Real-world use of workplace based assessments in surgical training: A UK nationwide cross-sectional exploration of trainee perspectives and consensus recommendations from the Association of Surgeons in Training.

BACKGROUND: Despite widespread uptake, the utility of Workplace Based Assessments (WBAs) is disputed and evidence underpinning their use is largely based upon their completion in ideal conditions, rather than the real-world setting. AIM: To ascertain the real-world usage of WBAs, as perceived by UK surgical trainees. MATERIALS AND METHODS: An anonymous online questionnaire conducted nationally via the Association of Surgeons in Training (ASiT). Evaluation of 906 completed trainee responses, across all surgical specialties and training levels, employed mixed methods to interpret quantitative and qualitative data. RESULTS: The sample permitted a 3.0% confidence level with acceptable internal consistency (Cronbach's alpha 0.755). Formative use was supported by 72.5% and summative use was rejected by almost as many (66.3%). WBA use was perceived to deviate markedly from that recommended by the Joint Committee on Surgical Training (JCST). Significant misuse was identified and elements perceived as inaccurate appear commonplace across the breadth of surgical specialties. Inaccurate completion was acknowledged by 89.6% of respondents and some trainers appear complicit, 147 individuals (16.2%) having reported this to trainers, 40.9% aware of 'unobserved sign-off', and 33.6% aware of 'password disclosure' by trainers. Furthermore, a majority of trainees felt the Annual Review of Competency Progression (ARCP) respected WBA quantity above quality (55.4%), and a third felt pressure to overstate the number completed (32.0%). Reasons for misuse appeared largely centred upon time restraints, lack of engagement and a will to achieve the required targets for career progression. 1.5 CONCLUSIONS: This study demonstrates that UK surgical trainees perceive that most trainees deviate from guidance in their use of WBAs. This is worrying in both the apparent frequency and nature of misuse and somewhat undermines existing evidence for their role in surgical training. Trainees perceive that required numbers of WBAs are too high, that training programmes fail to encourage their use as formative assessments, and that there is a lack of engagement by many trainees and trainers. We present consensus recommendations from ASiT for the improvement of WBA use in UK surgical training.

Surgical trainees' experience of pregnancy, maternity and paternity leave: a cross-sectional study.

BACKGROUND: Internationally, supporting surgical trainees during pregnancy, maternity and paternity leave is essential for trainee well-being and for retention of high-calibre surgeons, regardless of their parental status. This study sought to determine the current experience of surgical trainees regarding pregnancy, maternity and paternity leave. METHODS: A cross-sectional anonymised electronic voluntary survey of all surgical trainees working in the UK and Ireland was distributed via the Association of Surgeons in Training and the British Orthopaedic Trainees' Association. RESULTS: There were 876 complete responses, of whom 61.4% (n=555) were female. 46.5% (258/555) had been pregnant during surgical training. The majority (51.9%, n=134/258) stopped night on-call shifts by 30 weeks' gestation. The most common reason for this was concerns related to tiredness and maternal health. 41% did not have rest facilities available on night shifts. 27.1% (n=70/258) of trainees did not feel supported by their department during pregnancy, and 17.1% (n=50/258) found the process of arranging maternity leave difficult or very difficult. 61% (n=118/193) of trainees felt they had returned to their normal level of working within 6 months of returning to work after maternity leave, while a significant minority took longer. 25% (n=33/135) of trainees found arranging paternity leave difficult or very difficult, and the most common source of information regarding paternity leave was other trainees. CONCLUSION: Over a quarter of surgical trainees felt unsupported by their department during pregnancy, while a quarter of male trainees experience difficulty in arranging paternity leave. Efforts must be made to ensure support is available in pregnancy and maternity/paternity leave.

Surgical safety checklist training: a national study of undergraduate medical and nursing student teaching, understanding and influencing factors.

