Differences in progression by surgical specialty: a national cohort study.

The aim of surgical training across the 10 surgical specialties is to produce competent day 1 consultants. Progression through training in the UK is assessed by the Annual Review of Competency Progression (ARCP). OBJECTIVE: This study aimed to examine variation in ARCP outcomes within surgical training and identify differences in outcomes between specialties. DESIGN: A national cohort study using data from the UK Medical Education Database was performed. ARCP outcome was the primary outcome measure. Multilevel ordinal regression analyses were performed, with ARCP outcomes nested within trainees. PARTICIPANTS: Higher surgical trainees (ST3-ST8) from nine UK surgical specialties were included (vascular surgery was excluded due to insufficient data). All surgical trainees across the UK with an ARCP outcome between 2010 and 2017 were included. RESULTS: Eight thousand two hundred and twenty trainees with an ARCP outcome awarded between 2010 and 2017 were included, comprising 31 788 ARCP outcomes. There was substantial variation in the proportion of non-standard outcomes recorded across specialties with general surgery trainees having the highest proportion of non-standard outcomes (22.5%) and urology trainees the fewest (12.4%). After adjustment, general surgery trainees were 1.3 times more likely to receive a non-standard ARCP outcome compared with trainees in trauma and orthopaedics (T&O) (OR 1.33, 95% CI 1.21 to 1.45, p=0.001). Urology trainees were 36% less likely to receive a non-standard outcome compared with T&O trainees (OR 0.64, 95% CI 0.54 to 0.75, p<0.001). Female trainees and older age were associated with non-standard outcomes (OR 1.11, 95% CI 1.02 to 1.22, p=0.020; OR 1.04, 95% CI 1.03 to 1.05, p<0.001). CONCLUSION: There is wide variation in the training outcome assessments across surgical specialties. General surgery has higher rates of non-standard outcomes compared with other surgical specialties. Across all specialties, female sex and older age were associated with non-standard outcomes.

The impact of frailty on trauma outcomes using the Clinical Frailty Scale.

BACKGROUND: Population ageing is a worldwide phenomenon; thanks to improvements in medical care and living standards. The Office of National Statistics in the UK predicts that the fastest growing age group in coming decades will be those over 85 years. This is reflected in Trauma Audit and Research Network data, which has highlighted a shift in caseload from a majority of young males to elderly patients at UK Major Trauma Centres (MTC). This study of elderly trauma patients admitted to a UK MTC reviews the links between frailty, using the Canadian Study of Health and Aging Clinical Frailty Scale (CFS), and outcomes from trauma. METHODS: A retrospective database review of patients > 65 years old admitted to our MTC was performed. We identified 1125 eligible patients of which 729 had a recorded CFS. Those without a CFS were omitted. The primary outcome measured was in-hospital mortality. Secondary measures were Injury Severity Score, length of stay, trauma team activation on arrival and discharge destination. Multivariate regression analyses were performed using STATA v 15. RESULTS: Those of CFS 5-9 (frail) were 2.6 times more likely to die than the CFS 1-4 (pre-frail) (OR 2.65, 95% CI 1.47-4.78). The frail group was also 56% less likely to have a trauma call on admission (OR 0.44, 95% CI 0.30-0.65) and 61% less likely to be discharged to their usual place of residence (OR 0.39, 95% CI 0.28-0.55). CONCLUSION: We advocate the use of the Clinical Frailty Scale as a screening tool for frailty in trauma patients, highlighting those at risk of increased length of stay and mortality, subsequently assisting healthcare providers with setting realistic expectations with family members. LEVEL OF EVIDENCE: Level III, prognostic and epidemiological.

Personal Characteristics Associated with Progression in Trauma and Orthopaedic Specialty Training: A Longitudinal Cohort Study.

