Surgical Education and Training in Australia and New Zealand

Surgical education for medical students in Australia and New Zealand is provided by 19 universities in Australia and 2 in New Zealand. One surgical college is responsible for managing the education, training, assessment, and professional development programs for surgeons throughout both countries. The specialist surgical associations and societies act as agents of the college in the delivery of these programs, the extent of which varies among specialties. Historically, surgical training was divided into basic and specialist components with selection required for each part. In response to a number of factors, a new surgical education and training program has been developed. The new program incorporates a single merit-based national selection directly into the candidate's specialty of choice. The existing curriculum for each of the nine specialties has been remodeled to a competence-based format in line with the competence required to undertake the essential roles of a surgeon. New standards and criteria have been produced for accreditation of health care facilities used for training. A new basic surgical skills education and training course has been developed, with simulation playing an increasing role in all courses. Trainees' progress is assessed by workplace-based assessment and formal examinations, including an exit examination. The sustained production of sufficient competent surgeons to meet societal needs encompasses many challenges including the recruitment of appropriate graduates and the availability of adequate educational and clinical resources to train them. Competence-based training is an attractive educational philosophy, but its implementation has brought its own set of issues, many of which have yet to be resolved.     

The role of surgical simulation and the learning curve in robot-assisted surgery

New surgical teaching methods are continuously being developed to overcome the learning curves of new advanced surgical procedures. The learning curve is recognized in most minimally invasive and robot-assisted surgery. The development of complex skills-training models and simulators, although in its infancy, has started to facilitate the transfer of these skills to novice surgeons without increasing the risk to patients’ safety. Robotic surgery, whether in the specialties of urology, general surgery, or cardiac surgery, has become the ideal platform to integrate simulators for teaching purposes. Its different interface requires the surgeon to acquire more advanced skills compared with conventional open or laparoscopic surgery. However, simulators can allow the naïve surgeon to develop these skills and pass the learning curve without the medico–legal implications of surgical training, limitations in trainee working hours, and ethical considerations of learning basic skills on humans.     

Comparison of surgical outcomes between teaching and nonteaching hospitals in the Department of Veterans Affairs

OBJECTIVE: To determine whether the investment in postgraduate education and training places patients at risk for worse outcomes and higher costs than if medical and surgical care was delivered in nonteaching settings. SUMMARY BACKGROUND DATA: The Veterans Health Administration (VA) plays a major role in the training of medical students, residents, and fellows. METHODS: The database of the VA National Surgical Quality Improvement Program was analyzed for all major noncardiac operations performed during fiscal years 1997, 1998, and 1999. Teaching status of a hospital was determined on the basis of a background and structure questionnaire that was independently verified by a research fellow. Stepwise logistic regression was used to construct separate models predictive of 30-day mortality and morbidity for each of seven surgical specialties and eight operations. Based on these models, a severity index for each patient was calculated. Hierarchical logistic regression models were then created to examine the relationship between teaching versus nonteaching hospitals and 30-day postoperative mortality and morbidity, after adjusting for patient severity. RESULTS: Teaching hospitals performed 81% of the total surgical workload and 90% of the major surgery workload. In most specialties in teaching hospitals, the residents were the primary surgeons in more than 90% of the operations. Compared with nonteaching hospitals, the patient populations in teaching hospitals had a higher prevalence of risk factors, underwent more complex operations, and had longer operation times. Risk-adjusted mortality rates were not different between the teaching and nonteaching hospitals in the specialties and operations studied. The unadjusted complication rate was higher in teaching hospitals in six of seven specialties and four of eight operations. Risk adjustment did not eliminate completely these differences, probably reflecting the relatively poor predictive validity of some of the risk adjustment models for morbidity. Length of stay after major operations was not consistently different between teaching and nonteaching hospitals. CONCLUSION: Compared with nonteaching hospitals, teaching hospitals in the VA perform the majority of complex and high-risk major procedures, with comparable risk-adjusted 30-day mortality rates. Risk-adjusted 30-day morbidity rates in teaching hospitals are higher in some specialties and operations than in nonteaching hospitals. Although this may reflect the weak predictive validity of some of the risk adjustment models for morbidity, it may also represent suboptimal processes and structures of care that are unique to teaching hospitals. Despite good quality of care in teaching hospitals, as evidenced by the 30-day mortality data, efforts should be made to examine further the structures and processes of surgical care prevailing in these hospitals.     

Changing trends of surgical approaches for uterine prolapse: an 11-year population-based nationwide descriptive study

Introduction and hypothesis

The interest of uterus-preserving surgery has been growing. Based on a nationwide database, we examined surgical procedures for uterine prolapse in Taiwan during the study period of 1997–2007, a total of 11?years.

