Assessing operative competence in core surgical training: A reliability analysis.

BACKGROUND: This study quantifies the number of observations required to reliably assess the operative competence of Core Surgical Trainees (CSTs) in Ireland, using the Supervised Structured Assessment of Operative Performance (SSAOP) tool. METHODS: SSAOPs (April 2016-February 2021) were analysed across a mix of undifferentiated procedures, as well as for three commonly performed general surgery procedures in CST: appendicectomy, abdominal wall hernia repair, and skin/subcutaneous lesion excision. Generalizability and Decision studies determined the number of observations required to achieve dependability indices ≥0.8, appropriate for use in high-stakes assessment. RESULTS: A total of 2,294 SSAOPs were analysed. Four assessors, each observing 10 cases, can generate scores sufficiently reliable for use in high-stakes assessments. Focusing on a selection of core procedures yields more favourable reliability indices. CONCLUSION: Trainers should conduct repeated assessments across a smaller number of procedures to improve reliability. Programs should increase the assessor mix to yield sufficient dependability indices for high-stakes assessment.

Increasing the use of perioperative risk scoring in emergency laparotomy: nationwide quality improvement programme.

BACKGROUND: Emergency laparotomy is associated with high morbidity and mortality. The early identification of high-risk patients allows for timely perioperative care and appropriate resource allocation. The aim of this study was to develop a nationwide surgical trainee-led quality improvement (QI) programme to increase the use of perioperative risk scoring in emergency laparotomy. METHODS: The programme was structured using the active implementation framework in 15 state-funded Irish hospitals to guide the staged implementation of perioperative risk scoring. The primary outcome was a recorded preoperative risk score for patients undergoing an emergency laparotomy at each site. RESULTS: The rate of patients undergoing emergency laparotomy receiving a perioperative risk score increased from 0-11 per cent during the exploratory phase to 35-100 per cent during the full implementation phase. Crucial factors for implementing changes included an experienced central team providing implementation support, collaborator engagement, and effective communication and social relationships. CONCLUSIONS: A trainee-led QI programme increased the use of perioperative risk assessment in patients undergoing emergency laparotomy, with the potential to improve patient outcomes and care delivery.

Attrition From a National Surgical Training Program: A Qualitative Analysis.

OBJECTIVE: The objective of this study was to examine the trainee experience to identify some of the factors which contribute to attrition from surgical training. SUMMARY BACKGROUND: Not all trainees who commence a surgical training program continue and complete it. Surgical training can be personally and professionally demanding and trainees may, for a multitude of reasons, change career direction. Attrition from surgical training impacts upon multiple stakeholders: A decision to leave may be difficult and time consuming for the individual and can generate unanticipated inefficiency at a systems level. This project examined attrition from a national surgical training program to deepen understanding of some of the causes of the phenomenon. METHODS: A qualitative study was performed. A purposeful sampling strategy was used to identify representative participants. Semistructured interviews were conducted with eleven trainees who withdrew or considered doing so. A thematic analysis was performed to examine the experiences of trainees and explore the factors which influenced a decision to withdraw. FINDINGS: Five major themes emerged from the interview data: delivery of training, the training atmosphere, influence of seniors, concerns regarding progression, and the perception of the future role with respect to lifestyle. CONCLUSIONS: The personal experience of surgical training is crucial in informing a decision to withdraw from a program. Voluntary attrition is appropriate where doctors, after experiencing some time in surgical training, recognize that a surgical career does not meet their expectation. However, improving the delivery of training by addressing the concerns identified in this study may serve to enhance the personal training experience and hence maximize retention.

How do Trainers and Trainees use Formative Workplace-based Assessments of Operative Competence to Deliver and Receive Structured Feedback?

