Defining quality assessment in vascular surgery training: an expert Delphi process

INTRODUCTION

A robust and reproducible way of assessing training should optimise and standardise vascular surgical training. This study describes the methodology supporting the Vascular Surgery Specialty Advisory Committee regional quality assurance reports for vascular surgery training programmes in the UK.

METHODS

A Delphi consensus exercise was performed to establish the domains of training that most appropriately assess the quality of a vascular surgery training programme. A total of 54 stakeholders were invited to participate, including trainees, training programme directors and members of the vascular speciality advisory committee (SAC), vascular society executive and education committees.

RESULTS

A total of 39 stakeholders successfully completed the three-stage Delphi process over 15 weeks. The domains identified as most appropriate to assess the quality of a vascular training programme were: Joint Committee on Surgical Training (JCST) survey results, clinical experience, regional education programmes, radiology support, timetable, regional support for trainees, trainer support for trainees, opportunities for professional development, trainee-rated quality of consultant teaching and training, and trainee recommendation of the post.

CONCLUSIONS

This study describes a method to identify and prioritise domains that are appropriate to assess the quality of a vascular training programme. The domains that were identified as appropriate to assess quality are transferable internationally and the Delphi methodology could be used by other training schemes to 'fine-tune' their own domains to review and optimise the quality of their own training programmes.

The RCS England COVID-19 Surgical Research Group: early findings and lessons to influence surgical practice

INTRODUCTION

Surgeons and allied professionals have been quick to respond to the need for evidence during the COVID-19 pandemic. The Royal College of Surgeons of England (RCS England) has provided formal recognition, support and guidance to all members of its interdisciplinary collaborative COVID Research Group (RCS CRG). We describe research conducted by members of this group, initial findings and lessons for clinical practice so far.

METHODS

Members of the more than 50 projects included so far in the RCS CRG portfolio were invited to provide a summary of their project and findings to date. The 26 summaries received were collated and broad themes identified to produce this summary document.

RESULTS

Wide-ranging projects have been conducted by members of the RCS CRG, rapidly yielding crucial insights into the behaviour of the SARS-CoV-2 pathogen, its impact on patients and staff, the challenges it presents to surgical practice and investigation into methods to adapt and overcome such challenges.

CONCLUSIONS

The response of the surgical research community to COVID-19 has been rapid and well-organised. Early establishment of a formal network under the auspices of RCS England has assisted efficient research collaboration and delivery, while avoiding academic duplication between groups. This has led to a high research output, directly informing and substantially influencing practice throughout and beyond the pandemic.

Variation in training requirements within general surgery: comparison of 23 countries

Background

Many differences exist in postgraduate surgical training programmes worldwide. The aim of this study was to provide an overview of the training requirements in general surgery across 23 different countries.

Methods

A collaborator affiliated with each country collected data from the country's official training body website, where possible. The information collected included: management, teaching, academic and operative competencies, mandatory courses, years of postgraduate training (inclusive of intern years), working‐hours regulations, selection process into training and formal examination.

Results

Countries included were Australia, Belgium, Canada, Colombia, Denmark, Germany, Greece, Guatemala, India, Ireland, Italy, Kuwait, the Netherlands, New Zealand, Russia, Saudi Arabia, South Africa, South Korea, Sweden, Switzerland, UK, USA and Zambia. Frameworks for defining the outcomes of surgical training have been defined nationally in some countries, with some similarities to those in the UK and Ireland. However, some training programmes remain heterogeneous with regional variation, including those in many European countries. Some countries outline minimum operative case requirement (range 60–1600), mandatory courses, or operative, academic or management competencies. The length of postgraduate training ranges from 4 to 10 years. The maximum hours worked per week ranges from 38 to 88 h, but with no limit in some countries.

Conclusion

Countries have specific and often differing requirements of their medical profession. Equivalence in training is granted on political agreements, not healthcare need or competencies acquired during training.