Methods

The operations, either uterine suspension or hysterectomy, due to the diagnosis of uterine prolapse were indentified into the study. Data on several parameters were collected for analysis, i.e., the surgical type, patient factors (age and concomitant anti-incontinence surgery), surgeon factors (age and gender), and hospital factors (accreditation level and ownership). Data of this study were obtained from the inpatient expenditures by admission files of the National Health Insurance Research Database (NHIRD). The NHIRD was established by the National Health Research Institute with the aim of promoting research into current and emerging medical issues in Taiwan.

Results

In total, 31,038 operations were identified for this study. There was a trend for increased use of uterine suspension with uterine preservation during the latter years, evidenced by joinpoint regression analyses. More women who were younger (<50?years) or had concomitant anti-incontinence surgery received uterine suspension. Younger surgeons (<50?years) and male surgeons tended to perform more uterine suspensions. As for hospital accreditation, more uterine suspension surgeries were performed in regional hospitals, followed by local hospitals and medical centers. As for hospital ownership, more uterine suspension surgeries were performed in private hospitals, followed by not-for-profit and government-owned hospitals.

Conclusions

There has been a considerable change in the surgical approach for uterine prolapse in Taiwan over the past 11?years. Patient age and concomitant anti-incontinence surgery, surgeon age and gender, and hospital accreditation and ownership may correlate with the choice of surgery for women with uterine prolapse.     

Anaesthesia for endoscopic surgery

Shared airway procedures are unique in that both anaesthetist and surgeon are working in the same anatomical field. Close cooperation between anaesthetist and surgeon, an understanding of each other’s problems and knowledge of specialist equipment are often required. There is no ideal anaesthetic technique for all endoscopy procedures and the technique chosen depends on the patient’s general condition, the size, mobility and location of the lesion, the use of a laser, and surgical requirements. Smooth emergence and recovery from anaesthesia are essential.     

Anaesthesia for endoscopic surgery

Shared airway procedures are unique in that both anaesthetist and surgeon are working in the same anatomical field. Close cooperation between anaesthetist and surgeon, an understanding of each other’s problems and knowledge of specialist equipment are often required. There is no ideal anaesthetic technique for all endoscopy procedures and the technique chosen depends on the patient’s general condition, the size, the mobility and location of the lesion, the use of a laser, and surgical requirements. Smooth emergence and recovery from anaesthesia are essential.     

A new surgical education and training programme

Educating and training tomorrow's surgeons has evolved to become a sophisticated and expensive exercise involving a wide range of learning methods, opportunities and stakeholders. Several factors influence this process, prompting those who provide such programmes to identify these important considerations and develop and implement appropriate responses. The Royal Australasian College of Surgeons embarked on this course of action in 2005, the outcome of which is the new Surgical Education and Training programme with the first intake to be selected in 2007 and commence training in 2008. The new programme is competency based and shorter than any designed previously. Implicitly, it recognizes in the curriculum and assessment development and processes, the nine roles and their underpinning competencies identified as essential for a surgeon. It is an evolution of the previous programme retaining that which has been found to be satisfactory. There will be one episode of selection directly into the candidate's specialty of choice and those accepted will progress in an integrated and seamless fashion, provided they meet the clinical and educational requirements of each year. The curriculum and assessment in the basic sciences include both generic and specially aligned components from the commencement of training in each of the nine surgical specialties. Born of necessity and developed through extensive research, discussion and consensus, the implementation of this programme will involve many challenges, particularly during the transition period. Through cooperation, commitment and partnerships, a more efficient and better outcome will be achieved for trainees, their trainers and their patients.     

Evolution of the final fellowship examination

The Royal Australasian College of Surgeons Final Fellowship or exit examination, common to nine surgical specialties, has undergone substantial change since the beginning of formal assessment in 1934. These changes reflect the altered requirements of the different specialties and developments in examination techniques and technology. Although there is now some variation between specialties in the format of each segment of the examination, consistency remains with seven segments of the examination being common to all specialties – two written papers, two clinical segments and three vivas. Approval for Fellowship, indicating success in the examination, is the responsibility of the full Court of Examiners although guided by each Specialty Court. During the past decade the examination has become more structured and objective and all candidates experience similar assessment. Considerable work has been undertaken to ensure that the examination process is appropriate and fair. A review of examination outcomes 2001–2007 shows some variation between specialties. Although the basis for this is multifactorial, some differences between Specialty Courts of Examiners in the structure of the examination and the assessment process may be small contributory factors. With an increased emphasis on competence‐based assessment during training the form of this exit examination will continue to evolve.     

