Annals of the Royal College of Surgeons of England (1990) vol. 72, 243-246
The Southampton teaching triad: an audit of operative surgical instruction J F Thompson FRCS Research Fellow, Vascular Unit
Consultant Surgeon
M E Fergus
A D B Chant
BSc
RGN
Research Sister
J H H Webster
MChir FRCS
MS FRCS Consultant Surgeon
G T Royle MS FRCS Consultant Surgeon
Royal South Hants Hospital, Southampton
Key words: Quality
assurance;
Health
care;
Medical education; Audit
Clinical audit and regular morbidity and mortality meetings required of ali units involved in surgical training. Agreed standards of training are under discussion in the face of new examinations and have not at present been formally evaluated. In order to quantify the level of operative surgery instruction in this unit, a prospective 'Teaching Audit' has been undertaken, using an extension of the existing surgical audit. Results, which are presented as a standardised diagram, reflect the relationship between trainer and trainee. Problems, such as missed teaching opportunities, were identified. The method can be applied to any specialty, and may be useful in planning teaching resources and surgical training are
It seems reasonable that the teaching activities of firms training junior surgeons in general, and 'career' registrars in particular, should be measurable. This would enable teaching programmes to be planned to provide a broad based training, and would also help to maintain high standards. With this in mind, an experimental teaching audit extending over a 6-month period has been undertaken.
Methods
programmes.
Quality assurance is now an accepted part of surgical life in the United Kingdom, and plays an important role in improving standards of clinical practice. Audit is of limited value, however, unless the information collected is part of a learning exercise for all involved. Recently, the importance of selecting appropriate surgical trainees and the possibility of introducing techniques based on aptitude testing and personality assessment has been debated at a Royal College of Surgeons of England Symposium (1). The College requires that hospitals should hold regular morbidity and mortality meetings in order to maintain recognition for the training of surgical staff. Correspondence to: J F Thompson FRCS, Research Fellow, Vascular Unit, Royal South Hants Hospital, Southampton S09 4PE
Clinical audit in this unit has been greatly facilitated by the employment of a research nurse with a special responsibility for coordinating audit. Surgeons operate at various hospitals in the district, and data is collected at these different sites. Surgical complications are gathered from many different sources, including domiciliary visits. The data is at present sifted manually, pending the introduction of a computerised system, and is discussed at regular morbidity and mortality meetings. The teaching audit itself is based on an adaptation of the theatre register. The 'Operating Surgeon' column in the register was subdivided into four quadrants. The surgeon was defined as the operator performing the major part, or the crucial portion of the operation. First and second assistant (if applicable), were recorded. Similar entries were made when the senior registrar was instructing junior staff. The consultant in charge of the case was recorded separately, and his actual whereabouts noted; whether scrubbed for instruction as first assistant, or present in the theatre suite for 'over-the-shoulder'
244
F Thompson et al.
instruction. Log books were kept by surgeons in training, and feedback from the junior staff was used to verify the results of the raw audit figures. In order to place the results in context, the structure of the firm involved requires explanation. The Royal South Hants Hospital is one of the two University Teaching Hospitals in Southampton, and as well as the teaching commitment has a large clinical workload. The unit studied has three NHS consultant surgeons. One is involved wholly with vascular surgery; one is a newly appointed extra consultant responsible for the breast screening unit, as well as general surgery with an interest in endoscopy, and the third undertakes both vascular and general surgery. A senior registrar is shared, a post-fellowship registrar works mainly with the senior surgeon, and a prefellowship registrar mainly with the other two, though there is considerable cross cover, both formal and informal, which increases the potential for teaching. The period studied consisted of the final 3 months of one prefellowship registrar's appointment, and the first 3 months of his successor's job, in order to eliminate bias due to the increased teaching required at the beginning of an attachment.
O
CONSULTANT
([S SENIOR REGISTRAR
REGISTRAR Figure 1. Vascular surgery triad (including amputations). Figures shown are actual numbers of operations performed; varicose veins are excluded.