INTRODUCTION: Use of the WHO surgical safety checklist is consistently recognised to reduce harm caused by human error during the perioperative period. Inconsistent engagement is considered to contribute to persistence of surgical Never Events in the National Health Service. Most medical and nursing graduates will join teams responsible for the perioperative care of patients, therefore appropriate undergraduate surgical safety training is needed. AIMS: To investigate UK medical and nursing undergraduate experience of the surgical safety checklist training. METHODS: An eight-item electronic questionnaire was distributed electronically to 32 medical schools and 72 nursing schools. Analysis was conducted for the two cohorts, and responses from final year students were included. RESULTS: 87/224 (38.8%) of medical students received teaching on the surgical safety checklist, compared with 380/711 (52.0%) of nursing students. 172/224 (76.8%) of medical students and 489/711 (66.9%) of nursing students understood its purpose and 8/224 (3.6%) medical students and 54/711 (7.4%) nursing students reported never being included in the Time Out. After adjusting for confounding factors, provision of formal teaching in checklist use increased understanding significantly (OR 50.39 (14.07 to 325.79, P<0.001)), as did routine student involvement in time outs (OR 5.72 (2.36 to 14.58, P<0.001)). DISCUSSION: Knowledge of perioperative patient safety systems and the ability to participate in safety protocols are important skills that should be formally taught at the undergraduate level. Results of this study show that UK undergraduate surgical safety checklist training does not meet the minimum standards set by the WHO.

Impact of Surgical Lighting on Intraoperative Safety in Low-Resource Settings: A Cross-Sectional Survey of Surgical Providers.

BACKGROUND: Safe surgery requires high-quality, reliable lighting of the surgical field. Little is reported on the quality or potential safety impact of surgical lighting in low-resource settings, where power failures are common and equipment and resources are limited. METHODS: Members of the Lifebox Foundation created a novel, non-mandatory, 18-item survey tool using an iterative process. This was distributed to surgical providers practicing in low-resource settings through surgical societies and mailing lists. RESULTS: We received 100 complete responses, representing a range of surgical centres from 39 countries. Poor-quality surgical field lighting was reported by 40% of respondents, with 32% reporting delayed or cancelled operations due to poor lighting and 48% reporting electrical power failures at least once per week. Eighty per cent reported the quality of their surgical lighting presents a patient safety risk with 18% having direct experience of poor-quality lighting leading to negative patient outcomes. When power outages occur, 58% of surgeons rely on a backup generator and 29% operate by mobile phone light. Only 9% of respondents regularly use a surgical headlight, with the most common barriers reported as unaffordability and poor in-country suppliers. CONCLUSIONS: In our survey of surgeons working in low-resource settings, a majority report poor surgical lighting as a major risk to patient safety and nearly one-third report delayed or cancelled operations due to poor lighting. Developing and distributing robust, affordable, high-quality surgical headlights could provide an ideal solution to this significant surgical safety issue.

Less than full-time training in surgery: a cross-sectional study evaluating the accessibility and experiences of flexible training in the surgical trainee workforce.

OBJECTIVES: Generational changes in lifestyle expectations, working environments and the feminisation of the medical workforce have seen an increased demand in postgraduate less than full-time training (LTFT). Despite this, concerns remain regarding access to, and information about, flexible training for surgeons. This study aimed to assess the opinions and experiences of LTFT for surgical trainees. DESIGN: Prospective, questionnaire-based cross-sectional study. SETTING/PARTICIPANTS: An electronic, self-administered questionnaire was distributed in the UK and Republic of Ireland through mailing lists via the Association of Surgeons in Training and British Orthopedic Trainee Association. RESULTS: Overall, 876 completed responses were received, representing all grades of trainee across all 10 surgical specialties. Median age was 33 years and 63.4% were female. Of those who had undertaken LTFT, 92.5% (148/160) were female. Most worked 60% of a full-time post (86/160, 53.8%). The reasons for either choosing or considering LTFT were childrearing (82.7%), caring for a dependent (12.6%) and sporting commitments (6.8%). Males were less likely to list childrearing than females (64.9% vs 87.6%; p<0.0001). Only 38% (60/160) found the application process easy and 53.8% (86/160) experienced undermining behaviour from workplace staff as a result of undertaking LTFT. Of all respondents, an additional 53.7% (385/716) would consider LTFT in future; 27.5% of which were male (106/385). Overall, only 9.9% of all respondents rated current LTFT information as adequate. Common sources of information were other trainees (47.3%), educational supervisors (20.6%) and local postgraduate school website (19.5%). CONCLUSIONS: Over half of surgical trainees working LTFT have experienced undermining behaviour as a result of their LTFT. Despite a reported need for LTFT in both genders, this remains difficult to organise, access to useful information is poor and negative attitudes among staff remain. Recommendations are made to provide improved support and information for those wishing to pursue LTFT.