Use of the eLogbook in surgical training in the United Kingdom: A nationwide survey and consensus recommendations from the Association of Surgeons in Training

INTRODUCTION

Accurate recording of operative cases is essential during training to demonstrate experience. However, indicative numbers delineating minimum desirable experience may incentivise exaggeration or misrepresentation of experience. This study aimed to determine perceptions of real-world eLogbook use among UK surgeons in training.

MATERIAL AND METHODS

An anonymous online questionnaire was disseminated electronically using a pre-planned yield-maximisation strategy, incorporating regional champions, email and social media. Evaluation employed mixed methods in a combined interpretation of quantitative and qualitative data from the questionnaire. Recommendations for development of the eLogbook were itemised from respondents' free text items and a modified Delphi process, conducted within the Council of the UK national trainee representative body, the Association of Surgeons in Training, determined the strength of each recommendation.

RESULTS

Analysis included 906 complete responses from training-grade surgeons (34.8% female) from all UK recognised specialties and all grades of training. More than two-thirds (68.5%) believed that overstatement or misrepresentation of case involvement occurs. A fifth (20.8%) reported witnessing trainees logging cases they had not actually participated in and almost a third (32.7%) had witnessed overstatement, yet few (15.1%) had raised such an issue with a supervisor. Most (85.2%) respondents had few or no eLogbook entries validated. More than a quarter of respondents felt pressure to overstate their involvement in cases (28.6%) and the number recorded (28.1%). Almost a third (31.5%) felt the required case number for completion of training was not achievable. Female trainees were less likely to feel well supervised (p = 0.022) and to perceive targets for completion of training were achievable (p = 0.005). Thematic analysis identified four key themes to explain logbook misuse: Pressure to achieve training milestones; eLogbook functionality issues; training deficiencies and probity.

CONCLUSIONS

Inaccurate operative recording was widely reported, primarily in response to perceived pressure to achieve targets for career progression. Operative logbooks may not be as accurate as intended. Consensus recommendations are made for improvement in the eLogbook and its use.

Supporting doctors as healthcare quality and safety advocates: Recommendations from the Association of Surgeons in Training (ASiT)

BACKGROUND

As front-line healthcare staff, doctors in surgical training occupy a unique organisational space rotating through hospitals and services in which they witness first hand both good and bad practice. This puts trainees in a clear position to identify and raise patient safety issues, and to contribute to discussions regarding quality and safety improvement. However, there are a number of real and perceived barriers to trainees doing so. These include concerns about the impact on training assessments and career progression, and uncertainty about the appropriate route.

METHODS

Paper-based survey of delegates attending the Association of Surgeons in Training (ASiT) conference (response rate 73%; 479/652).

RESULTS

288 (60%) of trainees reported previous concerns over practices and behaviour of colleagues that might pose risks to patient care including concerns over poor performance (n = 243; 84%), bullying (n = 45; 16%), alcohol and drug abuse (n = 15; 5%) and mental health problems (n = 8; 3%). However, 53% (n = 153) did not escalate these concerns. 178 (37%) of trainees also reported concerns over hospital policies, protocols or systems that might pose a risk to patient care, with 46% (n = 82) not escalating such concerns. Respondents highlighted fear of personal vilification or reprisal (n = 224; 47%), fear of impact on career (n = 206; 43%) and a lack of confidence in the process (n = 170; 36%) as barriers to whistleblowing. More senior trainees were significantly more likely to raise concerns than more junior grades (p < 0.0001).

CONCLUSION

These results highlight worrying issues around reporting concerns, with trainees often "silent witnesses" to poor performance in healthcare. Adverse events must provide opportunities for learning to improve future outcomes. Herein, ASiT proposes 14 recommendations to improve protection for trainees in raising patient safety concerns. These include the creation of a positive workplace culture, promoting the active involvement of trainees in quality improvement discussions, with clear mechanisms for trainees to raise concerns.

Body composition and bone health in adolescents after Roux-en-Y gastric bypass for severe obesity

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGB) causes changes in body composition and bone metabolism, yet little is known about effects in adolescents.