Results In vascular surgery there were 254 operations, excluding invasive radiology, performed during the 6 months studied. Varicose vein surgery was deliberately excluded, as all grades perform large numbers of these operations, and their inclusion would merely enlarge all three circles. Consultants (Fig. 1) were involved in 57% of all operations, and taught in 74% of these cases. Senior Registrars taught 21% of the time, and were involved in 45% of all operations. Registrars received consultant tuition in 53% of the cases in which they were involved. Analysis of individual operations (Table I), shows a broad spread of responsibility. It is noteworthy that unsupervised registrars performed 40% of the amputations. In both breast surgery (Fig. 2), and endoscopy (Fig. 3), the consultant and senior registrar operated separately. A registrar was only available for a small number of breast operations, so that he operated with the consultant in only 4% of cases. Similarly, in endoscopy, registrar teaching was only possible in three cases due to other
commitments; this lack of support for the new consultant and lack of teaching for junior staff was by necessity rather than choice. General surgical figures (Fig. 4), were dominated by the large numbers of operations performed by registrars. Registrars received consultant teaching in 14% of cases, and were taught by the senior registrar in 12%.
Discussion In vascular surgery, the immediate conclusion from the data is that a considerable proportion of consultant theatre time is spent teaching. This must be qualified, however, as each operation has a different approach. For example, in aortic cases it is common practice for the
Table I. Vascular procedures performed with grades of operators
Aortobifemoral Aneurysm Femoropopliteal Carotid Amputation Others
C
C+SR
C+SR+Reg
C+Reg
1 4
3 5 6
11
12 6 9 2
1 5
1
13 7 11 1 6 12
5 23
C = consultant; SR = senior registrar; Reg = registrar
SR+Reg
SR
Reg
2 3 7
1
5 9
5
-
5 5
14 9
21 22
The Southampton Teaching Tiad
245
Q CONSULTANT O
O CONSULTANT
SENIOR REGISTRAR
(J) SENIOR REGISTRAR
Q REGISTRAR Figure 2. Breast
surgery
triad.
consultant surgeon to perform the proximal aortic anastomosis, or to supervise the senior registrar. The registrar is then taken through one distal anastomosis, while the first assistant performs the other. It was generally felt by the junior staff that the audit was an accurate reflection of the true state of affairs in elective vascular cases, and individually kept log books confirmed this. Amputations deserve special mention. Despite unit policy to the contrary, a large number of amputations were still performed by registrars, usually out of hours. However, bare statistics do not always reflect the true
CONSULTANT
SENIOR REGISTRAR
REGISTRAR
Figure 3. Endoscopy triad; 68%
were
colonoscopies.
O REGISTRAR
Figure 4. General surgery triad.
situation; of the 52 major amputations, 21 were guillotine amputations which were subsequently converted to a definitive stump when the patient's condition had improved. Anaesthesia in this group of patients should probably be administered by a senior anaesthetist, with the same attention to intensive monitoring and postoperative detail as a patient undergoing reconstruction. The expediency of the weekend or evening amputation in high risk cases, which is an unfortunate result of the high case load during the day, is therefore in question. The majority of breast operations were performed by a consultant or senior registrar. These include large numbers of patients undergoing localisation procedures and excision biopsy, as well as definitive breast surgery. This is an important area of expertise for trainees, who will increasingly be faced with impalpable screen detected lesions in the future, as screening programmes expand. It is unfortunate that most of these cases were performed without a trainee present, and this underutilised teaching opportunity is well illustrated in Fig. 2. This particular triad also illustrates another important point. The senior registrar shown is in fact 'on loan' from another firm, and provides a pure service commitment. Future consultant appointments should consider the provision of an adequate infrastructure of junior support, as increased clinical workload by consultants alone may erode training opportunities for juniors, and both teaching and research time for consultants. A similar missed teaching opportunity occurred in endoscopy, in which almost all procedures were performed by a single consultant or senior registrar with no juniors present. Colonoscopy, in particular, is an important diagnostic and therapeutic technique, with a lengthy
246
J F Thompson et al.
