Surgical training in the 21st century: Are we limited by training time or are we just distracted?

The aim of any surgical training programme is to produce competent, effective, and safe individuals, who will go on to deliver high quality patient care, for a prolonged period at an affordable cost. The fundamental principles of surgical training have remained unchanged for years, despite there being increasing concerns relating to trainee recruitment, retention, and morale. There is no benefit in ascribing shortcomings of surgical training to uncontrollable factors such as the European Working Time Directive, unprecedented NHS service demand following COVID-19 and economic uncertainty. Instead, we must look introspectively at existing opportunities for improvement in order to continue to produce high quality surgeons in the NHS.

Junior doctor engagement in rota writing during the COVID 19 crisis

The COVID-19 pandemic placed an unprecedented demand on the NHS. In response, high-intensity rotas were implemented with short notice. This project aimed to fairly and safely step down the COVID response rota as normal working patters resumed.A cross-sectional survey was distributed to doctors on the medical COVID rota. It explored their views on the step-down process. The majority of respondents (68%) had concerns including discrepancy between on calls and lack of opportunity to plan leave. A document of key themes in the feedback was prepared and presented to senior clinical managers.Intervention and ImprovementThe new rota produced ensured an even distribution of shifts and honoured pre-existing leave. The new rota was compliant and ran to completion for every trainee. Comparison of stepping down to the trust rota vs our new rota reduced inter-trainee shift variation. Night shift discrepancy SD reduced from 2.89 to 0.97, long day (ward cover) on-calls reduced from SD 3.57 to 1.12 and long day (take) shifts SD 0.98 to 0.56.Following implementation a second cross-sectional survey was distributed. 85% agreed or strongly agreed that there was sufficient staffing levels ‘on call’ and 80% agreed or strongly agreed that there was sufficient staffing levels on the wards. 95% found they were able to take their annual leave and 80% agreed or strongly agreed that there was an even distribution of on-call and night shifts.ConclusionThe success of our project relied on good engagement with colleagues to collect a representative view for leverage in discussions with seniors, and produced a result that was fairer for trainees, sustainable, and preferable for rota coordinators and senior clinical management. Active collaboration in the rota design process will improve junior doctor engagement, well-being and job satisfaction.

Clinical Characteristics and Predictors of Mortality in Patients with COVID-19 Infection Outside Intensive Care.

BACKGROUND/INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has affected all aspects of inpatient hospital medicine with patients admitted from level 1 (general medical wards) to level 3 (intensive care). Often, there are subtle physiological differences in these cohorts of patients. In particular, in intensive care, patients tend to be younger and have increased disease severity. Data, to date, has combined outcomes from medical and intensive care cohorts, or looked exclusively at intensive care. We looked solely at the level 1 (medical) cohort to identify their clinical characteristics and predictors of outcome. PATIENTS AND METHODS: This was a retrospective study of adult patients admitted to a central London teaching hospital with a diagnosis of COVID-19 from 23rd March to 7th April 2020 identified from the hospital electronic database. Any patients who required level 2 or 3 care were excluded. RESULTS: A total of 229 patients were included for analysis. Increased age and frailty scores were associated with increased 30-day mortality. Reduced renal function and elevated troponin blood levels are also associated with poor outcome. Baseline observations showed that increased oxygen requirement was predictive for mortality. A trend of increased mortality with lower diastolic blood pressure was noted. Lymphopenia was not shown to be related to mortality. CONCLUSION: Urea and creatinine are the best predictors of mortality in the level 1 cohort. Unlike previous intensive care data, lymphopenia is not predictive of mortality. We suggest that these factors be considered when prognosticating and for resource allocation for the treatment and escalation of care for patients with COVID-19 infection.