Aesthetic surgical training in the UK independent sector--the clients' view: Results of a survey on 155 private patients.

As training opportunities in cosmetic surgery become less frequent in teaching hospitals, this survey set out to examine the attitudes of patients towards extending this training into the independent health sector. We questioned 155 private patients, 95% of who were happy for trainees to sit in during their consultations. Of these, 85% were comfortable with the presence of the trainee throughout their appointments and 92% said they saw advantages in having such trainees present. However, patients were less enthusiastic about trainees carrying out procedures, under consultant supervision and for a reduced fee. The survey found that while 49% felt it was a good idea, only 32% would consider it for themselves. Seventeen percent of patients thought this offer alone was inappropriate. This survey has shown that while the vast majority of private patients supported and were happy to participate in higher surgical training during private consultations, fewer would consider the possibility of cosmetic surgery performed by supervised trainees for reduced fees. The implications of these findings for higher surgical training in Plastic Surgery in the UK are discussed.     

Is there enough time to train? An audit of core surgical training rotas

BackgroundThe Joint Committee on Surgical Training (JCST) have published a series of quality indicators (QIs) which act as a benchmark against which the quality of surgical training can be assessed. This audit aims to compare core surgical training (CST) rotas in our region against the JCST QI 10's minimum standard of 5 consultant supervised training sessions per week.MethodsCore surgical trainees in one training region were contacted requesting their on-call rotas from rotations undertaken during the 2019/20 academic year. Rotas were analysed in a protocolised manner, with the number of potential training sessions available calculated and compared against the JCST QI 10 minimum recommendation.ResultsTwenty-four rotas were assessed across 17 hospitals. Only six (25%) of rotas achieved the JCST QI 10 standard. There was a mean deficit of 18.5 (±29.5) training sessions per 6-month rotation. Rotas compliant with JCST QI 10 used a mean rota pattern of 1 in 11 compared to 1 in 9 for those failing to meet the target.Further analysis, comprising of the addition of expected consultant led training whilst on call, led to an improvement in compliance to 9 (38%) and 13 (54%) of rotas when there was an addition of 0.5 h and 1 h of consultant supervised training time per on-call session respectively.ConclusionMany core surgical trainee rotas in the region are non-compliant with JCST QI 10, indicating a lack of regular consultant-led training opportunities. A move to a reduced on-call commitment with the use of supporting medical practitioners could be considered to improve this.     

Training in the private sector: what works and how do we increase opportunities?

In Australia 61% of elective surgery takes place in private hospitals where current opportunities for surgical education and training (SET) are limited. The situation will shortly be compounded because of the large increase in local medical graduates, many of whom will aspire to be surgeons. How and where to train these extra surgeons to meet the expanding needs of the community must be addressed. Two models of private sector training are reviewed both of which involved combined training in both private and public sectors. Two second‐year (SET 2) positions were created from one public hospital SET position by using the private sector for 3.5 days per week for 3 months of a 6‐month rotation. The second model was applicable to post‐fellowship training with a fairly even split between public and private sector responsibilities. In the first year, four registrars shared the two 6‐month rotations for the SET 2 position. Trainees did the required minimum procedures (range 109–139) with primary operating targets of 20–25% (range 21–32%). The post‐fellowship position in colorectal surgery was greatly enhanced by the private sector involvement with regard to operating experience as well as meeting part of the remuneration of the trainee. Successful models for training within the private sector in Australia can be found. To expand training in the private sector there will need to be a cultural shift in the perceptions of surgeons, patients, administrators, and trainees. Funding for posts may be available to those private hospitals that can meet the Royal Australasian College of Surgeons’ accreditation standards for posts and hospitals.     

Role of the surgical trainee in upper gastrointestinal resectional surgery.

