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DOI: 10.

1308/147363509X475781

C O M PA R I S O N O F S H O SURGICAL LOGBOOKS A G E N E R AT I O N A PA R T

RL Thomas ST3 in General Surgery, St Georges Hospital, London N Karanjia Consultant Hepatopancreaticobiliary Surgeon, Royal Surrey County Hospital, Guildford

There is current concern regarding operative experience obtained by senior house officers (SHOs) during basic surgical training prior to beginning registrar level.1,2 Anecdotally, working hours are greatly reduced compared to 20 years ago. The reduction in experience is attributed to the New Deal, which was introduced by the Department of Health in 1991 to improve working conditions for doctors, primarily through reduction of working hours to 76 per week maximum by 1996. In addition, Calmanisation, ie the introduction of the specialist trainee registrar grade of training, and the recent introduction of the European Working Time Directive (EWTD) have both had an effect on juniors working hours.
Ann R Coll Surg Engl (Suppl) 2009; 91:356359

Comparison of working patterns

We compared the general surgical logbooks of two surgical SHOs from the mid 1980s and the mid 2000s (20 years apart) in the same training centre. The first trainee appointed (surgeon A) had full training in general surgery and is now a professor of hepatobiliary surgery; the second, (surgeon B) is a registrar-level ST3 trainee in general surgery, equivalent to first-year surgical registrar. Surgeon A qualified in June 1983 and worked as an SHO in general surgery on two firms during two periods: January 1986 to July 1986 (vascular, breast, endocrine and general surgery) and July 1987 to January 1988 (upper gastrointestinal (GI), colorectal and general surgery), a total of 12 months. During this period trainee A followed a 1-in-2 on-call rota working for two consultants for each six-month period. In addition there was on each firm a senior registrar and a registrar. Surgeon B qualified in August 2003 and worked in the same centre as an SHO in general surgery between February 2006 and November 2007. During this time he rotated through: hepatobiliary (three months), breast (six months), colorectal (seven months), upper GI (three months). There was also a three-month period spent as an intensive care clinical fellow. During this basic surgical training scheme, a roughly 1-in-6 partial-shift rota was followed, compliant at band 2b with a maximum of 48 hours per week. Surgeon B worked a total of 19 months as a general surgical SHO. With regards to examinations, surgeon A obtained primary FRCS in February 1985

and final FRCS in May 1987 (London) after six months of general surgical SHO posts, whereas surgeon B obtained MRCS in October 2006 (intercollegiate/London) after nine months of similar posts. See Table 1 for a comparison of working patterns for both surgeons.

The use of electronic logbooks is now a requirement for all surgical trainees. The logbook used by surgeon B is the Association of Surgeons of Great Britain and Ireland (ASGBI) logbook available on the Intercollegiate Surgical Curriculum Project (ISCP) website: www.iscp.ac.uk. This logbook allows a great deal of data storage per operation, including American Society of Anaesthesiology (ASA) grading, National Confidential Enquiry into Patient Outcome and Death (NCEPOD) rating, time of operation and level of supervision. It also allows the trainee to revisit and edit the page to enter any complications that may have occurred. The named trainer can also be recorded and there is a facility for free text to add any additional, relevant information. The electronic logbook also allows the trainee to show activity for any periods in the form of a spreadsheet and allows consolidation of each type of operation and levels of supervision for operations in each specialy. In contrast, the logbook of surgeon A is unusual in that it exists at all, logbooks being uncommon in surgery until relatively recently. The form is a Collins A5 notebook recording the names and hospital number of each patient. A note is made of other members of the team, at that time constituting consultant,

Comparison of logbooks

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senior and junior registrars. There is no mention of the level of supervision and only operations performed by surgeon A with trainer scrubbed or unscrubbed are recorded. For each case, neither ASA grading, nor NCEPOD rating, nor an indication of the time of operation is recorded.

