A systematic review and cohort study of operative training in general surgery

Elsey, Elizabeth (2019) A systematic review and cohort study of operative training in general surgery. PhD thesis, University of Nottingham.

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Surgical training in the UK has seen many changes over recent years with a move towards competency-based curricula requiring trainees to undertake workplace-based assessments and meet operative experience targets. Data from assessments and operative experience are collected routinely but have not been used to understand the outcomes of the UK national General Surgery specialty training programme. The aim of this thesis was to understand the operative experience of General Surgery specialty trainees in the UK.

The first study in this thesis (Chapter 2) explored published data for the operative experience of General Surgery trainees completing training worldwide. With the exception of the USA, very few studies had been published. Of the five countries that had reported relevant data, there was wide variation seen in operative experience with a mean pooled estimate of 1366 procedures (95% CI 1026- 1707) per trainee at completion of training and marked heterogeneity between studies (I2= 99.6%). Whilst the included studies quantified operative experience, none had linked experience to a formal measure of technical competency or provided evidence of competency attainment through training.

The three other studies in the thesis used routinely collected surgical training data from a national cohort of General Surgery trainees in the UK from 2007- 2016. The key data sources for these studies were the Intercollegiate Surgical Curriculum Programme (ISCP) database and the eLogbook database. Both databases are mandatory in UK surgical training and linked by trainee GMC number. Trainees record placement and assessment information in the ISCP and operative experience data in the eLogbook.

Following work to determine the timeline of training for each trainee, two cohorts were defined; those that had completed training (n=360) and those that remained in training at the time of data extraction (n=994).(Chapter 3).

The first study using ISCP data aimed to evaluate trends in the time taken out of training and the impact on the duration of UK General Surgery specialty training. (Chapter 4) This study found an increasing number of trainees taking time out of training (54.5% of In Training cohort vs 45.9% of Completed Training cohort, p <0.01). The most common reason for time out of training was for research with 35.1% of the In-Training cohort undertaking research out of programme compared to 6.1% of those who had completed training (p <0.01). This trend is increasing the time taken to complete specialty training with those In-Training who had already taken time out of programme predicted to take a median 8.0 (iqr 7.0-9.0) years to complete training compared to a median 6.0 (iqr 6.0-7.0) years in those who had already completed training.

The next study in the thesis explored the use of the procedure-based assessment (PBA) in judging the competency of trainees undertaking General Surgery index procedures. It explored the relationship between increasing operative experience and changing PBA outcomes. (Chapter 5) Differences in this association were identified between index procedures and the results provide further understanding of the validity of the PBA within General Surgery specialty training. This study also evaluated the number of procedures undertaken to award of competency (as judged by the PBA) and found this differed to current UK curricula targets for operative experience.

The final study aimed to determine the autonomy of General Surgery specialty trainees by assessing changing procedural supervision and PBA outcomes through the course of an entire training programme. (Chapter 6) This study found that supervision of trainees varied both by index procedure and by stage of training. The proportion of all index procedures recorded as unsupervised increased through training (p<0.05) and varied between index procedures with 91.2% of appendicectomies, 40.6% of emergency laparotomies and 17.4% of segmental colectomies recorded as unsupervised during the final year of training.

This thesis provides evidence of operative experience and competency outcomes in General Surgery specialty training. It suggests that the way in which procedural competency is attained varies between index procedures and that current UK indicative numbers for operative experience do not relate to the operative experience required for competency. This work uses surgical training data to reflect the changing autonomy through training, providing evidence of changing entrustment decisions in keeping with current trends for assessing competency in post-graduate medical education.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: West, Joe
Humes, David
Griffiths, Gareth
Keywords: Training in General Surgery in the UK
Subjects: W Medicine and related subjects (NLM Classification) > WO Surgery
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID: 56059
Depositing User: Elsey, Elizabeth
Date Deposited: 19 Jul 2019 04:40
Last Modified: 07 May 2020 11:47
URI: https://eprints.nottingham.ac.uk/id/eprint/56059

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