Establishing the predictive validity of the intercollegiate membership of the Royal Colleges of surgeons written examination: MRCS Part A.

Successful completion of the Intercollegiate Membership of the Royal Colleges of Surgeons (MRCS) examination is mandatory for surgical trainees entering higher specialist training in the United Kingdom. Despite its international reputation, and the value placed on the examination in surgical training, there has been little evidence of its predictive validity until recently. In this review, we present a summary of findings of four recent Intercollegiate studies assessing the predictive validity of the MRCS Part A (written) examination. Data from all four studies showed statistically significant positive correlations between the MRCS Part A and other written examinations taken by surgical trainees over the course of their education. The studies summarised in this review provide compelling evidence for the predictive validity of this gatekeeping examination. This review will be of interest to trainees, training institutions and the Royal Colleges given the value placed on the examination by surgical training programmes.

Establishing the predictive validity of the intercollegiate membership of the Royal Colleges of surgeons written examination: MRCS part B.

The Intercollegiate Membership of the Royal Colleges of Surgeons (MRCS) is a high-stakes postgraduate examination taken by thousands of surgical trainees worldwide every year. The MRCS is a challenging assessment, highly regarded by surgical training programmes and valued as a gatekeeper to the surgical profession. The examination is taken at considerable personal, social and financial cost to surgical trainees, and failure has significant implications for career progression. Given the value placed on MRCS, it must be a reliable and valid assessment of the knowledge and skills of early-career surgeons. Our first article 'Establishing the Predictive Validity of the Intercollegiate Membership of the Royal Colleges of Surgeons Written Examination: MRCS Part A' discussed the principles of assessment reliability and validity and outlined the mounting evidence supporting the predictive validity of the MRCS Part A (the multiple-choice questionnaire component of the examination). This, the second article in the series discusses six recently published studies investigating the predictive validity of the MRCS Part B (the clinical component of the examination). All national longitudinal cohort studies reviewed have demonstrated significant correlations between MRCS Part B and other assessments taken during the UK surgical training pathway, supporting the predictive validity of MRCS Part B. This review will be of interest to trainees, trainers and Royal Colleges given the value placed on the examination by surgical training programmes.

Differential attainment at MRCS according to gender, ethnicity, age and socioeconomic factors: a retrospective cohort study.

OBJECTIVE: A recent independent review on diversity and inclusivity highlighted concerns that barriers to surgical career progression exist for some groups of individuals and not others. Group-level differences in performance at the Intercollegiate Membership of the Royal Colleges of Surgeons (MRCS) examinations have been identified but are yet to be investigated. We aimed to characterise the relationship between sociodemographic differences and performance at MRCS. DESIGN: Retrospective cohort study. SETTING: Secondary care. PARTICIPANTS: All UK MRCS candidates attempting Part A (n = 5780) and Part B (n = 2600) between 2013 and 2019 with linked sociodemographic data in the UK Medical Education Database (https://www.ukmed.ac.uk). MAIN OUTCOME MEASURES: Chi-square tests established univariate associations with MRCS performance. Multiple logistic regression identified independent predictors of success, adjusted for medical school performance. RESULTS: Statistically significant differences in MRCS pass rates were found according to gender, ethnicity, age, graduate status, educational background and socioeconomic status (all p < 0.05). After adjusting for prior academic attainment, being male (odds ratio [OR] 2.34, 95% confidence interval [CI] 1.87-2.92) or a non-graduate (OR 1.98, 95% CI 1.44-2.74) were independent predictors of MRCS Part A success and being a non-graduate (OR 1.77, 95% CI 1.15-2.71) and having attended a fee-paying school (OR 1.51, 95% CI 1.08-2.10) were independent predictors of Part B success. Black and minority ethnic groups were significantly less likely to pass MRCS Part B at their first attempt (OR 0.41, 95% CI 0.18-0.92 for Black candidates and OR 0.49, 95% CI 0.35-0.69 for Asian candidates) compared to White candidates. CONCLUSIONS: There is significant group-level differential attainment at MRCS, likely to represent the accumulation of privilege and disadvantage experienced by individuals throughout their education and training. Those leading surgical education now have a responsibility to identify and address the causes of these attainment differences.

Timing of urinary catheter removal after colorectal surgery with pelvic dissection: A systematic review and meta-analysis.

