.61) and higher complication rate (OR = 2.38; 95% CI: 1.31-4.32).

CONCLUSION

Patients who underwent surgery during educational course developed a poorer outcome after POP repair and higher complication rate.

Training in oesophageal surgery--the gold standard: a prospective study

INTRODUCTION

Competency in complex oesophagogastric surgery, within the current climate of changes to medical training and reduced hours, requires repeated, focused, hands-on training. We describe the training methods for oesophagectomy in our institution.

METHODS

All oesophageal resections under the care of one consultant surgeon are regarded as training cases. When trainees start they are shown the first resection; subsequently, the trainees then perform every case with the consultant scrubbed. Consultant input consists of retraction and tips in difficult situations. All data were collected on a prospective database.

RESULTS

Two hundred and seventy patients (215 males, median age=64 years) underwent primary oesophagectomy under the consultant, between January 2000 and May 2007. Fifteen resections (6%) were performed solely by the consultant. ASA grading was: I=15, II=154, III=95, IV=5, and unrecorded=1. In-hospital mortality and clinically apparent leak rate was 1.9% (5 deaths) and 6.2% (n=17), respectively. Reoperation was required in 15 patients (5.5%). The median length of hospital stay was 14 days (range=8-95 days). Median lymph node yield was 13 (range=0-64).

CONCLUSIONS

Trainees under supervision can competently perform an oesophagectomy without compromising patient care. An early hands-on approach leads to a rapid ascent of the learning curve and is essential in today's climate of limited training opportunity.