learning curve. It is unfortunate that the opportunity for training juniors in endoscopy is currently underexploited. Teaching audit may identify this kind of discrepancy; even if surgical trainees are not available for instruction, juniors from other specialties may be able to gain experience, and a registrar from the gastroenterology unit has recently taken advantage of this opportunity. The results of the general surgery audit were largely predictable, with large numbers of procedures being performed by registrars. There is some overlap with the juniors, but two points arise. Firstly, the data is diluted by large numbers of relatively minor procedures, and so it was felt that future audit should discriminate between major/intermediate and minor surgery. Secondly, it would be useful to consider emergencies separately, although registrars felt that they were well supported at night if assistance was required. A particular local problem is that the new consultant general surgeon has insufficient operating time to deal
with all the urgent (cancer) surgery arising from outpatients and emergency 'takes'. Many colonic resections are at present performed by the senior registrar or postfellowship registrar whenever they can be fitted in; a situation which is far from satisfactory. Overall, the audit provided interesting and relevant information which provoked much thought and discussion. The data supports the case for adequate support for new consultant appointments, and has demonstrated satisfactory teaching in one area, and has highlighted underexploited teaching opportunities in another two.
Reference I Symposium-Personality assessment techniques and aptitude testing as aids to the selection of surgical trainees. Ann R Coll Surg Engl 1988;70:265-9.
Received 12 December 1989
Notes on books Decision Making in Surgery of the Chest edited by Laurens R Pickard. 168 pages. W B Saunders Company, Philadelphia. 1989. £47.00. ISBN 0 7216 1168 0
edition of a well-known series. The editors hope that the content of the volume will be palatable, interesting, informative and intellectual.
Ten years ago the average surgeon was unlikely to know the meaning of the term algorithm. Today, algorithms are increasingly used in journal articles, textbooks and lectures. This book gives 75 algorithms which cover the surgery of the heart, great vessels, lungs, chest wall and oesophagus. The author admits that not all subjects can be analysed in this way and therefore the book is selective.
Selected References in Orthopaedic Trauma by A H C Ratliff, J H Dixon, P A Magnussen and S K Young. 124 pages, paperback. Springer-Verlag, Heidelberg. £14.95. 1989. ISBN 3 540 19556 4
Perspectives in Shock Research: Metabolism, Immunology, Mediators and Models edited by John C Passmore. 346 pages, illustrated. Alan R Liss Inc., New York. 1989. $70.00. ISBN 0 8451 5149 5 The Proceedings of a conference held on shock in Wisconsin in June 1988 and printed from camera-ready copy. Numerous papers are given under the general headings of organ blood flow, endotoxaemia, molecular and immunological responses to injury, clinical trials and the use of hypertonic solutions for shock resuscitation.
Yearbook of Vascular Surgery 1989 edited by John J Bergan and James S T Yao. 327 pages, illustrated. Yearbook Medical Publishers Inc., Chicago. 1989. £42.00. ISBN 0 8151 0678 5 Vascular trauma, especially iatrogenic, together with coagulopathies, lasers and photoenergy, are some of the recent advances in vascular surgery that are covered in this new
Two senior registrars and two consultants have met at weekly intervals to select the most important references in the English speaking literature, both classic and up-to-date, that deal with orthopaedic trauma. They have then appended a succinct commentary as to why they have chosen these particular articles rather than the thousands of others that have been published over the years. The result is an original and exceedingly useful review volume which will unquestionably be of value to all examination candidates as well as their examiners. The layout is clear, the text highly readable and the lack of illustration matters not a whit.
Controversies in General Surgery edited by T G Allen-Mersh. 122 pages, paperback. Edward Arnold, London. 1989. £10.00. ISBN 0 340 49649 5 Ten controversies in general surgery are presented, each by two authors, both of whom are uncommitted to any particular point of view. The first author assembles supporting evidence in the best possible light and points to flaws in the opposing view. The opposite view is then similarly argued by the second author. No attempt is made to judge the debates and the reader is left to decide which view is correct. Vascular, gastrointestinal and oncological topics are covered.