BACKGROUND: Urinary catheters are routinely placed before colorectal surgery. Enhanced recovery after surgery (ERAS) recommends their removal as soon as possible. However, premature removal risks urinary retention, and delayed removal increases risk of urinary tract infections (UTIs). This meta-analysis aims to synthesise the published literature on the optimal timing of urinary catheter removal following colorectal surgery with pelvic dissection. MATERIALS AND METHODS: The protocol for this meta-analysis is registered on PROSPERO (CRD42019150030).Pubmed, Ovid and Web of Science databases were searched (January 2020). Primary outcomes included urinary retention and catheter associated UTI. The intervention was removal of urinary catheter following colorectal surgery with pelvic dissection on postoperative days 1-2 (early); 3-4 (intermediate); or 5+ (late). Meta-analysis was performed using Comprehensive meta-analysis V2. RESULTS: Eight papers were analysed. 883 patients had early catheter removal, 236 intermediate and 204 late. Early catheter removal was associated with increased risk of urinary retention when compared to late removal RR = 2.352 95% CI = 1.370-4.038 (p = 0.002). No significant difference in urinary retention was found between early and intermediate or intermediate and late catheter removal groups. Early catheter removal was associated with reduced risk of UTIs compared to late removal RR = 0.498, 95% CI 0.306-0.811, (p = 0.005). No significant difference in UTIs was found between early and intermediate or intermediate and late catheter removal groups. CONCLUSIONS: Removal of urinary catheters on postoperative day 3-4 provides a balance between minimising the risks of urinary retention and UTIs. This analysis can be used to finesse future ERAS protocols concerning catheter removal in colorectal surgery involving pelvic dissection.

Does performance at the intercollegiate Membership of the Royal Colleges of Surgeons (MRCS) examination vary according to UK medical school and course type? A retrospective cohort study.

OBJECTIVES: The knowledge, skills and behaviours required of new UK medical graduates are the same but how these are achieved differs given medical schools vary in their mission, curricula and pedagogy. Medical school differences seem to influence performance on postgraduate assessments. To date, the relationship between medical schools, course types and performance at the Membership of the Royal Colleges of Surgeons examination (MRCS) has not been investigated. Understanding this relationship is vital to achieving alignment across undergraduate and postgraduate training, learning and assessment values. DESIGN AND PARTICIPANTS: A retrospective longitudinal cohort study of UK medical graduates who attempted MRCS Part A (n=9730) and MRCS Part B (n=4645) between 2007 and 2017, using individual-level linked sociodemographic and prior academic attainment data from the UK Medical Education Database. METHODS: We studied MRCS performance across all UK medical schools and examined relationships between potential predictors and MRCS performance using χ2 analysis. Multivariate logistic regression models identified independent predictors of MRCS success at first attempt. RESULTS: MRCS pass rates differed significantly between individual medical schools (p<0.001) but not after adjusting for prior A-Level performance. Candidates from courses other than those described as problem-based learning (PBL) were 53% more likely to pass MRCS Part A (OR 1.53 (95% CI 1.25 to 1.87) and 54% more likely to pass Part B (OR 1.54 (1.05 to 2.25)) at first attempt after adjusting for prior academic performance. Attending a Standard-Entry 5-year medicine programme, having no prior degree and attending a Russell Group university were independent predictors of MRCS success in regression models (p<0.05). CONCLUSIONS: There are significant differences in MRCS performance between medical schools. However, this variation is largely due to individual factors such as academic ability, rather than medical school factors. This study also highlights group level attainment differences that warrant further investigation to ensure equity within medical training.

Performance at medical school selection correlates with success in Part A of the intercollegiate Membership of the Royal College of Surgeons (MRCS) examination.

Medical schools in the UK typically use prior academic attainment and an admissions test (University Clinical Aptitude Test (UCAT), Biomedical Admissions Test (BMAT) or the Graduate Medical School Admissions Test (GAMSAT)) to help select applicants for interview. To justify their use, more information is needed about the predictive validity of these tests. Thus, we investigated the relationship between performance in admissions tests and the Membership of the Royal College of Surgeons (MRCS) examination.The UKMED database (https://www.ukmed.ac.uk) was used to access medical school selection data for all UK graduates who attempted MRCS Part A (n=11 570) and Part B (n=5690) between 2007 and 2019. Univariate and multivariate logistic regression models identified independent predictors of MRCS success. Pearson correlation coefficients examined the linear relationship between test scores and MRCS performance.Successful MRCS Part A candidates scored higher in A-Levels, UCAT, BMAT and GAMSAT (p<0.05). No significant differences were observed for MRCS Part B. All admissions tests were found to independently predict MRCS Part A performance after adjusting for prior academic attainment (A-Level performance) (p<0.05). Admission test scores demonstrated statistically significant correlations with MRCS Part A performance (p<0.001).The utility of admissions tests is clear with respect to helping medical schools select from large numbers of applicants for a limited number of places. Additionally, these tests appear to offer incremental value above A-Level performance alone. We expect this data to guide medical schools' use of admissions test scores in their selection process.