OBJECTIVES

The objective of this study was to report dual-energy X-ray absorptiometry measures and serum bone markers, hypothesizing that bone turnover increases after surgery.

METHODS

Inclusion criteria included the following: age 13-18 years and body mass index (BMI) >35 kg/m² . Seventy-two adolescents (22 boys; mean age 16.5 years; BMI 44.8 kg/m² ) undergoing RYGB underwent dual-energy X-ray absorptiometry and serum bone marker analyses preoperatively and annually for 2 years.

RESULTS

Mean BMI reduction at 2 years was 15.1 kg/m² . Body composition changes included a reduction in fat mass (51.8% to 39.6%, p < 0.001) and relative increase in lean mass (47.0% to 58.1%, p < 0.001). In contrast to previous studies in adults, adolescent boys lost a greater percentage of their body fat than girls (-17.3% vs. -9.5%, p < 0.001). Individual bone mineral density Z-scores (BMD-Z) at baseline were within or above the normal range. The mean (SD) BMD-Z was 2.02 (1.2) at baseline, decreasing to 0.52 (1.19) at 2 years. Higher concentrations of serum CTX (p < 0.001) and osteocalcin (p < 0.001) were observed in boys throughout the study period. Levels rose in the first year, before decreasing modestly in the second. Levels of serum markers of bone synthesis and resorption were higher in boys, whose skeletal maturity occurs later than girls'.

CONCLUSIONS

Differences in body fat and lean mass proportions were observed according to sex following RYGB. Bone turnover increased, and BMD decreased to levels approaching a norm for age. Long-term outcome will determine the clinical relevance.

Taking ASiT’s Foundation Skills in Surgery course to Rwanda

The Association of Surgeons in Training’s role in strengthening the health infrastructure of a nation still scarred from genocide two decades on.

A cross sectional study of surgical training among United Kingdom general practitioners with specialist interests in surgery

OBJECTIVES

Increasing numbers of minor surgical procedures are being performed in the community. In the UK, general practitioners (family medicine physicians) with a specialist interest (GPwSI) in surgery frequently undertake them. This shift has caused decreases in available cases for junior surgeons to gain and consolidate operative skills. This study evaluated GPwSI's case-load, procedural training and perceptions of offering formalised operative training experience to surgical trainees.

DESIGN

Prospective, questionnaire-based cross-sectional study.

SETTING/PARTICIPANTS

A novel, 13-item, self-administered questionnaire was distributed to members of the Association of Surgeons in Primary Care (ASPC). A total 113 of 120 ASPC members completed the questionnaire, representing a 94% response rate. Respondents were general practitioners practising or intending to practice surgery in the community.

RESULTS

Respondents performed a mean of 38 (range 5-150) surgical procedures per month in primary care. 37% (42/113) of respondents had previously been awarded Membership or Fellowship of a Surgical Royal College; 22% (25/113) had completed a surgical certificate or diploma or undertaken a course of less than 1 year duration. 41% (46/113) had no formal British surgical qualifications. All respondents believed that surgical training in primary care could be valuable for surgical trainees, and the majority (71/113, 63%) felt that both general practice and surgical trainees could benefit equally from such training.

CONCLUSIONS

There is a significant volume of surgical procedures being undertaken in the community by general practitioners, with the capacity and appetite for training of prospective surgeons in this setting, providing appropriate standards are achieved and maintained, commensurate with current standards in secondary care. Surgical experience and training of GPwSI's in surgery is highly varied, and does not yet benefit from the quality assurance secondary care surgical training in the UK undergoes. The Royal Colleges of Surgery and General Practice are well placed to invest in such infrastructure to provide long-term, high-quality service and training in the community.

Implications of the shape of training review for surgery

Published in 2013, the Shape of Training review is an independent review of postgraduate medical training overseen by Professor david Greenaway. 1 This review has set out recommendations for the structure and delivery of training for the next 30 years, 1 including a framework and timescale for this reconfiguration. There is a wide range of key themes, listed in Table 1 . The changes proposed in its 19 recommendations are far-reaching, with implications for both current and future surgical trainees in the UK.

