|Home | About | Journals | Submit | Contact Us | Français|
Concern is being expressed about the state of basic surgical training in the context of growing demands to improve service provision in the National Health Service. Taking ophthalmology as a case example, we sent questionnaires to all 466 senior house officers (SHOs) in recognized surgical training posts in England, Wales, Scotland and Northern Ireland. The main outcome measures were intraocular surgery performed in the previous two weeks and since starting as an SHO in ophthalmology; access to protected teaching time or cases on theatre lists; and supervision during surgery. Phakoemulsification, the most common type of cataract surgery, was used as a generic indicator of intraocular procedures. 314 (67%) of the SHOs responded. Of those working in the hospital in the previous two weeks, 50% had performed at least one component part of a phakoemulsification (phako) operation and 44% had performed at least one full phako operation. The average number of full phako operations done per week was 0.741. 77% reported some protected surgical teaching time over the two weeks and those with protected teaching time reported more full phako operations per week. Of those who had performed at least one surgical procedure in the previous two weeks, 79% had been supervised by a consultant. Of those who had completed two or more years' training as an SHO, only 42% met the Royal College of Ophthalmologists minimum requirement of 50 complete intraocular operations performed under supervision. Women were less likely than men, and SHOs in district general hospitals were less likely than those in teaching hospitals, to have achieved this target. As many as half the SHOs in ophthalmology are not receiving an adequate basic surgical training. If this continues it may prove difficult to train sufficient new surgeons to an acceptable standard to meet the increasing demands of an ageing population. This is not an issue for ophthalmology alone but for all surgical specialties.
Surgery and the context in which it is performed have changed considerably in the UK. Advances in technology have improved outcome so that patients now expect an intervention to result in full and rapid recovery. At the same time, the modernization agenda in the National Health Service (NHS) has created pressures on hospitals to reduce waiting times and to deliver increased choice for patients1 while also meeting the demands of clinical governance.2 These growing demands on service provision create many challenges for training the surgeons of the future, who inevitably take longer to perform procedures than senior doctors and require supervision. Those at the very start of specialist training, senior house officers (SHOs), are likely to be disproportionately affected by these changed circumstances since they need the greatest input into training and therefore have the greatest potential to disrupt surgical throughput.3 The major reform of training in recent years (Calman reforms of 1993)4 addressed the needs of specialist registrars without considering the SHO grade. While steps are being taken to remedy this,5 questions remain as to the quality of the basic specialist training received by current SHOs.
This paper aims to describe the level of basic surgical training in one specialty, ophthalmology, in the light of the growing pressures on service provision in the NHS. Ophthalmology provides a good case example for examining the state of basic surgical training, since in this specialty surgical training is largely in relation to one procedure—phakoemulsification cataract surgery—and clear guidelines have been agreed by the Royal College of Ophthalmologists6 as to what constitutes a basic minimum standard of training. Cataract surgery is the most commonly performed operation in the UK and recent policy initiatives have stressed the need to increase the number of procedures performed in order to reduce waiting lists.7 In none of these has proper consideration been given to their potential impact on training junior doctors.8 Although this paper focuses on SHOs in ophthalmology, the findings are of relevance to other surgical specialties that must also provide training within the context of increased service pressures.
A self-completion questionnaire was developed to describe SHOs' surgical experience in relation to the recommendations set out by the Royal College of Ophthalmologists in their Guide For Basic Specialist Training In Ophthalmology.6 This provides for a formally structured programme involving both laboratory-based and patient-based training. Patient-based training begins with extraocular procedures and progresses to more complex intraocular procedures over the course of a year. Training in small incision (‘keyhole’) phakoemulsification cataract surgery begins with mastering the various components of the procedure (‘part phako’) before performance of the complete procedure (‘full phako’), all under supervision. SHOs are expected to attend at least one protected operating list a week (which implies that the trainee will have hands-on surgical experience during this session). The overall expectation is that, by the end of the second year of training, SHOs will have achieved reasonable proficiency in phakoemulsification and performed a minimum of 50 complete intraocular operations under supervision.
The questionnaire asked about laboratory training and facilities; theatre lists, surgical experience and supervision; and background and demographic details. Participants were asked their self-assessed ethnicity according to Office for National Statistics categories;9 other questions used the categories found in the Workforce Census for England.10 A final section invited free comments with regard to surgical training as an ophthalmic SHO. The operation most commonly performed by ophthalmologists, phakoemulsification cataract surgery, was used as the exemplar procedure throughout the questionnaire. To reduce reporting error, participants were asked to report their activities in the previous week and in the week before that; these were then averaged to give rates per week. Longer time frames were used as appropriate.