OBJECTIVE: The aim of this study is to assess the quality of feedback provided to surgical trainees in the operating theatre, and to further investigate how trainees and trainers use workplace-based assessment in practice with regards to frequency and timing of assessments. DESIGN: A retrospective study of all submitted Supervised Structured Assessments of Operative Performance (SSAOPs) from April 25, 2016 to February 2, 2021 was conducted. SETTING: Surgical trainees in the Republic of Ireland across all national surgical training sites submitted SSAOPs through an online platform. PARTICIPANTS: Assessments of operative competence (SSAOPs) from all Core Surgical Trainees (in their first two years of dedicated post-graduate surgical training) were included for analysis, regardless of surgical subspecialty. A total of 2294 assessments were submitted from April 25, 2016 to February 2, 2021 by 330 core surgical trainees and 379 surgeon assessors. Five hundred of these assessments were randomly selected and scored for quality of feedback using a modified "Task, Gap, Action (TGA)" framework. RESULTS: Of all 2294 submitted assessments, 1905 (83.04%) were submitted in the latter 3 months of each rotation, and 803 (35%) were submitted in the last month. Only 51 of 270 (18.89%) of trainees in their first year and 33 of 236 trainees in their second year (13.98%) submitted more than the minimum required number of assessments (6 per year). Of 500 randomly selected assessments, 362 (72.4%) had documented written feedback. The mean 'Gap' and 'Action' scores were low, at 0.44/3 and 0.53/3 respectively. CONCLUSIONS: Trainees do not submit more than the required number of operative workplace-based assessments. Assessments are submitted at the end of the trainee's rotation, limiting their formative value. The quality of written feedback is poor and could be improved significantly by encouraging a "Task," "Gap" and "Action" approach.

Surgical trainee experience and opinion of robotic surgery in surgical training and vision for the future: a snapshot study of pan-specialty surgical trainees.

BACKGROUND:  Robotic surgery is well established across multiple surgical specialities in the United Kingdom (UK) and Republic of Ireland (ROI). We aimed to elucidate current surgical trainee experience of and attitudes to robotic surgery in a surgical training programme across the UK and ROI to determine the future role of robotic surgery in international surgical training programmes. Methods: A pan-specialty trainee cross-sectional study was performed on behalf of the Association of Surgeons in Training (ASiT) using mixed-methodology. Round 1: a digital questionnaire was disseminated to all ASiT members. Round 2: 'live-polling' was performed prior to and following the Robotic Surgery plenary session convened at the ASiT 2020 International Conference (Birmingham). Data analysis was performed using a combination of quantitative and qualitative methods. RESULTS:  Three hundred and four responses were analysed (n = 244 digital questionnaire, n = 60 live-polling). Overall, 73.8% (n = 180) of trainees would value greater access to robotic surgery training. 73.4% (n = 179) believed that robotic surgery was important for the future of their desired specialty and 77.2% (n = 156) believed it should be incorporated into formal surgical training. Qualitative analysis identified that trainees believe that robotic training should have a formal role in surgical training. Perceived disadvantages of robotic surgery experience in surgical training included expense and the current impact of consultant robotic learning curves on training. CONCLUSION:  Current surgical trainees desire greater access to robotic surgery in surgical training. Robotic surgery is developing an increasing role in current surgical practice and it is important that it is introduced in a timely, evidence-based fashion to surgical trainees at an appropriate stage of training.

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.

Bullying and undermining behaviours in surgery: A qualitative study of surgical trainee experiences in the United Kingdom (UK) & Republic of Ireland (ROI).