The Southampton teaching triad: an audit of operative surgical instruction J F Thompson FRCS Research Fellow, Vascular Unit
Consultant Surgeon
M E Fergus
A D B Chant
BSc
RGN
Research Sister
J H H Webster
MChir FRCS
MS FRCS Consultant Surgeon
G T Royle MS FRCS Consultant Surgeon
Royal South Hants Hospital, Southampton
Key words: Quality
assurance;
Health
care;
Medical education; Audit
Clinical audit and regular morbidity and mortality meetings required of ali units involved in surgical training. Agreed standards of training are under discussion in the face of new examinations and have not at present been formally evaluated. In order to quantify the level of operative surgery instruction in this unit, a prospective 'Teaching Audit' has been undertaken, using an extension of the existing surgical audit. Results, which are presented as a standardised diagram, reflect the relationship between trainer and trainee. Problems, such as missed teaching opportunities, were identified. The method can be applied to any specialty, and may be useful in planning teaching resources and surgical training are
It seems reasonable that the teaching activities of firms training junior surgeons in general, and 'career' registrars in particular, should be measurable. This would enable teaching programmes to be planned to provide a broad based training, and would also help to maintain high standards. With this in mind, an experimental teaching audit extending over a 6-month period has been undertaken.
Methods
programmes.
Quality assurance is now an accepted part of surgical life in the United Kingdom, and plays an important role in improving standards of clinical practice. Audit is of limited value, however, unless the information collected is part of a learning exercise for all involved. Recently, the importance of selecting appropriate surgical trainees and the possibility of introducing techniques based on aptitude testing and personality assessment has been debated at a Royal College of Surgeons of England Symposium (1). The College requires that hospitals should hold regular morbidity and mortality meetings in order to maintain recognition for the training of surgical staff. Correspondence to: J F Thompson FRCS, Research Fellow, Vascular Unit, Royal South Hants Hospital, Southampton S09 4PE
Clinical audit in this unit has been greatly facilitated by the employment of a research nurse with a special responsibility for coordinating audit. Surgeons operate at various hospitals in the district, and data is collected at these different sites. Surgical complications are gathered from many different sources, including domiciliary visits. The data is at present sifted manually, pending the introduction of a computerised system, and is discussed at regular morbidity and mortality meetings. The teaching audit itself is based on an adaptation of the theatre register. The 'Operating Surgeon' column in the register was subdivided into four quadrants. The surgeon was defined as the operator performing the major part, or the crucial portion of the operation. First and second assistant (if applicable), were recorded. Similar entries were made when the senior registrar was instructing junior staff. The consultant in charge of the case was recorded separately, and his actual whereabouts noted; whether scrubbed for instruction as first assistant, or present in the theatre suite for 'over-the-shoulder'
244
F Thompson et al.
instruction. Log books were kept by surgeons in training, and feedback from the junior staff was used to verify the results of the raw audit figures. In order to place the results in context, the structure of the firm involved requires explanation. The Royal South Hants Hospital is one of the two University Teaching Hospitals in Southampton, and as well as the teaching commitment has a large clinical workload. The unit studied has three NHS consultant surgeons. One is involved wholly with vascular surgery; one is a newly appointed extra consultant responsible for the breast screening unit, as well as general surgery with an interest in endoscopy, and the third undertakes both vascular and general surgery. A senior registrar is shared, a post-fellowship registrar works mainly with the senior surgeon, and a prefellowship registrar mainly with the other two, though there is considerable cross cover, both formal and informal, which increases the potential for teaching. The period studied consisted of the final 3 months of one prefellowship registrar's appointment, and the first 3 months of his successor's job, in order to eliminate bias due to the increased teaching required at the beginning of an attachment.
O
CONSULTANT
([S SENIOR REGISTRAR
REGISTRAR Figure 1. Vascular surgery triad (including amputations). Figures shown are actual numbers of operations performed; varicose veins are excluded.