Postgraduate education in surgery and surgical specialties]

Accreditation system of postgraduate training in surgery was started by the Japan Surgical Society (JSS) in 1979, and since then more than 6,800 surgeons has been certified by examination performed by JSS in general surgery. This accreditation system has greatly contributed to the improvement of postgraduate training in general surgery in Japan; since the start of this system operative experiences of surgical residents have increased by 40% and reached to the level of 580 during the 4-year period. In order to further improve the level and quality of surgical care of the patients in Japan, it may be necessary to reform and adjust the accreditation system of postgraduate training in clinical specialties which was started quite separately by each medical specialty society. Probably, to establish a board for each medical specialties should become necessary in the near future to be officially recognized in the medical system of Japan.     

Importance of hospital versus surgeon volume in predicting outcomes for gastric bypass procedures

BackgroundA relationship between surgical volume and improved surgical outcomes has been described in gastric bypass patients but the relative importance of surgeon versus hospital volume is unknown. Our objective was to examine whether in-hospital and 30-day mortality are determined more by surgeon volume or hospital volume or whether each has an independent effect. A retrospective cohort study was performed of all hospitals in Pennsylvania providing gastric bypass surgery from 1999 to 2003.MethodsData from the Pennsylvania Health Care Cost Containment Council included 14,714 gastric bypass procedures in patients aged >18 years. In-hospital and 30-day mortality were stratified by hospital volume categories (high [≥300], medium [125–299], and low [<125]) and surgeon volume categories (high [≥50] and low [<50]). Multivariate analyses were performed using logistic regression analysis to control for patient demographics and severity.ResultsHigh-volume surgeons at high-volume hospitals had the lowest in-hospital mortality rates of all categories (.12%) and low-volume surgeons at low-volume hospitals had the poorest outcomes (.57%). The same trend was observed for 30-day mortality (.30% versus .98%). After controlling for other covariates, high-volume surgeons at high-volume hospitals also had significantly lower odds of both in-hospital (odds ratio 20, P = .002) and 30-day mortality (odds ratio .30, P = .001). This relationship held true even after excluding surgeons who only performed procedures within a single year.ConclusionIn Pennsylvania, both higher surgeon and hospital volume were associated with better outcomes for bariatric surgical procedures. Although a high-surgeon volume correlated with lowered mortality, we also found that high-volume hospitals demonstrated improved outcomes, highlighting the importance of factors other than surgical expertise in determining the outcomes.     

Understanding WHO Surgical Checklist Implementation: Tricks and Pitfalls. An Observational Study

Background

The purpose of the present study was to assess the reliability of implementation data regarding the surgical safety checklist (SSC) and to identify which factors influence actual implementation.

Methods

The study was a retrospective record-based evaluation in a regional network of nine Spanish hospitals, combined with a complementary direct-observation study that included a survey of the surgical teams’ attitudes. SSC compliance and associated factors were assessed and compared in a retrospective sample of 280 operations and a concurrent sample of another 85 surgical interventions.

Results

In the retrospective evaluation the SSC was present in 83.1 % of cases, fully completed in 28.4 %, with 69.3 % of all possible items checked. The concurrent direct-observation study showed that recorded compliance was unreliable (κ < 0.13 for all items) and significantly higher (p < 0.001) than actual compliance. Over-registration occurred across hospitals and surgical specialties. Factors associated with recorded compliance included hospital size, surgical specialty, and the use of an electronic format. In actual (direct-observation) compliance, a positive attitude on the part of the surgeon is an overriding significant factor (OR 12.8), along with using the electronic format, which is consistently and positively associated with recorded compliance but negatively related to actual compliance.

Conclusions

Recorded SSC compliance may be widely unreliable and higher than actual compliance, particularly when recording is facilitated by using an electronic format. A positive attitude on the part of the surgical team, particularly surgeons, is associated with actual compliance. Effective use of the SSC is a far more complex adaptive process than the usual mandatory strategy.     

A proposal for thyroid surgery: criteria to identify the references of endocrine surgery

Indicators of effectiveness and quality of care are needed to improve the outcomes in many surgical fields. International and national studies in thyroid surgery have not clearly documented an association between number of cases and outcome quality, but it is essential for the figure of a highly experienced surgeon, able to provide proof of positive outcomes. Therefore, we try to underline the structural and technical requirements in thyroid surgery. Moreover, the need for an accreditation program is outlined.     