BACKGROUND: Bullying and undermining (B/U) behaviours are documented in the international surgical workplace. This study is the largest assessment of prevalence of B/U behaviours within UK & ROI surgical training to date. MATERIALS AND METHODS: UK & ROI surgical trainees were electronically surveyed in July 2017. The survey was open for one month and sent to all registered trainees at Core and Specialty level by the Joint Committee on Surgical Training (JCST) along with email and social media dissemination by the Association of Surgeons in Training (ASiT) and the British Orthopaedic Trainees Association (BOTA). A consensus session on the topic was conducted at the ASiT Conference in Edinburgh in March 2018. Standards for reporting of Qualitative Research were followed. RESULTS: 1412 responses were received (26.6% response rate). All training regions, grades and specialties were represented. 60% of trainees (n = 837) reported witnessing or experiencing B/U behaviours in the surgical workplace. The most common reports related to sexism; 42% (n = 568) reported witnessing or experiencing sexist language/attitudes in the workplace. This was reported more by female respondents (66% compared to 27% male). 21% (n = 291) and 13% (n = 180) reported witnessing or personally experiencing racist and homophobic language or attitudes respectively. Consultants were identified as the most frequent perpetrators. The surgical wards or theatres were the most frequently reported areas that trainees either witnessed or experienced B/U behaviours. Of those trainees who had reported a personal experience of B/U behaviours (n = 344), 20% described their experiences of reporting as negative or very negative. 48.1% of respondents felt that surgery as a whole had a moderate, high or very high degree of a concern about B/U behaviours. CONCLUSION: B/U behaviours are prevalent in the surgical domain. Urgent action is required to eradicate this unacceptable behaviour. A cross-specialty, intercollegiate response is required to tackle this issue and improve the working culture in surgery for all.

Volume and in-hospital mortality after emergency abdominal surgery: a national population-based study.

​OBJECTIVES: Emergency abdominal surgery (EAS) refers to high-risk intra-abdominal surgical procedures undertaken for acute gastrointestinal pathology. The relationship between hospital or surgeon volume and mortality of patients undergoing EAS is poorly understood. This study examined this relationship at the national level. ​DESIGN: This is a national population-based study using a full administrative inpatient dataset (National Quality Assurance Improvement System) from publicly funded hospitals in Ireland. ​SETTING: 24 public hospitals providing EAS services. ​PARTICIPANTS AND INTERVENTIONS: Patients undergoing EAS as identified by primary procedure codes during the period 2014-2018. ​MAIN OUTCOME MEASURES: The main outcome measure was adjusted in-hospital mortality following EAS in publicly funded Irish hospitals. Mortality rates were adjusted for sex, age, admission source, Charlson Comorbidity Index, procedure complexity, organ system and primary diagnosis. Differences in overall, 7-day and 30-day in-hospital mortality for hospitals with low (<250), medium (250-449) and high (450+) volume and surgical teams with low (<30), medium (30-59) and high (60+) volume during the study period were also estimated. ​RESULTS: The study included 10 344 EAS episodes. 798 in-hospital deaths occurred, giving an overall in-hospital mortality rate of 77 per 1000 episodes. There was no statistically significant difference in adjusted mortality rate between low and high volume hospitals. Low volume surgical teams had a higher adjusted mortality rate (85.4 deaths/1000 episodes) compared with high volume teams (54.7 deaths/1000 episodes), a difference that persisted among low volume surgeons practising in high volume hospitals. ​CONCLUSION: Patients undergoing EAS managed by high volume surgeons have better survival outcomes. These findings contribute to the ongoing discussion regarding configuration of emergency surgery services and emphasise the need for effective clinical governance regarding observed variation in outcomes within and between institutions.

Current Controversies in the Management of Diverticulitis: A Review.

BACKGROUND: Symptomatic diverticular disease is challenging for patients, clinicians and health services. The prevalence increases with age and BMI and as such, the burden of this disease is set to increase with higher rates of acute presentations already documented. The natural history of recurrent episodes, complications and symptom progression is not fully understood. Furthermore, medical and surgical management strategies are under constant appraisal, debate and evolution. METHODS: A review of the contemporary literature was performed to examine the emerging trend towards conservative treatment. RESULTS: Routine use of in-patient, intravenous antibiotics may not be required and outpatient management is possible for certain patients. Universal colonoscopy examination after uncomplicated acute diverticulitis is controversial but is mandatory after complicated episodes. Recent, high-profile, clinical trials suggest that less aggressive surgical management of both acute and chronic presentations may be feasible in some cases. CONCLUSIONS: Diverticulitis is a common yet challenging topic that demands clinicians to provide an individualised yet evidence-based approach.