Results In vascular surgery there were 254 operations, excluding invasive radiology, performed during the 6 months studied. Varicose vein surgery was deliberately excluded, as all grades perform large numbers of these operations, and their inclusion would merely enlarge all three circles. Consultants (Fig. 1) were involved in 57% of all operations, and taught in 74% of these cases. Senior Registrars taught 21% of the time, and were involved in 45% of all operations. Registrars received consultant tuition in 53% of the cases in which they were involved. Analysis of individual operations (Table I), shows a broad spread of responsibility. It is noteworthy that unsupervised registrars performed 40% of the amputations. In both breast surgery (Fig. 2), and endoscopy (Fig. 3), the consultant and senior registrar operated separately. A registrar was only available for a small number of breast operations, so that he operated with the consultant in only 4% of cases. Similarly, in endoscopy, registrar teaching was only possible in three cases due to other
commitments; this lack of support for the new consultant and lack of teaching for junior staff was by necessity rather than choice. General surgical figures (Fig. 4), were dominated by the large numbers of operations performed by registrars. Registrars received consultant teaching in 14% of cases, and were taught by the senior registrar in 12%.
Discussion In vascular surgery, the immediate conclusion from the data is that a considerable proportion of consultant theatre time is spent teaching. This must be qualified, however, as each operation has a different approach. For example, in aortic cases it is common practice for the
Table I. Vascular procedures performed with grades of operators
Aortobifemoral Aneurysm Femoropopliteal Carotid Amputation Others
C
C+SR
C+SR+Reg
C+Reg
1 4
3 5 6
11
12 6 9 2
1 5
1
13 7 11 1 6 12
5 23
C = consultant; SR = senior registrar; Reg = registrar
SR+Reg
SR
Reg
2 3 7
1
5 9
5
-
5 5
14 9
21 22
The Southampton Teaching Tiad
245
Q CONSULTANT O
O CONSULTANT
SENIOR REGISTRAR
(J) SENIOR REGISTRAR
Q REGISTRAR Figure 2. Breast
surgery
triad.
consultant surgeon to perform the proximal aortic anastomosis, or to supervise the senior registrar. The registrar is then taken through one distal anastomosis, while the first assistant performs the other. It was generally felt by the junior staff that the audit was an accurate reflection of the true state of affairs in elective vascular cases, and individually kept log books confirmed this. Amputations deserve special mention. Despite unit policy to the contrary, a large number of amputations were still performed by registrars, usually out of hours. However, bare statistics do not always reflect the true
CONSULTANT
SENIOR REGISTRAR
REGISTRAR
Figure 3. Endoscopy triad; 68%
were
colonoscopies.
O REGISTRAR
Figure 4. General surgery triad.
situation; of the 52 major amputations, 21 were guillotine amputations which were subsequently converted to a definitive stump when the patient's condition had improved. Anaesthesia in this group of patients should probably be administered by a senior anaesthetist, with the same attention to intensive monitoring and postoperative detail as a patient undergoing reconstruction. The expediency of the weekend or evening amputation in high risk cases, which is an unfortunate result of the high case load during the day, is therefore in question. The majority of breast operations were performed by a consultant or senior registrar. These include large numbers of patients undergoing localisation procedures and excision biopsy, as well as definitive breast surgery. This is an important area of expertise for trainees, who will increasingly be faced with impalpable screen detected lesions in the future, as screening programmes expand. It is unfortunate that most of these cases were performed without a trainee present, and this underutilised teaching opportunity is well illustrated in Fig. 2. This particular triad also illustrates another important point. The senior registrar shown is in fact 'on loan' from another firm, and provides a pure service commitment. Future consultant appointments should consider the provision of an adequate infrastructure of junior support, as increased clinical workload by consultants alone may erode training opportunities for juniors, and both teaching and research time for consultants. A similar missed teaching opportunity occurred in endoscopy, in which almost all procedures were performed by a single consultant or senior registrar with no juniors present. Colonoscopy, in particular, is an important diagnostic and therapeutic technique, with a lengthy
246
J F Thompson et al.