The 'New Deal' set out by the Department of Health in 1991, together with the introduction of specialist 6-year training grades by Calman in 1993, has resulted in a decrease in available training time for surgeons in the UK. There is also an emerging belief that surgical procedures performed by trainees might compromise patient outcome. This study examines the level of trainee experience in a specialist gastrointestinal unit and whether operation by a trainee surgeon adversely affects patient outcome. All patients in the University Department of Surgery, Royal Infirmary, Edinburgh, undergoing oesophagogastric, hepatic or pancreatic resection between January 1994 and December 1996 were entered into the study. The early clinical outcome (in-hospital mortality and morbidity, considered in three groups: anastomotic leak, other technique-related complications and non-technique-related complications) was evaluated with regard to the grade of surgeon (consultant or trainee) performing the operation. Of the 222 patients undergoing major upper gastrointestinal resection during the study period, 100 (45%) were operated on by trainees. Trainees were assisted and closely supervised by consultants in all but six resections. There was no major difference in mortality rate (consultant, 4.1% vs trainee, 5%), incidence of non-technique-related complications (consultant, 6.7% vs trainee, 7.1%), anastomotic leaks (consultant, 10.7% vs trainee, 5%) or technique-related complications (consultant, 18.9% vs trainee, 15%) between the two grades of surgeon. In a specialist unit, the early clinical outcome of patients undergoing major upper gastrointestinal resection by supervised trainees is no worse than in those operated on by consultants. Participation of trainees in such complex procedures enhances surgical training and does not jeopardise patient care.     

Effects of the European Working Time Directive on anaesthetic training in the United Kingdom

Decreases in the hours worked by trainee anaesthetists are being brought about by both the New Deal for Trainees and the European Working Time Directive. Anticipated improvements in health and safety achieved by a decrease in hours will be at the expense of training time if the amount of night-time work remains constant. This audit examined the effects of a change from a partial to a full shift system on a cohort of trainee anaesthetists working in a large district general hospital in the South-west of England. Logbook and list analyses were performed for two 10-week periods: one before and one after the decrease in hours. An 18% decrease in the number of cases done and an 11% decrease in the number of weekly training lists were found for specialist registrars. A 22% decrease in the number of cases done and a 14% decrease in the number of weekly training lists were found for senior house officers. Furthermore, a decrease of one service list per specialist registrar per week was seen, which will have implications for consultant manpower requirements.     

The effect of COVID-19 on surgical training

The COVID-19 pandemic has had a huge impact on society, healthcare in general and also on training in surgery. Cancellation of elective procedures, redeployment and establishment of green sites have combined with other factors to create significant gaps in training experience in operative and all other areas of surgery. There are nearly a million cases which have been lost to training since March 2020 and recovery means that tens of thousands of extra training cases have to be performed every month to recover that experience. There are pressures to address huge waiting list backlogs which may squeeze out time for training unless training is considered at the heart of any recovery plan. #NoTrainingTodayNoSurgeonsTomorrow. New, no blame, COVID ARCP outcomes have helped recognize the impact of the pandemic on progression and significant trainee and trainer organizations are united in raising the profile of the training crisis and offering a suite of suggestions on how to speed recovery. Disruption caused by the pandemic has allowed existing simulation and conferencing platforms to finally be widely accepted and the importance of the wider surgical team in supporting surgical training to be realized. New, outcomes-based curricula, with better feedback at their centre, will speed recovery of training trajectories. We should embrace the opportunity for change to help short and medium term recovery and improve the delivery of surgical training into the future.     

A Cost‐Benefit Analysis of Government Compensation of Kidney Donors

From 5000 to 10 000 kidney patients die prematurely in the United States each year, and about 100 000 more suffer the debilitating effects of dialysis, because of a shortage of transplant kidneys. To reduce this shortage, many advocate having the government compensate kidney donors. This paper presents a comprehensive cost‐benefit analysis of such a change. It considers not only the substantial savings to society because kidney recipients would no longer need expensive dialysis treatments—$1.45 million per kidney recipient—but also estimates the monetary value of the longer and healthier lives that kidney recipients enjoy—about $1.3 million per recipient. These numbers dwarf the proposed $45 000‐per‐kidney compensation that might be needed to end the kidney shortage and eliminate the kidney transplant waiting list. From the viewpoint of society, the net benefit from saving thousands of lives each year and reducing the suffering of 100 000 more receiving dialysis would be about $46 billion per year, with the benefits exceeding the costs by a factor of 3. In addition, it would save taxpayers about $12 billion each year.     