Less Than Full-time Training in surgical specialities: Consensus recommendations for flexible training by the Association of Surgeons in Training.

Changes in lifestyle, career expectations, and working environments, alongside the feminisation of the workforce have resulted in an increased demand for Less Than Full-time Training (LTFT) within surgery. However, provision of and adequacy of flexible training remain variable. It is important that LTFT options are provided to ensure surgery is an attractive and viable career option, and can compete with other specialties to attract and retain the best candidates to maintain high standards of patient care. LTFT options should be readily available to both genders within surgical specialities. Furthermore, improved information for those considering LTFT should be available, locally, regionally and nationally. Training within LTFT posts should be tailored to the training requirements of the individual, in order to achieve the competencies necessary for completion of training. The recommendations set out in this consensus statement should inform the trainee's position and help guide discussions with respect to the provision of LTFT within surgery.

Promoting research and audit at medical school: evaluating the educational impact of participation in a student-led national collaborative study.

BACKGROUND: Medical students often struggle to engage in extra-curricular research and audit. The Student Audit and Research in Surgery (STARSurg) network is a novel student-led, national research collaborative. Student collaborators contribute data to national, clinical studies while gaining an understanding of audit and research methodology and ethical principles. This study aimed to evaluate the educational impact of participation. METHODS: Participation in the national, clinical project was supported with training interventions, including an academic training day, an online e-learning module, weekly discussion forums and YouTube® educational videos. A non-mandatory, online questionnaire assessed collaborators' self-reported confidence in performing key academic skills and their perceptions of audit and research prior to and following participation. RESULTS: The group completed its first national clinical study ("STARSurgUK") with 273 student collaborators across 109 hospital centres. Ninety-seven paired pre- and post-study participation responses (35.5%) were received (male = 51.5%; median age = 23). Participation led to increased confidence in key academic domains including: communication with local research governance bodies (p < 0.001), approaching clinical staff to initiate local collaboration (p < 0.001), data collection in a clinical setting (p < 0.001) and presentation of scientific results (p < 0.013). Collaborators also reported an increased appreciation of research, audit and study design (p < 0.001). CONCLUSIONS: Engagement with the STARSurg network empowered students to participate in a national clinical study, which increased their confidence and appreciation of academic principles and skills. Encouraging active participation in collaborative, student-led, national studies offers a novel approach for delivering essential academic training.

Health Education England, Local Education and Training Boards (LETBs) and reform of healthcare education: implications for surgical training.

BACKGROUND: National Health Service (NHS) reforms have changed the structure of postgraduate healthcare education and training. With a Government mandate that promotes multi-professional education and training aligned with policy driven initiatives, this article highlights concerns over the impact that these changes may have on surgical training. DISCUSSION: The creation of Health Education England (HEE) and its local education and training boards (LETBs), which are dominated by NHS healthcare providers, should result in greater accountability of employers in workforce planning, enhanced local responsibility and increased transparency of funding allocation. However, these changes may also create a potential poacher-turned-gamekeeper role of employers, who now have responsibility for junior doctors' training. Analysis of LETB membership reveals a dearth of representation of surgeons, who comprise only 2% of board members, with the input of trainees also seemingly overlooked. A lack of engagement with the LETBs by the independent sector is a concern with increasing numbers of training opportunities potentially being lost as a result.The new system also needs to recognise the specific training needs required by the craft specialties given the demands of technical skill acquisition, in particular regarding the provision of simulation training facilities and trainer recognition. However, training budget cuts may result in a disproportionate reduction of funding for surgical training. Surgical training posts will also be endangered, opportunities for out-of-programme experience and research may also decline and further costs are likely to be passed onto the trainee. SUMMARY: Although there are several facets to the recent reforms of the healthcare education and training system that have potential to improve surgical training, concerns need to be addressed. Engagement from the independent sector and further clarification on how the LETBs will be aligned with commissioning services are also required. Surgical training is in danger of taking a back seat to Government mandated priorities. Representation of trainees and surgeons on LETB committees is essential to ensure a surgical viewpoint so that the training needs of the future consultant workforce meet the demands of a 21st century health service.

Postoperative nonsteroidal anti-inflammatory drugs and risk of anastomotic leak: meta-analysis of clinical and experimental studies.