Surgical training in primary care: consensus recommendations by the Association of Surgeons in Training

Health service reconfigurations may result in increasing numbers of minor surgical procedures migrating from secondary care in hospitals to primary care in the community. Procedures may be performed by General Practitioners with a specialist interest in Surgery, or secondary care Surgeons who are sub-contracted to perform procedures in the community. Surgical training in such procedures, which are currently hospital based, may therefore be adversely affected unless surgical training also takes advantage of these opportunities. There is potential for surgical trainees to benefit from training in the community setting. ASiT supports the development of formal surgical training in the community setting for junior surgical trainees, providing high standards of patient care and training provision are ensured. Anticipated problems relating to the migration of surgical services to the community relate to the availability and quality assurance of training opportunities in primary care, its funding, including exposure to issues of indemnity cover for trainees, and also the release of surgical trainees from hospital duties in order to attend these training opportunities. These consensus recommendations set out a framework through which both patient care and training remain at the forefront of these continued service reconfigurations.

Association of Surgeons in Training conference: Belfast 2014

The Association of Surgeons in Training (ASiT) is a professional body and registered charity working to promote excellence in surgical training for the benefit of junior doctors and patients alike. ASiT is independent of the National Health Service (NHS), Surgical Royal Colleges, and specialty associations and represents trainees in all ten surgical specialties. ASiT was delighted to welcome all four surgical Royal College Presidents and over 650 delegates to Belfast for ASiT 2014. With a theme of Marginal Gains, the conference programme explored collaboration, simulation training and human factors, complimented by debates including the Shape of Training Review (ShOT), several focussed parallel sessions and ten subsidised pre-conference training courses. Almost £4000 was awarded by the incoming President, Mr Vimal Gokani, to delegates across more than 30 prizes for delegates who presented the highest scoring academic work from over 1200 submitted abstracts.

Randomized clinical trial of intraoperative superficial cervical plexus block versus incisional local anaesthesia in thyroid and parathyroid surgery

Background

Moderate wound pain and opiate analgesia requirement is reported following thyroid and parathyroid surgery. A randomized clinical trial was performed to investigate whether intraoperative superficial cervical plexus block (SCPB) would decrease postoperative pain and analgesia use.

Methods

Patients were randomized to incisional local anaesthesia (control) or incisional local anaesthesia plus intraoperative SCPB. The primary outcome measure was pain, assessed by a visual analogue scale (VAS). Secondary outcome measures were analgesia use (strong opiates defined as having potency at least as strong as that of oral morphine), respiratory rate and sedation score. Primary outcome measures were analysed with non-parametric tests, as well as with receiver operating characteristic (ROC) curves calculated as area under the curve (AUC) to discriminate between trial limbs.

Results

Twenty-nine patients were randomized to each group. Pain (VAS) scores were lower in patients who received intraoperative SCPB than in controls 30 min after surgery and subsequently (P &lt; 0·020 at all time points), with a median pain score of zero on the day of operation in the SCPB group. Corresponding analysis of ROC curves showed differences between groups at 30 min (AUC = 0·722, P = 0·012), 90 min (AUC = 0·747, P = 0·005), 150 min (AUC = 0·803, P &lt; 0·001) and 210 min (AUC = 0·849, P &lt; 0·001) after surgery, and at 07.00 hours on postoperative day 1 (AUC = 0·710, P = 0·017). Fewer patients in the SCPB group required strong opiates (5 of 29 versus 16 of 29 in the control group; P = 0·003) and rescue opiates (6 of 29 versus 20 of 29; P &lt; 0·001).

Conclusion

Intraoperative SCPB reduces pain scores following thyroid and parathyroid surgery, and reduces the requirement for strong and rescue opiates. Registration number: 2009-012671-98 (https://www.clinicaltrialsregister.eu).