The effect of the European Working Time Directive on anaesthetic working patterns and training

There is concern that the European Working Time Directive 2009 has led to reduced time available for training, and this study examined if this has been the case. For two identical six‐month periods in 1999 (pre‐Directive) and 2009 (post‐Directive), weekly data were collected on the total number of sessions attended by trainees, the number of supervised sessions and the leave days taken. A total of 5925 theatre sessions were analysed (2353 in 1999 and 3572 in 2009). For ST1‐2 trainees, there was a 37% increase in theatre sessions attended (p = 0.02), with a 77% increase in the number of these sessions supervised by a consultant (p = 0.02). For ST3‐7 trainees, there was a reduction in the number of theatre sessions attended of 27% (p = 0.03), but this was not accompanied by a significant increase in the number of consultant‐supervised sessions (11% increase; p = 0.18). The aggregate median increase in weekly consultant‐supervised theatre sessions per trainee increased for ST1‐2 trainees (70% increase; p = 0.0016) but not for ST3‐7 trainees (11% increase; p = 0.31). For neither trainee group did training time decline. Our data contradict the hypothesis that the European Working Time Directive has reduced access to training, or suggest that if it has, other factors (such as improved trainee rostering) have overridden its effect.     

Modernizing assessment of surgical trainees in the workplace

Surgical training has evolved significantly over the last few decades. The old model of an informal apprenticeship and ad-hoc mentoring by a single or small team of consultant supervisors has been slowly replaced with formal assessment against a standardized specialty curriculum and annual review of competence by a panel of trainers. The introduction of new surgical curricula from August 2021 has continued this modernization of surgical assessment with greater emphasis on quality of interactions between trainer and trainee. The requirement of a fixed number of work-place based assessments to be completed per year has been dropped. There is a move to competency-based assessment rather than time based. Competencies have been divided into core competencies (Generic Professional Capabilities) and key competencies of a speciality (Capabilities in Practice). These will be assessed by a group of consultant supervisors, and structured and constructive feedback will be provided using the multi-consultant report, a tool designed to give defined feedback that can be actioned by trainees. Trainees will be able to measure their performance against tangible goals and see their progressions towards acquiring the skills required of a day one consultant.     

Surgery in a district general hospital

All operations performed in all surgical specialties in a district general hospital over a 4-week period were monitored. Although most elective operations were performed or supervised by trained staff, the service, particularly emergency care, was heavily dependent on incompletely trained doctors. Consultants, who operated on 41% of elective cases, were more likely to perform major operations. Supervision of junior surgeons for elective surgery was considered satisfactory. Thirty-one per cent of all major cases were performed by doctors in training, usually under supervision. However, 86% of all emergency operations were performed by trainee surgeons without consultant supervision. A consultant anaesthetist or clinical assistant attended all elective operating lists and either supervised or gave the anaesthetic. However, anaesthetists in training were not usually supervised for emergency cases outside normal working hours. It is worrying that one-third of all procedures were undertaken by surgeons who had been on duty for periods in excess of 24 h.     

Trainee surgery in teaching hospitals: is there a cost?

The morbidity rate for 2858 patients undergoing thyroidectomy over the 10 year period January 1977-December 1986 was examined and related to the involvement of a surgical trainee in the operative procedure. There was no overall difference in specific complication rates related to the surgical procedure, being 13.8% when the procedure was undertaken by a consultant, and 13.1% when a surgical trainee was involved in the procedure. There was a significant increase (P = 0.0025) in operative time increasing from 127 min for the consultant to 146 min when the trainee was involved (a 15% increase). There was no significant difference in bed stay for any of the groups. Surgical trainees can be safely taught operative skills under supervision without risk of increased complications. There is a cost, however, to the hospital system in terms of increased demands on time and operative facilities.     