A cross-sectional study examining MRCS performance by core surgical training location.

BACKGROUND: In the UK, core surgical training (CST) is the first specialty experience that early-career surgeons receive but training differs significantly across CST deaneries. To identify the impact these differences have on trainee performance, we assessed whether success at the Membership of the Royal College of Surgeons (MRCS) examinations is associated with CST deanery. METHODS: A retrospective cohort study of UK trainees in CST who attempted MRCS between 2014 and 2020 (n = 1104). Chi-squared tests examined associations between locality and first-attempt MRCS performance. Multivariate logistic regression models identified the likelihood of MRCS success depending on CST deanery. RESULTS: MRCS Part A and Part B pass rates were associated with CST deanery (p < 0.001 and p = 0.013, respectively). Candidates that trained in Thames Valley (Odds Ratio [OR] 2.52 (95% Confidence Interval [CI] 1.00-6.42), North Central and East London (OR 2.37 [95% CI 1.04-5.40]) or South London (OR 2.36 [95% CI 1.09-5.10]) were each more than twice as likely to pass MRCS Part A at first attempt. Trainees from North Central and East London were more than ten times more likely to pass MRCS Part B at first attempt (OR 10.59 [95% CI 1.23-51.00]). However, 68% of candidates attempted Part A prior to CST and 48% attempted Part B before or during the first year of CST. CONCLUSION: MRCS performance is associated with CST deanery; however, many candidates passed the exam with little or any CST experience suggesting that some deaneries attract high academic performers. MRCS performance is therefore not a suitable marker of CST training quality.

Does performance at medical school predict success at the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination? A retrospective cohort study.

BACKGROUND: Identifying predictors of success in postgraduate examinations can help guide the career choices of medical students and may aid early identification of trainees requiring extra support to progress in specialty training. We assessed whether performance on the educational performance measurement (EPM) and situational judgement test (SJT) used for selection into foundation training predicted success at the Membership of the Royal College of Surgeons (MRCS) examination. METHODS: This was a longitudinal, cohort study using data from the UK Medical Education Database (https://www.ukmed.ac.uk). UK medical graduates who had attempted Part A (n=2585) and Part B (n=755) of the MRCS between 2014 and 2017 were included. χ2 and independent t-tests were used to examine the relationship between medical school performance and sociodemographic factors with first-attempt success at MRCS Part A and B. Multivariate logistic regression was employed to identify independent predictors of MRCS performance. RESULTS: The odds of passing MRCS increased by 55% for Part A (OR 1.55 (95% CI 1.48 to 1.61)) and 23% for Part B (1.23 (1.14 to 1.32)) for every additional EPM decile point gained. For every point awarded for additional degrees in the EPM, candidates were 20% more likely to pass MRCS Part A (1.20 (1.13 to 1.29)) and 17% more likely to pass Part B (1.17 (1.04 to 1.33)). For every point awarded for publications in the EPM, candidates were 14% more likely to pass MRCS Part A (1.14 (1.01 to 1.28)). SJT score was not a statistically significant independent predictor of MRCS success. CONCLUSION: This study has demonstrated the EPM's independent predictive power and found that medical school performance deciles are the most significant measure of predicting later success in the MRCS. These findings can be used by medical schools, training boards and workforce planners to inform evidence-based and contemporary selection and assessment strategies.

Human factors awareness and recognition during multidisciplinary team meetings.

Multidisciplinary team (MDT) meetings are widely used throughout medicine and dentistry, bringing together expertise and different opinions across many disciplines to benefit patient care. Depending on the cancer site and specialties involved, some MDTs can last for several hours, especially if there are many complex patients to discuss. However, concentration and attention can vary and distraction is almost inevitable with separate conversations between MDT members and the ever-increasing use of smartphones. The role of human factors (HF) in contributing to error is well known in high-risk activities including medicine and surgery. Surprisingly, while there is increasing awareness of their importance by medical and dental professionals to enhance patient safety, to our knowledge nothing to date has been published about the possible effect and role of HF at MDTs. Here we provide a brief HF overview and focus on the factors at an MDT that could lead to distraction, providing suggestions (including some from aviation) for possible ways to enhance and improve discussion during these often-long meetings. It is hoped that this paper will generate some thought and discussion around the current "normal" MDT practice in head and neck and other specialties and challenge colleagues to embrace HF and safety principles in a just and learning culture.