TABLE 1
COMPARISON OF WORKING PATTERNS BETWEEN SURGEONS A AND B Surgeon A Time in general surgery (months) Specialities (months) 12 Vascular/breast: 6 Upper GI/Colorectal: 6 Surgeon B 19 Hepatobiliary: 3 Breast: 6 Colorectal: 7 Upper GI: 3 Partial shift 1:6 48 (approx) 2B October 2006 9 months 10 months

The numbers of operations from each logbook were collated and compared. Distinctions were made between pre and post-membership/fellowship operating for each surgeon. Hernia repairs, closure of colostomy or ileostomy and cholecystectomy (open or laparoscopic) have been used as examples of elective surgery. Appendicectomy, abscess drainage and laparotomy (right hemicolectomy, perforated duodenal ulcer, adhesiolysis and small bowel resection) have been used to demonstrate volumes of emergency operating. Total numbers of emergency and elective operations performed have also been recorded. For the purposes of this comparison, the sixmonth periods either side of obtaining the MRCS/FRCS will be compared; this is intended to give a direct comparison of equivalent periods in each of the two surgeons training. There are clear discrepancies in operative experience between now and 20 years ago in both elective and emergency operating. Of the elective case numbers

Differing volumes of operative experience

Type of rota On calls Hours per week (approx) Banding MRCS or FRCS Time pre-membership Time post-membership

On call 1:2 100120 n/a May 1987 6 months 6 months

compared, the number of cases 20 years ago has fallen by over three-quarters (80 vs 18, see Table 2). For inguinal hernia repair the operations carried out has fallen by 82%. The largest differences lie in comparisons made after obtaining the FRCS or MRCS diploma. Surgeon A performed 32 post-FRCS hernia repairs whereas surgeon B performed only 6, 82% fewer than 20 years ago. This difference is also reflected in the number of cholecystectomies performed 20 years apart, the contemporary figure being reduced by a factor of 95%. These discrepancies may be partly explained by the introduction of

laparoscopic techniques for both cholecystectomy and hernia repair. It may also be explained by the fact that both surgeons worked in a hospital that is now a major training centre for laparoscopic surgical training with associated reduced junior trainee opportunities. Furthermore, surgeon A performed seven common bile duct explorations as an SHO whereas surgeon B performed none. With regards to emergency operating the differences are similar and again weighted in favour of surgeon A (see Table 3). Surgeon A performed a total of 70 appendicectomies as an SHO compared

TABLE 2
COMPARISON OF ELECTIVE OPERATING Surgeon A (19851987) Pre-FRCS Inguinal hernia Femoral hernia Other hernia Closure of stoma Cholecystectomy Common bile duct exploration Total 3 2 1 0 2 0 8 Post-FRCS 32 2 4 5 22 7 72 TOTAL 35 4 5 5 24 7 80 Pre-MRCS 5 0 6 0 0* 0 11 Surgeon B (20062007) Post-MRCS 1 0 3 2 1** 0 7 TOTAL 6 0 9 2 1 0 18

(only shown where performed with trainer scrubbed or unscrubbed, first and second assistant cases not shown) *Assisted at 15 laparoscopic cholecystectomies **Assisted at 17 laparoscopic cholecystectomies

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TABLE 3
COMPARISON OF EMERGENCY OPERATING, APENDICECTOMIES AND ABSCESS DRAINAGE Surgeon A (19851987) Pre-FRCS Appendicectomy Abscess drainage Laparotomy: right hemi Laparotomy: DU oversew Laparotomy: adhesiolysis Laparotomy: SB resection Total 1 46 3 45 4 91 0 10 0 3 0 13 0 1 1 1 0 1 0 1 1 0 0 0 38 7 0 Post-FRCS 32 5 3 TOTAL 70 12 3 3 6 0 Surgeon B (20062007) Pre-MRCS Post-MRCS 1 1 1 TOTAL 4 7 1

(Only cases performed with supervisor scrubbed or unscrubbed shown)

to 4 for surgeon B, a difference of over 90%. The numbers pre and postmembership were similar for both surgeons. For incision and drainage of abscesses, the figures were more similar (12 vs 7). There are further differences with regards to exploratory laparotomy, right hemicolectomy, duodenal ulcer oversew, adhesiolysis and small bowel resection, perhaps not normally considered as SHO operations. Surgeon A performed 6 laparotomies in total as an SHO, compared with only 1 for surgeon B. The numbers themselves are low for both surgeons though again reflect a significant difference in experience between the two eras.