Current prices versus minimum costs of production for CFTR modulators

BackgroundWhile the clinical benefits of CFTR modulators are clear, their high prices render them inaccessible outside of the world's richest countries. Despite this, there is currently limited evidence regarding global access to these transformative therapies. Therefore, this study aims to estimate the minimum costs of production of CFTR modulators, assuming robust generic competition, and to compare them with current list prices to evaluate the feasibility of increased global access to treatment.MethodsMinimum costs of production for CFTR modulators were estimated via an algorithm validated in previous literature and identification of cost-limiting key starting materials from published routes of chemical synthesis. This algorithm utilised per kilogram active pharmaceutical ingredient costs obtained from global import/export data. Estimated production costs were compared with published list prices in a range of countries.ResultsCosts of production for elexacaftor/tezacaftor/ivacaftor are estimated at $5,676 [$4,628-6,723] per year, over 90% lower than the US list price. Analysis of chemical structure and published synthetic pathways for elexacaftor/tezacaftor/ivacaftor revealed relatively straightforward routes of synthesis related to currently available products. Total cost of triple therapy for all eligible diagnosed CF patients worldwide would be $489 million per year. Comparatively, the annual cost at US list price would be $31.2 billion.ConclusionsElexacaftor/tezacaftor/ivacaftor could be produced via generic companies for a fraction of the list price. The current pricing model restricts access to the best available therapy, thereby exacerbating existing inequalities in CF care. Urgent action is needed to increase the availability of triple combination treatment worldwide. One strategy based on previous success is originator-issued voluntary licenses.     

A time-cost analysis of teaching a laparoscopic entero-enterostomy

OBJECTIVE: Determining the success of technical skill training for surgery residents should include not only the efficacy of the training in terms of skills learned but also the cost of the facility where the training occurs and the cost of faculty participation. Traditional training occurs in the operating room, but the cost of faculty time and operating room time has not been well established. Assessing the cost of traditional training may allow us to put the cost of building and maintaining skills laboratories in perspective. To estimate the cost of traditional training we have recorded the time and interventions necessary for our senior residents to do a laparoscopic entero-enterostomy. METHODS: Each senior resident (PGY3-5) was asked to perform a laparoscopic entero-enterostomy in its entirety as part of a laparoscopic gastric bypass. After cannulation of the abdomen and division of any adhesions, we timed the residents for the performance of the following group of tasks: finding the ligament of Treitz, dividing the bowel 50-60 cm downstream, and creating a 2-layer anastomosis at 125 or 200 cm distal to the ligament. We tracked total time and number of interventions, which are defined by the attending temporarily taking over the case. RESULTS: Twelve residents were tracked by this system. The average time to complete the task was 93.7 minutes (+/-11.9 SD). The average number of interventions per case was 1.5 (+/-1.1 SD). Nine residents completed more than 1 procedure. Seven residents reduced their operative time on the second attempt. Operative times between the first and second procedure showed a reduction of 4.4 minutes (+/-17.4 SD), although this was not statistically significant (p = 0.47). No adverse clinical sequelae developed in these small bowel anastomoses. Educational time was calculated by subtracting the resident time from the time it takes an attending or finishing laparoscopic fellow to complete this task (50 minutes). The educational time for each anastomosis was 43.7 minutes. Using the AAMC average salary for an assistant professor of surgery of $180,000 year and assuming a 60-hour work week, this is $45.52 in faculty costs per anastomosis. If the cost of an operating room is $2000 per hour, the educational cost is $1457 per anastomosis. In our program, providing our 15 senior residents an educational opportunity to perform 2 laparoscopic entero-enterostomies would cost $45,061 a year. CONCLUSION: Resident education is expensive. Knowledge of the cost of skills training in a traditional operative setting is necessary to put the costs associated with building and maintaining skills laboratories in perspective. Cost analyses and efficacy of teaching will allow us to rate the success of new educational techniques.     

Effect of supervised surgical training on outcomes after resection of colorectal cancer

BACKGROUND: The process of training surgeons in technique for resection of colorectal cancer should not compromise patient care or outcomes. The aim of this study was to compare morbidity, mortality and survival rates after resection performed by trainees with those for a consultant surgeon. METHODS: Outcomes for 150 patients operated on by a single colorectal surgeon at a private hospital were compared with those of 344 patients admitted under the same surgeon and operated on by closely supervised trainee surgeons in a public teaching hospital between 1995 and 2002. RESULTS: Co-morbidity was significantly more common in patients operated on by trainees; their American Society of Anesthesiologists grades were higher and tumours were more advanced. Of 16 postoperative complications evaluated, only respiratory and cardiac problems were significantly more common in patients operated on by trainees. There was no difference in operative mortality, local recurrence or 2-year survival rate after adjustment for age and tumour stage. CONCLUSION: Outcomes after resection for colorectal cancer did not differ between the consultant and trainees in the context of a closely supervised training programme.     