Changing Objective Structured Clinical Examinations Stations at Lunchtime During All Day Postgraduate Surgery Examinations Improves Examiner Morale and Stress.

BACKGROUND: Human factors are important causes of error, but little is known about their possible effect during objective structured clinical examinations (OSCE). We have previously identified stress and pressure in OSCE examiners in the postgraduate intercollegiate Membership of the Royal College of Surgeons (MRCS) examination. After modifying examination delivery by changing OSCE stations at lunchtime with no demonstrable effect on candidate outcome, we resurveyed examiners to ascertain whether examiner experience was improved. METHOD: Examiners (n = 180) from all 4 surgical colleges in the United Kingdom and Ireland were invited to complete the previously validated human factors questionnaire used in 2014. Aggregated scores for each of 4 previously identified factors were compared with the previous data. Unit-weighted z-scores and nonparametric Kruskal-Wallis methods were used to test the hypothesis that there was no difference among the median factor z-scores for each college. Individual Mann-Whitney-Wilcoxon tests (with appropriate Bonferonni corrections) were used to determine any differences between factors and the respective colleges. RESULTS: 141 Completed questionnaires were evaluated (78% response rate) and compared with 108 responses (90%) from the original study. Analysis was based on 26 items common to both studies. In 2014, the college with the highest candidate numbers (England) was significantly different in 1 factor (stress and pressure), compared with Edinburgh (Mann-Whitney-Wilcoxon: W = 1524, p < 0.001) and Glasgow colleges (Mann-Whitney-Wilcoxon: W = 104, p = 0.004). No differences were found among colleges in the same factor in 2016, Kruskall-Wallis: (χ2 (3) = 1.73, p = 0.63). Analysis of responses found inconsistency among examiners regarding mistakes or omissions made when candidates were performing well. CONCLUSION: After making changes to OSCE delivery, factor scores relating to examiner stress and pressure are now improved and consistent across the surgical colleges. Stress and pressure can occur in OSCE examiners and examination delivery should ideally minimize these issues, thereby improving morale is also likely to benefit candidates.

Systematic Review of Surgical Management of Nonmetastatic Renal Cell Carcinoma with Vena Caval Thrombus.

CONTEXT: Overall, 4-10% of patients with renal cell carcinoma (RCC) present with venous tumour thrombus. It is uncertain which surgical technique is best for these patients. Appraisal of outcomes with differing techniques would guide practice. OBJECTIVE: To systematically review relevant literature comparing the outcomes of different surgical therapies and approaches in treating vena caval thrombus (VCT) from nonmetastatic RCC. EVIDENCE ACQUISITION: Relevant databases (Medline, Embase, and the Cochrane Library) were searched to identify relevant comparative studies. Risk of bias and confounding assessments were performed. A narrative synthesis of the evidence was presented. EVIDENCE SYNTHESIS: The literature search identified 824 articles. Fourteen studies reporting on 2262 patients were included. No distinct surgical method was superior for the excision of VCT, although the method appeared to be dependent on tumour thrombus level. Minimal access techniques appeared to have better perioperative and recovery outcomes than traditional median sternotomy, but the impact on oncologic outcomes is unknown. Preoperative renal artery embolisation did not offer any oncologic benefits and instead resulted in significantly worse perioperative and recovery outcomes, including possibly higher perioperative mortality. The comparison of cardiopulmonary bypass versus no cardiopulmonary bypass showed no differences in oncologic outcomes. Overall, there were high risks of bias and confounding. CONCLUSIONS: The evidence base, although derived from retrospective case series and complemented by expert opinion, suggests that patients with nonmetastatic RCC and VCT and acceptable performance status should be considered for surgical intervention. Despite a robust review, the findings were associated with uncertainty due to the poor quality of primary studies available. The most efficacious surgical technique remains unclear. PATIENT SUMMARY: We examined the literature on the benefits of surgery to remove kidney cancers that have spread to neighbouring veins. The results suggest such surgery, although challenging and associated with high risk of complications, appears to be feasible and effective and should be contemplated for suitable patients if possible; however, many uncertainties remain due to the poor quality of the data.

Systematic review and meta-analysis of the clinical effectiveness of shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy for lower-pole renal stones.