BACKGROUND: Enhanced recovery programs following colorectal resection recommend the use of nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia. The present study aimed to assess whether postoperative NSAID use increased the risk of anastomotic leak. METHODS: A systematic review of published literature was performed for studies comparing anastomotic leak following NSAID administration versus control. Meta-analysis was conducted for studies in human patients and experimental animal models. The primary endpoint was anastomotic leak. RESULTS: The final analysis included 8 studies in humans and 12 experimental animal studies. Use of NSAIDs was significantly associated with anastomotic leak in humans (8 studies, 4,464 patients, odds ratio [OR] 2.14; p < 0.001). This effect was seen with nonselective NSAIDs (6 studies, 3,074 patients, OR 2.37; p < 0.001), but not with selective NSAIDs (4 studies, 1,223 patients, OR 2.32; p = 0.170). There was strong evidence of selection bias from all clinical studies, with additional inconsistent definitions and outcomes assessment. From experimental animal models, anastomotic leak was more likely with NSAID use (ten studies, 575 animals, OR 9.51; p < 0.001). Bursting pressures at day 7 were significantly lower in NSAID versus controls (7 studies, 168 animals, weighted mean difference -35.7 mmHg; p < 0.001). CONCLUSIONS: Emerging data strongly suggest that postoperative NSAIDs are linked to anastomotic leak, although most studies are flawed and may be describing pre-existing selection bias. However, when combined with experimental data, these increasing concerns suggest caution is needed when prescribing NSAIDs to patients with pre-existing risk factors for leak, until more definitive evidence emerges.

Quantifying factors influencing operating theater teaching, participation, and learning opportunities for medical students in surgery.

AIMS: Operating room experience offers a unique learning resource, potentially exposing medical students to surgical disease and treatments, use of anesthesia, basic science, team working, and communication skills. However, the alien nature of this environment to newcomers poses particular difficulties in harnessing this resource. This study aimed to assess the operating theater-based teaching and learning experiences of new medical graduates during their medical school course. METHODS: A 41-item, self-administered questionnaire survey was distributed to newly qualified medical school graduates from 1 university consisting of 5 separate teaching hospitals. Results were analyzed using GraphPad Prism 5.0. RESULTS: Questionnaires were returned by 209 of 312 graduates (67%). Overall, 121 (59%) respondents attended ≤50% of opportunities available to attend operating theater; 47% felt they knew what was expected of them when attending and only 13% had specific learning objectives set. An interest in pursuing a surgical career was stated by 24 (12%) respondents; this group was more likely to have attended ≥50% of operating theater opportunities (p = 0.0064). Those not intending to pursue a surgical career were more likely to have been discouraged by their experiences (p = 0.0001). Active participation while scrubbed, knowing what was expected, being made to feel welcome, and being set learning objectives were all significantly positively correlated with attendance. Although female respondents felt equally welcome, in comparison with their male colleagues, they were more likely to receive negative comments (p = 0.0106). The majority of respondents (80%) stated that attendance at operating theater sessions should be a mandatory component of the curriculum. CONCLUSIONS: Although operating theater attendance is recognized as an important component of the medical school curriculum, overall attendance at sessions was low. Attendance could be increased by ensuring students knowing what is expected of them, making them feel welcome, setting learning objectives, and allowed them to actively participate. These results highlight the need to ensure that the time spent by medical students in the operating room is positive and maximized to its full potential through structured learning involving all members of the theater team.

Causes and costs of a decade of litigation following emergency appendectomy in England.

BACKGROUND: There has been recent interest in the delayed and nonoperative management of appendicitis. The present study assessed the causes and costs of litigation against surgeons following emergency appendectomy, with an emphasis on claims relating to preoperative management. MATERIALS AND METHODS: Data were obtained from the English NHS Litigation Authority for claims relevant to appendectomy between 2002 and 2011. Two authors independently extracted data and classified it against predetermined criteria. RESULTS: Successful litigation occurred in 66 % of closed cases (147/223) with a total payout of £8.1 million. There were 24 claims against organizational operating room delays (9 % of total) and 27 against delayed diagnosis (10 %), with respective success rates of 70 and 68 %. From 21 claims relating to damage to fertility, nine were due to either delayed diagnosis or organizational operating room delays. Misdiagnosis was the second most common cause for litigation (16 %), but it had the lowest likelihood of success (49 %). Faulty surgical technique was the most common reason for litigation (39 %), with a 70 % likelihood of success. Of eight claims related to fatality, one was due to unacceptable preoperative delay leading to preventable perforated appendicitis. The overall highest median payouts were for claims of damage to fertility (£52,384), operating list delays (£44,716), and delayed diagnosis (£42,292). CONCLUSIONS: There were significant medicolegal risks surrounding delays related to access to operating lists and diagnosis. Whereas future evidence regarding the safety of delayed appendectomy may provide scientific defense against these claims, the present study provides evidence of the current medicolegal risk to surgeons following delayed treatment of appendicitis.