Training opportunities in liver transplantation surgery

BACKGROUND: Liver transplantation surgery is carried out in only a few selected centres in the UK. This study was performed with a view to identifying potential training opportunities available for the general and specialist higher surgical trainee, and also to assess the outcome following liver transplant surgery according to the grade of the surgeon performing the procedure. METHODS: Data on 111 liver transplants with caval preservation undertaken consecutively in a single unit during a 32-month period were collected and analysed. The transplant procedures were grouped into those performed by consultants and those performed by supervised trainees. Survival was estimated by the Kaplan-Meier method. The Cox regression model was used to examine the influence of grade of the surgeon on survival. chi2 and independent sample t tests were used to identify significant preoperative, intraoperative and postoperative variables. RESULTS: Trainees carried out 34 recipient hepatectomies (31 per cent), 47 implant procedures (42 per cent) and all 143 retrieval operations. The mean time taken by a supervised trainee to carry out a recipient hepatectomy and implantation was 183 and 44 min compared with 165 and 46 min for a consultant (P = 0. 22 and P = 0.44 respectively). The mean intraoperative red cell requirement was 8 units for both consultants and trainees (P = 0.85). The overall patient survival rate was 88 per cent at 3 years and the grade of the surgeon made no difference to survival or the occurrence of complications (P > 0.05). CONCLUSION: The outcome following liver transplantation with caval preservation did not differ according to the grade of the surgeon performing the procedure. Extensive training opportunities are available to learn hepatobiliary and vascular surgical techniques in liver transplantation surgery.     

Developing a VATS lobectomy programme--can VATS lobectomy be taught?

OBJECTIVE: Although VATS lobectomy has been demonstrated to be safe and effective, the technique is not widely practiced. This may, in part, reflect difficulty in acquiring appropriate skills. We have evaluated the effect of experience and training on surgical outcomes during the development and establishment of a VATS lobectomy programme. METHODS: Data were collected prospectively on 276 consecutive VATS lobectomies under the care of a single consultant as either the primary surgeon or supervising four trainees. The series was divided into cohorts of 46 patients. These comprised one trainee cohort and five sequential consultant cohorts. Statistical analysis utilised standard tests of significance. RESULTS: Increasing experience with the VATS lobectomy programme was associated with a significant reduction in operating time but intraoperative blood loss and postoperative stay were not influenced by increasing consultant surgical experience. Training was associated with a mean increase of 22 min operative time (p=0.0005) but no increase in intraoperative blood loss, morbidity, mortality or postoperative stay. The 46 trainee operative times were similar to the first 46 consultant cases. CONCLUSIONS: VATS lobectomy can be safely taught to trainee thoracic surgeons. However, in view of the limited number of centres undertaking VATS lobectomy, training should be coordinated at a national level to concentrate experience and improve uptake of this technique.     

Neurosurgery in Victoria, Australia: training and practice compared with the United Kingdom

In the UK there are currently great changes taking place in both higher surgical training and consultant practice. Australia inherited the British system, many aspects of which it retains, but has moved to a US type training programme. Recent experience of British and Australian neurosurgical practice allows useful comparisons to be made with possible benefit to both. Neurosurgery in Australia is a more consultant based service than that in the UK, with 73 consultants for a population of 18 million. Consultants work primarily from their private rooms and consultant numbers in the public sector are misleading as few of them approach full time. Neurosurgical training is organized on a national basis with a finite training programme. This consists of a rotation of different jobs supplemented by consultant led lectures and tutorials. Training is regularly monitored, with a final exit examination. The disadvantages are the relative lack of operating whilst training, many neurosurgeons becoming accredited with the personal operating experience expected of a British registrar; and the working hours; most trainees work 1 in 1, which precludes any sort of normal family life. In summary, the relative strengths of the British and Australian systems are largely complementary, there being ample scope for each to learn from the other.     

