Surveillance of surgical training by detailed electronic registration of logical components

Abstract

Objective: To obtain detailed information about the degree of surgical trainee supervision and delegation of procedures in a subspecialised department. Design: Operative procedures and their logical components were recorded in a database constructed in Microsoft Access. Information about operating surgeon and assistants and their grade was registered prospectively over 12 months. Subjects and methods: A total of 1250 intermediate or major procedures were performed by eight consultants, one staff specialist, four senior registrars, three specialist registrars, and five registrars. Main measure: Number of components performed by surgeons in each grade and the degree of supervision and delegation. Results: Eight hundred and eighty five of the operations were elective, while 365 were done as emergency procedures. Emergency procedures were far more often done by surgeons in training than by a staff surgeon, while the opposite was true for elective operations. Out of 323 elective operations done by surgeons in training, 189 were done under supervision (58.5%), while 119 out of 276 emergency operations done by surgeons in training were supervised (43.1%; p=0.0002). One hundred and twenty eight of 638 (20%) open abdominal operations were done by the most junior surgeons, and yet they closed 36% of all abdominal wounds. Although the most junior surgeons only served as operating surgeons in 39 of 334 bowel operations (12%), they constructed 24% of all stomas, and 20% of all anastomoses. Registrars and specialist registrars never constructed stomas or anastomoses without supervision. Conclusion: Detailed information about individual and general training and supervision was achieved by a simple registration. Significant additional information was obtained about the extent of delegation of components compared with standard registration of operative procedures.

Low complication rate after stoma closure. Consultants attended 90% of the operations

“…We adhere to a principle of perceiving each operation as a number of logical components, where some or all components may be delegated to junior surgeons. By doing this, we have achieved a high degree of delegation and supervision [24]. It is important to reassure patients and health‐care providers that trainees in colorectal surgery can obtain a similar quality of results as consultants if they are supervised [25,26].…”

Requirements for Trainee Logbooks

“…Surgical logbooks have also been used to make predictions about manpower 10 . They can validate the number of operations that trainees undertake and whether a reduction in the number of junior doctors’ hospital hours affects the quality of procedural training 11 . Logbooks could become a checklist to ensure that deficiencies in training or exposure are recognized so as to reduce the number of ‘first‐time’ surgeries being carried out by young consultants.…”

“…10 They can validate the number of operations that trainees undertake and whether a reduction in the number of junior doctors' hospital hours affects the quality of procedural training. 11 Logbooks could become a checklist to ensure that deficiencies in training or exposure are recognized so as to reduce the number of 'first-time' surgeries being carried out by young consultants. Reports of surgical logbooks and other surveys from the UK suggest that a decade ago, unsupervised learning was rife, particularly when surgical trainees were carrying out emergencies.…”

Comment on ‘Why do we do the same things so differently?’

“…More important is the impact on training. The majority of bowel anastomoses are performed by trainees under consultant supervision . The technique they use will depend on the consultant with whom they are working at the time and so they often perform each technique (with its own peculiarities) rarely.…”