Surgeon Mean Operative Times in Total Knee Arthroplasty in a Variety of Settings in a Health System

BackgroundHigh-quality care is essential in total joint arthroplasty. Multiple initiatives such as centers of excellence, patient optimization, and alternative payment models have demonstrated improved outcomes and decreased cost. Many studies have shown that longer operative times (OTs) are associated with increased frequency of postoperative complications. These findings often come from large data sets and may not accurately represent the average OT of individual surgeons. The purpose of this study was to determine the hospital and patient-related factors that influence OT.MethodsThis retrospective study reviewed OT of 6003 total knee arthroplasty cases performed by 41 surgeons at 4 hospitals in a single health-care system. Mean OT was calculated for each surgeon. The effect of surgeon, hospital-, and patient-related factors on OT was assessed.ResultsAmong the 41 surgeons, the mean OT was 105 ± 25 minutes. Two community hospitals had significantly faster OT compared with the tertiary care academic hospital. Surgeons’ OT for morbidly obese patients was significantly longer compared with normal, overweight, and obese patients. Surgeon volume, surgeon experience, trainee presence, and American Society of Anesthesiologists status did not significantly affect surgical time.ConclusionsOperative time was influenced by hospital-related (tertiary, community) and patient-related (morbid obesity vs lower body mass index groups) factors. However, specific surgeon factors (surgical volume, experience), surgical team factors (presence or absence of trainee), and patient factors (American Society of Anesthesiologists status) did not significantly alter the OT. Additional studies of larger health systems are needed to examine additional patient, surgeon, and hospital factors which may influence the OT.     

Challenges and strategies for determining workforce requirements in plastic surgery

BACKGROUND:

Accurate projections of the future plastic surgeon workforce are essential to provide a high standard of care and to properly allocate scarce health care resources. This is not a straightforward task. Longstanding concerns over physician surpluses have been replaced by fears of physician shortages.

METHODS:

A review of previous efforts to predict future plastic surgeon workforce requirements highlights the challenges associated with deriving a solution. Physician workforce is dependent on numerous factors, including both physician-supply factors, such as practice patterns and age, and population-demand factors including disease burden and socioeconomic factors. Factors unique to plastic surgery, such as overlap with other specialties and performance of uninsured services, must also be considered. Previous strategies from other areas of medicine are described with associated strengths and weaknesses. These strategies include needs- and demand-based approaches, economic analysis and benchmarking. Finally, the need for appropriate outcomes from which to assess adequacy of physician supply is discussed.

CONCLUSIONS:

Projections of future plastic surgeon workforce requirements must not only consider a multitude of physician supply and population demand factors, but also factors unique to plastic surgery. Future strategies to predict workforce requirements should balance the strengths and weaknesses of each approach with the data and outcomes available in plastic surgery.     

The European Working Time Directive and the Effects on Training of Surgical Specialists (Doctors in Training)

Summary Legislation launched with the EWTD was born as a “Protection of the clinical personnel against overwork for the benefit of Patients” (consumer protection and safety). It appeared that this legislation is in direct and severe conflict with former EU legislation to train competent surgical specialists. First experiences with the EWTD show far reaching and serious consequences on the training of surgical specialists as well as on medical care. There will be a reduction of about 30–35% of clinical and operative experience acquired during the usual 6 yrs of training, with many other negative aspects (see p. 7). All measures proposed so far to overcome the ensuing problems are unworkable. The training of competent surgical specialists as required by the Directive 93/16 EEC is no longer possible and serious problems with safe patient care will occur in the short term, if no political actions are taken. The surgical specialties, represented in the UEMS, provide a proposal for a working hour model consisting of 48 hrs working time (incl. service duties) plus additional 12 hrs reserved and protected for teaching and training. This model would adhere to the EWTD on the one hand, yet maintain the desired standard of training. This proposed exemption from the EWTD would be limited to the time of specialist training. We ask the responsible politicians to find a solution rapidly to prevent serious negative consequences. This motion is supported by the surgical specialties (neurosurgery, general surgery, orthopaedic surgery, paediatric surgery, cardio-thoracic surgery, vascular surgery, oto-rhino-laryngology, list not complete) of the member states of the EU, representing more than 80,000 surgical specialists.     