Patient and Provider-Identified Factors Contributing to Surgical Readmission After Colorectal Surgery

Purpose: Nearly one in seven surgical patients is readmitted to the hospital within 30 days of discharge. Few studies have identified patient-centric factors that raise the risk of both preventable and nonpreventable postoperative readmissions. Materials and Methods: Over 6 months in 2012, 48 colorectal surgical patients were identified on re-admission within 30 days of discharge. We prospectively obtained information on the patient's and primary surgeon's views on factors that contributed to readmission, and compiled data to produce an external list of contributing factors. A standard cost analysis was performed. Results: 48 colorectal surgery patients participated, and 47 were included in this patient-centric evaluation of factors leading to readmission. The three primary readmission diagnoses included dehydration, fever, and ileus or small bowel obstruction. Of all readmissions, 23% were considered to be preventable. 38% of patients had scheduled follow-up appointments that were documented in the medical record at the time of discharge. Providers identified several factors contributing to readmission including difficulty understanding discharge plan, medication management and premature discharge. Per patient, the cost of preventable readmission was $15,366 (±20%; $12,293–$18,439). Total preventable cost was $169,025 (±20%; $135,220–$202,829). Conclusions: The ability to obtain an outpatient postoperative appointment and the understanding of their own postoperative care were the most commonly identified barriers. Interventions to help reduce unnecessary readmissions include a standard discharge process and coordinator, and routine (<7 days) postdischarge outpatient appointments. Successful reduction of preventable readmissions would result in approximately $3.6 million in cost savings per 1,000 colorectal readmissions.     

The financial impact of teaching surgical residents in the operating room

BACKGROUND: There have been no published data regarding the cost of training surgical residents in the operating room. METHODS: At the University of Tennessee Medical Center-Knoxville, in addition to resident-performed teaching cases, some cases are performed without the assistance of residents by the same faculty. RESULTS: Sixty-two case categories involving 14,452 cases were compared for operative times alone. In 46 case categories (10,787 procedures), resident operative times were longer than faculty alone. In 16 case categories, resident operating times were shorter than faculty times. The net incremental operative time cost was 2,050 hours between July 1993 and March 1997. Assuming 4 years of operative training for 11 graduating chief residents, the cost per graduating resident was $47,970. CONCLUSION: Extrapolated to a national annual cost for the 1,014 general surgery residents who completed training in the 1997 academic year, the annual cost of training residents in the operating room is $53 million. This high monetary cost suggests the need for digital skills, selection criteria, the development of training curriculum and resource facilities, the pre-operating room need for suturing and stapling techniques, and perhaps the acquisition of virtual surgery training modules.     

Impact of the European Working Time Directive on exposure to operative cardiac surgical training.

OBJECTIVE: To evaluate the impact of the reduced working hours, an anticipated decline in case load and increasing patient risk profile, we performed a cohort study to determine the factors that influenced operative surgical training. METHODS: A historic cohort study design was utilised, and data were acquired from a prospective operative surgical database a year before, and a year after the introduction of the European Working Time Directive (EWTD) compliant rota (1st August 2004). Logistic regression was used to determine the predictors of operative surgical training, and individual variables were ranked by likelihood ratio. RESULTS: In total, 3312 cardiac surgical operations were performed over a 2-year period between 3rd August 2003 and 31st July 2005. The proportion of cases performed by trainees was 39% (626/1587) in the year before and 40% (695/1725) in the year after the introduction of WTD compliant rota. There were no differences in operative risk (logistic EuroSCORE of 8, P=0.853). Independent predictors for surgery performed by a trainee (in descending order of influence) were the consultant in charge (chi11(2) 273.1; P<0.001), procedure performed (chi5(2) 163.5; P<0.001), increasing seniority of trainee (chi2(2) 142.3; P<0.001), revision surgery (chi1(2) 45.9; P<0.001), lower EuroSCORE (chi1(2) 17.6; P<0.001), and better ventricular function (chi2(2) 7.8; P=0.020). The odds ratio of an operation performed by a trainee increased after the introduction of the EWTD compliant rota to 1.19 (95% CI 1.00-1.41; P=0.045). CONCLUSIONS: With a successful institution-specific training module and a commitment to training, exposure to operative surgical training can be sustained despite shortening of working hours.