Gender-related perceptions of careers in surgery among new medical graduates: results of a cross-sectional study.

BACKGROUND: Despite promotional measures at a national level, female surgeons account for only 10% of the consultant workforce in the United Kingdom. With rising proportions of female medical graduates, it is important that surgery continues to recruit the most able candidates regardless of sex. This study investigates the differing perceptions of surgical careers among recent medical school graduates and identifies factors discouraging female doctors from pursuing a career in surgery. METHODS: Newly qualified graduates from the University of Nottingham Medical School, Nottingham, UK, were invited to complete a nonmandatory questionnaire investigating career intentions and factors influencing this. RESULTS: Two hundred and eight questionnaires were returned (a 66% response rate). Male respondents were significantly more likely to rate surgery as an attractive or very attractive career (P = .0116). Overall, only 33 (25%) female doctors expressed interest in a surgical career as opposed to 33 (42%) male doctors (P = .010). Frequently cited reasons included no interest in surgery itself (21%) and negative attitudes toward women in surgery among the surgical teams (18%). Irrespective of career interests, 59% of male and 68% of female respondents believed surgery was not a career welcoming women (P = .186). Reasons included difficulty maintaining family life, limited flexible training, and lack of role models. CONCLUSIONS: This study identifies significant sex differences in the perception of surgical careers. The majority believes surgery does not welcome female trainees. Future strategies to promote surgery must address attitudes and behaviors in both sexes while taking active steps to support female surgeons during their training and in the workplace.

Extracurricular participation in research and audit by medical students: opportunities, obstacles, motivation and outcomes.

BACKGROUND: Medical students should learn to critically evaluate research to inform future evidence-based practice. Participation in research and audit at medical school can help develop these skills whilst prompting interest in academic pursuits. AIMS: We investigate medical student attitudes and participation in extracurricular research and audit focusing on their opportunities, obstacles, motivation and outcomes. METHOD: A 60-item questionnaire was distributed to final-year medical students graduating from the University of Nottingham Medical School in the United Kingdom. RESULTS: A total of 238 questionnaires were returned (response rate 75%). Of these, 86% felt research or audit experience was useful for medical students. The main driver for involvement was curriculum vitae (CV) improvement (51%). Male students and those involved in extracurricular research were more likely to agree that this experience should influence selection into training programmes (p = 0.017, p = 0.0036). Overall, 91 respondents (38%) had been involved in such activity with a mean number of projects undertaken of two (range one to four). Those interested in a surgical career were most likely to have undertaken projects (58%). Frequently cited obstacles to involvement were time constraints (74%) and a perceived lack of interest from potential supervisors (63%). CONCLUSIONS: Despite significant CV motivation, many are enthusiastic regarding extracurricular research opportunities but frustrated by obstacles faced. Our study suggests there is scope for providing further opportunities to participate in such activities at medical school.

A single-blind controlled study of electrocautery and ultrasonic scalpel smoke plumes in laparoscopic surgery.