The contribution of endoscopy quality measures to the development of interval colorectal cancers in the screening population: a systematic review.

BACKGROUND: Colon cancer is the second most common cause of cancer-related death and an important cause of morbidity. The natural history of carcinogenesis, via the adenoma-carcinoma sequence, permits screening, which reduces the relative risk of mortality by up to 16%. The efficacy of a screening programme is limited by the growth of interval colorectal cancers between screening examinations. Quantifying the rate of interval cancers and delineating contributing endoscopic factors are crucial to maximise the benefit of a screening program. METHODS: A systematic review was performed in accordance with PRISMA principles. Electronic databases were interrogated with a considered search strategy, and reference lists of retrieved papers were surveyed. For inclusion, studies included the rate of interval cancer (stated or calculated) and reported at least one of a predefined list of endoscopy characteristics. The primary outcome was to establish the rate of interval cancers. The secondary outcome was to determine the association between endoscopy quality measures and interval cancers. RESULTS: The search yielded 2067 papers. Seventy-six full text papers were reviewed. Fifteen papers met the inclusion criteria. In total, there were 117,793 colon cancers, 7281 of which were interval lesions, giving an overall rate of 6.2%. The adenoma detection rate (ADR) of the endoscopist performing the index operation was the most consistent endoscopy factor associated with development of interval cancers. The impact of setting, volume and bowel preparation varied between papers. CONCLUSION: Interval cancers reduce the efficacy of colorectal screening programmes. Ensuring the quality of the endoscopy process, specifically by increasing the ADR of practitioners, is crucial to the reduction of the rate of interval cancers.

Nasogastric nutrition is efficacious in severe acute pancreatitis: a systematic review and meta-analysis.

In patients with severe acute pancreatitis (AP), enteral nutrition is delivered by nasojejunal (NJ) tube to minimise pancreatic stimulation. Nasogastric (NG) feeding represents an alternative route. The primary objective of this systematic review and meta-analysis was to evaluate the efficacy of NG feeding. Secondary objectives were to compare the NG and NJ routes and assess the side effects of the former. The primary endpoint was exclusive NG feeding with delivery of 75% of nutritional targets. Additional outcomes included change to total parenteral nutrition (TPN), increased pain or disease severity, vomiting, diarrhoea, delivery rate reduction and tube displacement. Among the retrieved studies, six were found to be eligible for the qualitative review and four for the meta-analysis. NG nutrition was received by 147 patients; exclusive NG feeding was achieved in 90% (133/147). Of the 147 patients, 129 (87%) received 75% of the target energy. In studies where all subjects received exclusive NG nutrition, 82% (seventy-four of the ninety patients) received >75% of the intended energy. Compared with NJ nutrition, there was no significant difference in the delivery of 75% of nutritional targets (pooled risk ratio (RR) 1.02; 95% CI 0.75, 1.38.) or no increased risk of change to TPN (pooled RR 1.05; 95% CI 0.45, 2.48), diarrhoea (pooled RR 1.28; 95% CI 0.62, 2.66), exacerbation of pain (pooled RR 1.10; 95% CI 0.47, 2.61) or tube displacement (pooled RR 0.44; 95% CI 0.11, 1.73). Vomiting and diarrhoea were the most common side effects of NG feeding (13.3 and 12.9%, respectively). With respect to the delivery of nutrition, 11.2% of the patients required delivery rate reduction and 3.4% dislodged the tube. Other side effects included elevated levels of aspirates (9.1%), abdominal distension (1.5%), pain exacerbation (7.5%) and increased disease severity (1.6%). In conclusion, NG feeding is efficacious in 90% of patients. Further research is required to optimise the delivery of NG nutrition and examine 'gut-rousing' approaches to nutrition in patients with severe AP.