UNLABELLED: The prevalence of urolithiasis is increasing. Lower-pole stones (LPS) are the most common renal calculi and the most likely to require treatment. A systematic review comparing shock wave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotomy (PNL) in the treatment of ≤20 mm LPS in adults was performed. Comprehensive searches revealed 2741 records; 7 randomised controlled trials (RCTs) recruiting 691 patients were included. Meta-analyses for stone-free rate (SFR) at ≤3 mo favoured PNL over SWL (risk ratio [RR]: 2.04; 95% confidence interval [CI], 1.50-2.77) and RIRS over SWL (RR: 1.31; 95% CI, 1.08-1.59). Stone size subgroup analyses revealed PNL and RIRS were considerably more effective than SWL for >10 mm stones, but the magnitude of benefit was markedly less for ≤10 mm stones. The quality of evidence (Grading of Recommendations Assessment, Development, and Evaluation [GRADE]) for SFR was moderate for these comparisons. The median SFR from reported RCTs suggests PNL is more effective than RIRS. The findings regarding other outcomes were inconclusive because of limited and inconsistent data. Well-designed, prospective, comparative studies that measure these outcomes using standardised definitions are required, particularly for the direct comparison of PNL and RIRS. This systematic review, which used Cochrane methodology and GRADE quality-of-evidence assessment, provides the first level 1a evidence for the management of LPS. PATIENT SUMMARY: We thoroughly examined the literature to compare the benefits and harms of the different ways of treating kidney stones located at the lower pole. PNL and RIRS were superior to SWL in clearing the stones within 3 mo, but we were unable to make any conclusions regarding other outcomes. More data is required from reliable studies before firm recommendations can be made.

When does ultrasonography influence management in suspected appendicitis?

BACKGROUND: Accurate diagnosis of appendicitis is challenging, particularly in children. Moreover, opinion is divided over the role of ultrasonography (US) in its diagnosis and how US may influence management. This study compares the use of US in two tertiary paediatric hospitals and how it influenced the management of suspected appendicitis. METHODS: Data from acute admissions, radiology, histopathology and theatre were cross-referenced to review all children who underwent an appendicectomy (with or without preoperative US) for suspected appendicitis in Christchurch (CH) in New Zealand and Aberdeen (AB) in Scotland in 2009. RESULTS: Five hundred and ninety-nine patients (442 CH; 157 AB) were included, with similar age and gender distributions. US was performed in 23% of patients with an overall appendix visualization rate of 29%. The overall positive and negative predictive values were 67% and 100%, respectively. Females were more likely to have US than males (P < 0.001, χ(2) ). In females with no appendix seen on US, in the presence or absence of other pathology, a normal appendix was confirmed in 50% and 58%, respectively. Visualizing the appendix resulted in a lower rate of normal appendix at operation (20%, 4/20) compared with when the appendix was not visualized (56%, 14/25). CONCLUSION: Identification of a normal appendix on US seems sufficiently accurate to exclude appendicitis with confidence, while positive US should be interpreted in conjunction with the clinical features in influencing the decision to operate. The incidence of a non-inflamed appendix at operation could be reduced with an increased rate of appendiceal visualization by sonographers.

Cytoplasmic expression of p27(kip1) is associated with a favourable prognosis in colorectal cancer patients.

AIM: To evaluate the prognostic significance of p27(kip1) in colorectal cancer patients. METHODS: Cytoplasmic and nuclear p27(kip1) expression was evaluated in 418 colorectal cancers using tissue microarrays. Data were associated with known patient and tumor variables and long-term patient outcomes, providing further insight into the mechanisms by which p27(kip1) may influence tumor development. RESULTS: Nuclear and cytoplasmic p27(kip1) expressions were detected in 59% and 19% of tumors respectively. Cytoplasmic p27(kip1) was almost invariably associated with positive nuclear p27(kip1) expression. Neither case correlated with known clinical or pathological variables, including tumor stage, grade or extramural vascular invasion. Furthermore, nuclear p27(kip1) expression had no impact on survival. However, we identified a significant correlation between expression of cytoplasmic p27(kip1) and longer disease-specific survival times. On multivariate analysis, TNM stage and extramural vascular invasion were highly significant independent prognostic factors, with positive cytoplasmic p27 expression showing a trend towards improved patient survival (P = 0.059). CONCLUSION: These findings support the recent evidence that cytoplasmic p27(kip1) has a distinct and important biological role that can influence tumor outcome.