From the Directory of Training Posts in Ophthalmology, 2000-2001, we identified 476 ophthalmology SHOs. Between November 2000 and October 2001, numbered questionnaires were distributed to named individuals in each post. 10 questionnaires were subsequently excluded because the questionnaire was returned undelivered or the hospital post was not recognized for surgical training (e.g. it was designed for general practice vocational training only). Individuals who did not respond within two months were sent a follow-up questionnaire.
Questionnaire responses were entered onto a personal computer and analysed by means of SPSS 11.0 for Windows. Statistical tests included chi-square tests for categorical data, t-tests and Pearson's correlation coefficient for interval data, and logistic regression for multivariate analysis. Logistic regression is used when the outcome variable is dichotomous—in this case whether or not the participant had completed 50 full phako procedures. Forward and backward stepwise logistic regression was performed to identify the model that best fitted the data.
Useable questionnaires were returned by 314/466 SHOs in recognized surgical training posts, a response rate of 67%. The average age of participants was 29.9 years (95% CI 29.5 to 30.3, range 24-46). The mean length of time in training was 20.1 months (95% CI 18.5 to 21.6, range 1-103). Other characteristics of the participants are given in Table 1. Comparison between the study sample and all SHOs in ophthalmology in England shows a good match in relation to gender.9 Figures are not available for Wales, Scotland or Northern Ireland or for other demographic and background characteristics.
96% (302/314) of participants had been present in their hospital for at least one of the two weeks before completing the questionnaire, of whom 301 had attended at least one operating session. The other 12 participants had been attending courses, on leave or ill for the previous two weeks. Analyses relating to activity in the previous two weeks were confined to the 302 participants who were present in their hospital for at least one of the two study weeks; data from all 314 were used in analyses relating to longer time periods.
Phakoemulsification cataract surgery is composed of several distinct steps of increasing complexity, which the basic surgical trainee is expected to master before performing a full procedure. 50% (151/302, 95% CI 44-56%) of participants reported performing at least one part phako operation in the previous two weeks; the mean number of part phako procedures performed per week during this period was 0.789 (95% CI 0.6602-0.9178). Since starting as an ophthalmic SHO in the UK, 91% (276/305, 95% CI 87-94%) of participants had performed at least one part phako procedure.
44% (133/302, 95% CI 38-50%) of participants reported performing at least one full phako in the previous two weeks. The mean number of full phako operations performed per week was 0.741 (95% CI 0.605-0.8764%). SHOs working in a teaching hospital performed significantly more full phako operations in the previous two weeks than those working in a district general hospital (t=2.905, 297 df, P=0.004, mean difference 0.41, 95% CI 0.132-0.688).
Since starting as an ophthalmic SHO in the UK, 61% (192/314, 95% CI 56-67%) of participants had performed at least one full phako. The number performed was positively correlated to the length of time as an SHO in the specialty (r=0.262, P<0.01).
During the previous two weeks at least some time or cases protected for surgical teaching on at least one surgical list was reported by 77% (233/302), 95% CI 72-82%) of participants. 15% (45/302, 95% CI 11-19%) of participants reported that on at least one surgical list all time or cases had been protected for surgical teaching. Those who reported at least some protected surgical teaching time in the previous two weeks performed more full phakos per week than those who did not (t=2.69, 135 df, P<0.01, mean difference 0.387, 95% CI 0.102-0.672).
75% (228/302, 95% CI 71-80%) of participants had performed at least one surgical procedure (part or full phako) in the previous two weeks. Of these, 79% (180/228, 95% CI 74-84%) had been supervised by a consultant, and 35% (79/228, 95% CI 28-41%) had been supervised by a specialist registrar or staff grade surgeon. 5% (12/228, 95% CI 2-8%) had performed cataract surgery without supervision.