advantage of a wide range of training opportunities as well as private study time while at work. Prior to Calmanisation and the EWTD a surgical trainee could work approximately 30,000 hours between SHO and consultant level.4 This has fallen to an estimated 8,000 hours and is thought likely to fall further to 6,000 hours as the EWTD takes full effect.4 There is evidence that the directive and the New Deal have been detrimental to the training of surgeons.1,2 Gurjar showed that pre-Calman, the percentage of cases in which a basic surgical trainee (ie SHO) was the principal surgeon was 32%, rising to over 35% early in Calmanisation but falling to under 20% in the post-Calman era (20012002).2 More specifically, the rate of completed appendicectomy during this period fell from 60% to under 40%. Simultaneously the proportion of noncareer grade surgeons performing emergency operations rose sharply from under 15% pre-Calman to over 40% postCalman. These changes have also been reflected in outpatient clinic experience in a similar fashion.1 Furthermore, these data were echoed for inpatient operations where of the 458 procedures carried out during a study there was a fall of 34% in the proportion in which an SHO was present after the implementation of the

full-shift rota. Perhaps surprisingly, the number of emergency operations at which an SHO was present was unchanged.1 What is perhaps most disconcerting is that in this study the full-shift rota was found to be compliant at 52 hours per week significantly more than the current limit of 48 hours in effect from August 2009. In a similar study analysing SHO operating over an eight-year period between February 1997 and February 2005, elective operating experience for SHOs fell by 31% in ENT, 65% in general and vascular surgery, and 68% in urology.5 This was despite the numbers of SHOs in the specialties remaining unchanged during the period studied. For our operative examples for surgeons A and B the fall was 77%, which is in keeping with data in the other studies.

Surgical training has undergone a number of changes in recent years. Since the introduction of the EWTD in 2000, junior doctors hours of work have decreased. Since August 2004 the limit has been 56 hours per week and in August 2009 the limit has been reduced to 48 hours per week.3 This is very different from the 1980s when junior doctors were often expected to provide up to 100 hours per week, with the result that the quality of training and quantity of experience was high, involving a great deal of exposure at SHO level and beyond. During this time of course, trainees were able to take

Discussion

There is compelling evidence that the introduction of dedicated consultant-led training lists can ameliorate the erosion of operating opportunities, as recently demonstrated by Beaton.6 This study demonstrated that during a six-month period in which operative training lists were arranged for SHOs or house officers the average number of inguinal hernia repairs performed by SHOs rose from 1 to 5 (range 115), appendicectomies rose from 2 to 6 (range 119) and total

Proposed solutions?

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operative experience from 47 to 74 (range 30149). The institution of the supervised training list restored basic surgical training experience to pre-Calman levels while preserving rota compliance. In addition to this there is early evidence that surgical training in treatment centres may provide a valuable source of elective theatre experience for trainees as shown by Macleod in an encouraging recent study.7 Similarly, the issue of surgical training and the EWTD is being addressed by the realisation that surgical education must undergo radical changes in order to maintain high standards of trainees through maximising available opportunities. An example of this has been demonstrated by Allum and Markham, whereby the new surgical curriculum laid out in the ISCP (www.iscp.ac.uk) can be incorporated

into a pattern of training for junior surgical trainees.8 During this model, specialist trainee registrar years 2 and 3 would rotate through emergency surgery, general surgery and day surgery for varying lengths of time essentially following a modular system. At more advanced levels, ie specialist trainee/registar years 5 to 8, the model would be maintained, giving a progressive advancement in the level of the trainee according to the landmarks of the ISCP while exposing the trainee to scheduled emergency surgery. The bulk of the time at these stages would be in subspecialty training predominantly elective activity although it would appear that dedicated, supervised training lists are vital in ensuring a good level of experience is obtained by the trainee.

References
1. Marron CD, Byrnes CK, Kirk SJ. An EWTD-compliant shift rota decreases trainining opportunities. Ann R Coll Surg Engl (Suppl) 2005; 87: 24648. 2. Gurjar SV, McIrvine AJ. Working time changes: a raw deal for emergency operative training. Ann R Coll Surg (Suppl) 2005; 87: 14041. 3. Department of Health. HSC 2003/001 - Protecting staff; delivering services: implementing the European Working Time Directive for doctors in training. London: Crown copyright; January 2003. 4. Chikwe J, de Souza AC, Pepper JR. No time to train the surgeons. BMJ 2004 Feb 21; 328: 41819. 5. Varley I, Keir J, Fagg P. Changes in caseload and the potential impact on surgical training: a retrospective review of ones hospital experience. BMC Medl Educ 2006 Jan 18; 6: 6. 6. Beaton C, Hopper AN, Morgan MA et al. Influence of targeted basic surgical training lists on SHO operative experience in the EWTD era. Ann R Coll Surg Engl (Suppl) 2007; 89: 21416. 7. Macleod S, Black J. Surgical training in a treatment centre. Ann R Coll Surg Engl (Suppl) 2005; 87: 31617. 8. Allum WH, Markham NI. Surgical training and EWTD can it be done? Ann R Coll Surg Engl (Suppl) 2007; 89: 2069.

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