The European Working Time Directive and the Effects on Training of Surgical Specialists (Doctors in Training)

Summary Legislation launched with the EWTD was born as a “Protection of the clinical personnel against overwork for the benefit of Patients” (consumer protection and safety). It appeared that this legislation is in direct and severe conflict with former EU legislation to train competent surgical specialists. First experiences with the EWTD show far reaching and serious consequences on the training of surgical specialists as well as on medical care. There will be a reduction of about 30–35% of clinical and operative experience acquired during the usual 6 yrs of training, with many other negative aspects (see p. 7). All measures proposed so far to overcome the ensuing problems are unworkable. The training of competent surgical specialists as required by the Directive 93/16 EEC is no longer possible and serious problems with safe patient care will occur in the short term, if no political actions are taken. The surgical specialties, represented in the UEMS, provide a proposal for a working hour model consisting of 48 hrs working time (incl. service duties) plus additional 12 hrs reserved and protected for teaching and training. This model would adhere to the EWTD on the one hand, yet maintain the desired standard of training. This proposed exemption from the EWTD would be limited to the time of specialist training. We ask the responsible politicians to find a solution rapidly to prevent serious negative consequences. This motion is supported by the surgical specialties (neurosurgery, general surgery, orthopaedic surgery, paediatric surgery, cardio-thoracic surgery, vascular surgery, oto-rhino-laryngology, list not complete) of the member states of the EU, representing more than 80,000 surgical specialists.     

Granting clinical privileges for telerobotic surgery

Surgeons can now perform operations on their patients while sitting at a remote site. During telerobotic operations, the surgeon sits at a computer console. The computer translates the motions of the surgeon's hands into motions of the robotic instruments. Introduction of telerobotics into clinical practice raises issues comparable to those generated by the rapid introduction of laparoscopic cholecystectomy in the late 1980s. As a result, we have instituted processes in our hospitals for the granting of clinical privileges for telerobotic surgery. These processes are derived from the guidelines of the Society of American Gastrointestinal Endoscopic Surgeons for granting clinical privileges for laparoscopic general surgery. Our hospitals require the following: (1) board certification or board eligibility for the appropriate surgical board; (2) clinical privileges for the open and laparoscopic operations that will be performed telerobotically; (3) satisfactory completion of the Food and Drug Administration-mandated training course in the safe use of the robotic surgical system; (4) performance of telerobotic operations in animate models; (5) observation of clinical cases of telerobotic surgery by an expert surgeon; (6) acting as bedside assistant surgeon in telerobotic operations or supervision by a preceptor during the surgeon's initial operations; (7) observation by a proctor of the surgeon's initial clinical telerobotic operations; and (8) ongoing monitoring of surgical outcomes of telerobotic operations. This process has facilitated the safe and orderly introduction of telerobotics operations into clinical practice in our hospitals.     

La simulación como modelo de enseñanza en cirugía

Teaching of surgery has been affected by many factors over the last years, such as the reduction of working hours, the optimization of the use of the operating room or patient safety.Traditional teaching methodology fails to reduce the impact of these factors on surgeońs training. Simulation as a teaching model minimizes such impact, and is more effective than traditional teaching methods for integrating knowledge and clinical-surgical skills.Simulation complements clinical assistance with training, creating a safe learning environment where patient safety is not affected, and ethical or legal conflicts are avoided.Simulation uses learning methodologies that allow teaching individualization, adapting it to the learning needs of each student. It also allows training of all kinds of technical, cognitive or behavioural skills.     

The European Working Time Directive and the Effects on Training of Surgical Specialists (Doctors in Training)

Legislation launched with the EWTD was born as a "Protection of the clinical personnel against overwork for the benefit of Patients" (consumer protection and safety). It appeared that this legislation is in direct and severe conflict with former EU legislation to train competent surgical specialists.First experiences with the EWTD show far reaching and serious consequences on the training of surgical specialists as well as on medical care. There will be a reduction of about 30-35% of clinical and operative experience acquired during the usual 6 yrs of training, with many other negative aspects (see p. 7). All measures proposed so far to overcome the ensuing problems are unworkable. The training of competent surgical specialists as required by the Directive 93/16 EEC is no longer possible and serious problems with safe patient care will occur in the short term, if no political actions are taken.The surgical specialties, represented in the UEMS, provide a proposal for a working hour model consisting of 48 hrs working time (incl. service duties) plus additional 12 hrs reserved and protected for teaching and training. This model would adhere to the EWTD on the one hand, yet maintain the desired standard of training. This proposed exemption from the EWTD would be limited to the time of specialist training. We ask the responsible politicians to find a solution rapidly to prevent serious negative consequences.This motion is supported by the surgical specialties (neurosurgery, general surgery, orthopaedic surgery, paediatric surgery, cardio-thoracic surgery, vascular surgery, oto-rhino-laryngology, list not complete) of the member states of the EU, representing more than 80,000 surgical specialists.