AIM: To identify demographic factors, including protected characteristics, and training specific factors which predict a nonstandard Annual Review of Competency Progression (ARCP) outcome during Trauma and Orthopedic Specialty training in the United Kingdom (UK). METHOD: A longitudinal cohort study using data from UKMED was performed. ARCP outcome was the primary outcome measure. Multilevel univariate and multiple ordinal regression analyses were performed using STATA v 15. RESULTS: Two thousand five hundred and ten Trauma and Orthopedic surgery trainees (ST3-ST8) with an ARCP outcome between 2010 and 2017 were included, comprising 11,011 ARCP outcomes. Eighty five percent (2130/2510) of trainees were male. Eighty two percent of outcomes were satisfactory. Female trainees had a 26% increased risk of nonstandard outcome (OR 1.26 95% CI 1.10-1.44) after adjusting for other factors. Older age at ARCP was associated with an increased risk of nonstandard ARCP outcome (OR 1.04 95% CI 1.03-1.06). International medical graduates had a 34% decreased risk of nonstandard outcome compared to UK graduates (OR 0.66 95% CI 0.54-0.81). Less than full time training was not associated with risk of a nonstandard ARCP outcome (OR 0.92 95% CI 0.76-1.12). CONCLUSION: Female sex and older age at ARCP were significantly associated with nonstandard ARCP outcomes in Trauma and Orthopedic surgery, while international medical graduation was protective.

Factors Associated with Attrition and Performance Throughout Surgical Training: A Systematic Review and Meta-Analysis.

BACKGROUND: Attrition within surgical training is a challenge. In the USA, attrition rates are as high as 20-26%. The factors predicting attrition are not well known. The aim of this systematic review is to identify factors that influence attrition or performance during surgical training. METHOD: The review was performed in line with PRISMA guidelines and registered with the Open Science Framework (OSF). Medline, EMBASE, PubMed and the Cochrane Central Register of Controlled Trials were searched for articles. Risk of bias was assessed using the Newcastle-Ottawa scale. Pooled estimates were calculated using random effects meta-analyses in STATA version 15 (Stata Corp Ltd). A sensitivity analysis was performed including only multi-institutional studies. RESULTS: The searches identified 3486 articles, of which 31 were included, comprising 17,407 residents. Fifteen studies were based on multi-institutional data and 16 on single-institutional data. Twenty-nine of the studies are based on US residents. The pooled estimate for overall attrition was 17% (95% CI 14-20%). Women had a significantly higher pooled attrition than men (24% vs 16%, p < 0.001). Some studies reported Hispanic residents had a higher attrition rate than non-Hispanic residents. There was no increased risk of attrition with age, marital or parental status. Factors reported to affect performance were non-white ethnicity and faculty assessment of clinical performance. Childrearing was not associated with performance. CONCLUSION: Female gender is associated with higher attrition in general surgical residency. Longitudinal studies of contemporary surgical cohorts are needed to investigate the complex multi-factorial reasons for failing to complete surgical residency.

Evolution of non-operative management of liver trauma.

The management of complex liver injury has changed during the last 30 years. Operative management has evolved into a non-operative management (NOM) approach, with surgery reserved for those who present in extremis or become hemodynamically unstable despite resuscitation. This NOM approach has been associated with improved survival rates in severe liver injury and has been the mainstay of treatment for the last 20 years. Patients that fail NOM and require emergency surgery are associated with increased morbidity and mortality. Better patient selection may have an impact not only on the rate of failure of NOM, but the mortality rate associated with it. The aim of this article is to review the evidence that helped shape the evolution of liver injury management during the last 30 years.

Locoregional recurrence of breast cancer presenting as upper limb venous thromboembolism.

Locoregional recurrence of breast cancer is a major concern for both patient and oncologist. Presentation as venous thromboembolism (VTE) carries risk of delayed diagnosis and has a poor prognosis. Here we describe, for the first time in the literature, a delayed diagnosis of local recurrence of infiltrative inflammatory breast cancer presenting as extensive deep venous thrombosis of the upper arm veins. This case demonstrates the need for a high level of vigilance for recurrence of malignancy in patients with no concurrent risk factors for VTE and atypical clinical progression in order to reach a timely diagnosis.