BACKGROUND: Surgical smoke containing potentially carcinogenic and irritant chemicals is an inevitable consequence of intraoperative energized dissection. Different energized dissection methods have not been compared directly in human laparoscopic surgery or against commonly encountered pollutants. This study undertook an analysis of carcinogenic and irritant volatile hydrocarbon concentrations in electrocautery and ultrasonic scalpel plumes compared with cigarette smoke and urban city air control samples. METHODS: Once ethical approval was obtained, gas samples were aspirated from the peritoneal cavity after human laparoscopic intraabdominal surgery solely using either electrocautery or ultrasonic scalpels. All were adsorbed in Tenax tubes and concentrations of carcinogenic or irritant volatile hydrocarbons measured by gas chromatography. The results were compared with cigarette smoke and urban city air control samples. The analyzing laboratory was blinded to sample origin. RESULTS: A total of 10 patients consented to intraoperative gas sampling in which only one method of energized dissection was used. Six carcinogenic or irritant hydrocarbons (benzene, ethylbenzene, styrene, toluene, heptene, and methylpropene) were identified in one or more samples. With the exception of styrene (P = 0.016), a nonsignificant trend toward lower hydrocarbon concentrations was observed with ultrasonic scalpel use. Ultrasonic scalpel plumes had significantly lower hydrocarbon concentrations than cigarette smoke, with the exception of methylpropene (P = 0.332). No significant difference was observed with city air. Electrocautery samples contained significantly lower hydrocarbon concentrations than cigarette smoke, with the exception of toluene (P = 0.117) and methyl propene (P = 0.914). Except for toluene (P = 0.028), city air showed no significant difference. CONCLUSIONS: Both electrocautery and ultrasonic dissection are associated with significantly lower concentrations of the most commonly detected carcinogenic and irritant hydrocarbons than cigarette smoke. A nonsignificant trend toward lower hydrocarbon concentrations was seen with ultrasonic scalpel dissection compared with diathermy. The contamination levels in city air were largely comparable with those seen after ultrasonic scalpel use. Although hydrocarbon concentrations are low, cumulative exposures may increase health risks. Where concerns arise, ultrasonic scalpel dissection may be preferable.

Systematic review and meta-analysis of chewing-gum therapy in the reduction of postoperative paralytic ileus following gastrointestinal surgery.

BACKGROUND: Postoperative ileus has long been considered an inevitable consequence of gastrointestinal surgery. It prolongs hospital stay, increases morbidity, and adds to treatment costs. Chewing is a form of sham feeding reported to stimulate bowel motility. This analysis examines the value of chewing-gum therapy in treatment of postoperative ileus. METHODS: A search for randomized, controlled trials studying elective gastrointestinal surgery was undertaken using MEDLINE, Embase, Cochrane Controlled Trials Register, and reference lists. Outcomes were extracted including time to first flatus and bowel motion, length of stay, and complications. Statistical analysis was undertaken using the weighted mean difference (WMD) and random-effects model with 95% confidence intervals (CI). RESULTS: Seven studies with 272 patients were included. For time to first flatus the analysis favored treatment with a WMD of 12.6 h (17%) reduction (95% CI -21.49 to -3.72; P = 0.005). For time to first bowel motion, treatment was favored with a WMD of 23.11 h (22%) reduction (95% CI -34.32 to -11.91; P < 0.001). For length of stay, the analysis showed a nonsignificant trend toward treatment with WMD of 23.88 h (12%) reduction (95% CI -53.29 to +5.53; P = 0.11). There were no significant differences in complication rates. CONCLUSIONS: Chewing-gum therapy following open gastrointestinal surgery is beneficial in reducing the period of postoperative ileus, although without a significant reduction in length of hospital stay. These outcomes are not significant for laparoscopic gastrointestinal surgery.

Courvoisier's gallbladder: law or sign?

BACKGROUND: Variously described as Courvoisier's law, sign, or even gallbladder, this eponymous "law" has been taught to medical students since the publication of Courvoisier's treatise in 1890. METHODS: We reviewed Courvoisier's original "law," the modern misconceptions surrounding it, and the contemporary evidence supporting and explaining his observations. RESULTS: Courvoisier never stated a "law" in the context of a jaundiced patient with a palpable gallbladder. He described 187 cases of common bile duct obstruction, observing that gallbladder dilatation seldom occurred with stone obstruction of the bile duct. The classic explanation for Courvoisier's finding is based on the underlying pathologic process. With the presence of gallstones come repeated episodes of infection and subsequent fibrosis of the gallbladder. In the event that a gallstone causes the obstruction, the gallbladder is shrunken owing to fibrosis and is unlikely to be distensible and, hence, palpable. With other causes of obstruction, the gallbladder distends as a result of the back-pressure from obstructed bile flow. However, recent experiments show that gallbladders are equally distensible in vitro, irrespective of the pathology, suggesting that chronicity of the obstruction is the key. Chronically elevated intraductal pressures are more likely to develop with malignant obstruction owing to the progressive nature of the disease. Gallstones cause obstruction in an intermittent fashion, which is generally not consistent enough to produce such a chronic rise in pressure. CONCLUSION: We hope that reminding clinicians of Courvoisier's actual observations will reestablish the usefulness of this clinical sign in the way he intended.