learning curve. It is unfortunate that the opportunity for training juniors in endoscopy is currently underexploited. Teaching audit may identify this kind of discrepancy; even if surgical trainees are not available for instruction, juniors from other specialties may be able to gain experience, and a registrar from the gastroenterology unit has recently taken advantage of this opportunity. The results of the general surgery audit were largely predictable, with large numbers of procedures being performed by registrars. There is some overlap with the juniors, but two points arise. Firstly, the data is diluted by large numbers of relatively minor procedures, and so it was felt that future audit should discriminate between major/intermediate and minor surgery. Secondly, it would be useful to consider emergencies separately, although registrars felt that they were well supported at night if assistance was required. A particular local problem is that the new consultant general surgeon has insufficient operating time to deal
with all the urgent (cancer) surgery arising from outpatients and emergency 'takes'. Many colonic resections are at present performed by the senior registrar or postfellowship registrar whenever they can be fitted in; a situation which is far from satisfactory. Overall, the audit provided interesting and relevant information which provoked much thought and discussion. The data supports the case for adequate support for new consultant appointments, and has demonstrated satisfactory teaching in one area, and has highlighted underexploited teaching opportunities in another two.
Reference I Symposium-Personality assessment techniques and aptitude testing as aids to the selection of surgical trainees. Ann R Coll Surg Engl 1988;70:265-9.
Received 12 December 1989
Notes on books Decision Making in Surgery of the Chest edited by Laurens R Pickard. 168 pages. W B Saunders Company, Philadelphia. 1989. £47.00. ISBN 0 7216 1168 0
edition of a well-known series. The editors hope that the content of the volume will be palatable, interesting, informative and intellectual.
Ten years ago the average surgeon was unlikely to know the meaning of the term algorithm. Today, algorithms are increasingly used in journal articles, textbooks and lectures. This book gives 75 algorithms which cover the surgery of the heart, great vessels, lungs, chest wall and oesophagus. The author admits that not all subjects can be analysed in this way and therefore the book is selective.
Selected References in Orthopaedic Trauma by A H C Ratliff, J H Dixon, P A Magnussen and S K Young. 124 pages, paperback. Springer-Verlag, Heidelberg. £14.95. 1989. ISBN 3 540 19556 4
Perspectives in Shock Research: Metabolism, Immunology, Mediators and Models edited by John C Passmore. 346 pages, illustrated. Alan R Liss Inc., New York. 1989. $70.00. ISBN 0 8451 5149 5 The Proceedings of a conference held on shock in Wisconsin in June 1988 and printed from camera-ready copy. Numerous papers are given under the general headings of organ blood flow, endotoxaemia, molecular and immunological responses to injury, clinical trials and the use of hypertonic solutions for shock resuscitation.
Yearbook of Vascular Surgery 1989 edited by John J Bergan and James S T Yao. 327 pages, illustrated. Yearbook Medical Publishers Inc., Chicago. 1989. £42.00. ISBN 0 8151 0678 5 Vascular trauma, especially iatrogenic, together with coagulopathies, lasers and photoenergy, are some of the recent advances in vascular surgery that are covered in this new
Two senior registrars and two consultants have met at weekly intervals to select the most important references in the English speaking literature, both classic and up-to-date, that deal with orthopaedic trauma. They have then appended a succinct commentary as to why they have chosen these particular articles rather than the thousands of others that have been published over the years. The result is an original and exceedingly useful review volume which will unquestionably be of value to all examination candidates as well as their examiners. The layout is clear, the text highly readable and the lack of illustration matters not a whit.
Controversies in General Surgery edited by T G Allen-Mersh. 122 pages, paperback. Edward Arnold, London. 1989. £10.00. ISBN 0 340 49649 5 Ten controversies in general surgery are presented, each by two authors, both of whom are uncommitted to any particular point of view. The first author assembles supporting evidence in the best possible light and points to flaws in the opposing view. The opposite view is then similarly argued by the second author. No attempt is made to judge the debates and the reader is left to decide which view is correct. Vascular, gastrointestinal and oncological topics are covered.