The Royal College of Ophthalmologists guidelines specify that SHOs are expected to have carried out 50 intraocular procedures by the end of their second year of training. Only 42% (40/96, 95% CI 32-52%) of participants who had completed 2 or more years as an SHO met this requirement. Table 2 shows that those meeting the target are more likely to have been SHOs for longer (χ2=48.25, 2 d.f., P<0.001), more likely to be men than women (χ2=8.95, 1 df, P=0.003) and more likely to be in a teaching hospital than a non-teaching hospital (χ2=15.36, 1 df, P<0.001); there are no differences by self-ascribed ethnicity or where they qualified. These five variables were entered into a logistic regression (forward and backward stepwise); the model with the best fit included length of time as an SHO, gender and hospital type (model χ2 =52.88, 3 df, P<0.001). This shows that the length of time participants had been an SHO cannot fully explain whether or not they had performed 50 or more full phakos; both their gender and the type of hospital where they currently work make a significant contribution.
Cataract surgery is the most commonly performed operation in the UK and phakoemulsification cataract surgery was studied as a generic indicator of surgical training in ophthalmology. The strengths of the study derive from the research design, which involved contacting individuals in all recognized training posts in ophthalmic surgery throughout the UK and collecting detailed information on their surgical activity over specified time periods. The high response rate reflects the concern SHOs have expressed about their training. The main limitation of the study is its reliance on self-reported data that cannot be verified independently, although a focus on the previous two weeks as well as on longer time frames, helps to increase confidence in the accuracy of the data.
The findings of this survey raise questions as to whether SHOs are getting the opportunities that are essential to learn their craft.11 While virtually all SHOs had attended theatre lists in the previous two weeks, they performed very little surgery; the mean number of full phakos performed was less than one a week and a quarter had had no surgical experience at all in the previous two weeks. In the context of this limited activity, the high level of consultant supervision—while reassuring for trainees and patients alike—cannot be taken as reflecting a major commitment to training on their part. The low levels of protected surgical teaching time in theatre may also indicate a limited commitment to training; in the previous two weeks almost a quarter of SHOs had no protected teaching time or cases, and only 15% had one fully protected operating list. With so little protected time or so few cases, SHOs struggle to gain adequate practical experience. Thus, less than half of those who should have completed basic specialist training (that is, those with more than 25 months' training) had actually performed the minimum number of full phakos required by the College. Difficulties in gaining adequate hands-on experience have been reported in other surgical specialties, where low levels of consultant supervision are common12,13 and where the need to meet targets (such as cancer waiting list objectives) or the demands of higher specialist training take priority over basic surgical training for SHOs.8,14,15
While in general surgery SHOs may gain greater experience working in district general hospitals than in teaching hospitals,16 in ophthalmology basic surgical training seems especially problematic in district general hospitals. The reason is not clear. Perhaps in district general hospitals there is a greater focus on achieving service targets and less recognition of the requirement to train young surgeons. With the further proliferation of diagnostic and treatment centres, some outside the NHS, that are dedicated to increased throughput,17 the tension between service and training may worsen. By providing rapid treatment for substantial numbers of patients requiring routine surgery, diagnostic and treatment centres are likely to make it more difficult for SHOs to get adequate surgical training even within the context of teaching hospitals.
Whatever the constraints on basic surgical training in ophthalmology, they do not disproportionately affect SHOs from ethnic minorities or those who trained outside the UK. A high proportion of SHOs in ophthalmology are in these categories but studies amongst other groups of junior doctors have yielded similar reassurance.18,19 By contrast women, a minority in ophthalmology as in other surgical specialties,9 are clearly disadvantaged with regard to basic surgical training. The reasons are not obvious, although studies of junior doctors in other specialties have suggested that women are more likely to be bullied than men20 and to feel inadequately trained for clinical tasks.18 The experience of women in basic surgical training clearly warrants further attention.
Overall, the study found that, in the context of a health service preoccupied by the need to meet growing demands to improve service provision and to address rising patient expectations, even a well organized, clearly described and straightforward programme of basic specialist training has not succeeded in ensuring adequate surgical training for SHOs. If this continues, it may prove difficult to train sufficient new surgeons to an adequate standard to meet the increasing demands an ageing population will bring. Minor improvements can be made on the ground, but surgical training is unlikely to improve substantially until NHS policies on service provision recognize and take into account the requirements for training new surgeons. This is not an issue for ophthalmology alone but for all surgical specialties.
We thank Alcon Laboratories for a grant of £7000 to cover the costs of conducting the study and for help in distributing questionnaires. Alcon Laboratories had no part in the design, conduct or analysis of the survey or the presentation of findings. Miss H C Seward provided helpful comments and support during the project.