Senior House Officer training: some myths exposed

P.A.HURLEY and S.PATERSON-BROWN
University Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, U.K.

A prospective study of general surgical experience obtained by 13 first year Senior House Officers (SHOs) in South East Scotland is presented. On average a Senior House Officer (SHO) operating as the principal surgeon performed 15 appendicectomies (range 7-26), 17 inguinal herniorrhaphies (range 7-42) and 17 varicose vein operations (range 5-33) over their first 12 months. The senior author, as a first year SHO in 1985, performed 23 appendicectomies, 36 inguinal herniorrhaphies and 18 varicose vein operations as the principal surgeon. The operative supervision of SHOs provided either by the Consultant or the Registrar varied widely between units despite a uniformity in available training operations. Clearly many opportunities are being lost within the region and greater organisation is necessary in some units to capitalise on existing training opportunities and thus optimise SHO training. In general, it is still possible, despite the reduction in working hours, for SHOs to receive similar operative experience now as was possible 13 years ago.

Keywords: SHO training, supervision, recommendations

J.R.Coll.Surg.Edinb., 44, October 1999, 324-7

INTRODUCTION

Surgical training has changed dramatically in the last five years. In the pre-Calman era an apprenticeship of long hours allowed a protracted exposure to clinical material and consequently the gradual attainment of surgical competence. Today, training is significantly shorter and, in addition to the constraints imposed by the implementation of the Calman Report¹ and the reduction in doctors’ hours², the cumulative effects of the Confidential Enquiry into Post-Operative Deaths³, waiting list initiatives and increased day-case surgery^4,5 have resulted in a continual erosion of training time and training opportunities. Whilst the long term consequences of these changes are speculative, this study, by documenting the operative experience of first year general surgical SHOs in South East Scotland and comparing them with the SHO experience 13 years ago, attempts to outline the short to medium term impact.

SUBJECTS AND METHODS

Senior House Officers on the South East Scotland Basic Surgical Training Scheme, and those in stand-alone posts, were asked to record prospectively for one year (February 1997-February 1998) all operations in which they were the principal surgeon. The grade of assistant in each case was documented. Three key operations were analysed in detail. Varicose veins and inguinal herniorrhaphy were selected to represent elective operative experience and open appendicectomy was selected as an emergency operation. The total number of each operation performed per unit was obtained from the Lothian Surgical Audit Database. Operative experience was then compared to the senior author’s experience collected prospectively as a first year general surgical SHO in 1985 and to levels of experience recommended in a recent paper by Crofts et al.⁶

RESULTS

The overall experience of the SHOs is shown in Table 1.

Table 1: SHO experience as the principal surgeon over 12 months

Operative Supervision

The level of operative supervision provided by consultants and registrars varied widely between units in South East Scotland (Figure 1). Consultants provided most of the SHO supervision, the highest level occurring in Hospital 4, unit 1. The level of operative supervision of SHOs attached to Hospital 4, unit 2 was lower than any other unit in the region. Furthermore, it is clear that registrars continue to make a significant contribution to the supervision of operations performed by the SHO, particularly in Hospital 2.

Figure 1: The number of operations assisted by the consultant or registrar in each unit, per SHO per month

Varicose Vein Surgery

SHOs obtained a wide range of experience in varicose vein surgery (Figure 2). Four out of the 13 SHOs exceeded both the recommended level of experience and the experience obtained by the first year SHO in 1985. However, three SHOs performed less than 9 varicose vein operations in 12 months. The average number performed by a SHO as the principal surgeon is 17 (range 5-33) and the recommended number of varicose vein operations to be performed in one year as principal surgeon is 21.⁶

Figure 2: The number of varicose vein operations performed by each SHO as the principal surgeon over 12 months. * Recommended number of operations.6 # Number of operations performed by the senior author as a first year SHO in 1985

Inguinal Herniorrhaphy

On average a SHO performed 17 supervised inguinal herniorraphies (range 7-42) in 12 months (Figure 3). The first year SHO in 1985 performed 36 inguinal herniorrhaphies and the recommended number for this operation is 20.6 This target is exceeded by three out of the 13 SHOs, while four performed less than 8 in 12 months.

Figure 3: Number of inguinal herniorrhaphies performed by each SHO as the principal surgeon in 12 months.  *Recommended number of operations.6 # Number of inguinal herniorrhaphies by the senior author as the principal surgeon in 1985

Appendicectomy

The average number of appendicectomies performed by an SHO in 12 months is 15 (range 7-26) (Figure 4). Five SHOs performed less than 10 open appendicectomies in 12 months while the SHO in 1985 performed 23 appendicectomies as the principal surgeon.

Figure 4: Number of appendicectomies performed by each SHO as the principal surgeon in 12 months. * Number performed by the senior author as the principal surgeon in 1985

Available Operations

Using Lothian Surgical Audit Database, the number of operations performed in each unit for the year 1997 for each of the three operations considered was determined. This figure was divided by the number of SHOs attached to that unit to obtain the number of operations potentially available per SHO attached to each unit (Table 2).

Table 2: The number of each operation performed in each unit between February 1997 and February 1998. The number of operations potentially available per SHO is shown

DISCUSSION

Surgical training remains a topical issue and it is clear that despite the recent changes, good training opportunities still exist for SHOs in South East Scotland. Whilst acknowledging that operative volume is not the primary indicator of surgical competence⁷ this study does allow a meaningful, although shorthand, vocabulary when commenting on training regimens and their impact.

What is striking is the fact that while the level of consultant supervision of SHOs attached to some units in South East Scotland is extremely good, other units, despite having an adequate number of training operations per SHO, were unable to provide similar levels of supervision. Similarly, the volume of operative experience obtained by SHOs over 12 months is extremely variable.

In South East Scotland, SHOs are, on average, approaching the target levels suggested in a recent paper by Crofts et al.⁶ Indeed, some exceed the recommended level, and the experience obtained by the senior author of this article as a first year general surgical SHO in 1985. These individuals highlight the potential training available and the commitment of both trainer and trainee in spite of the reduced working hours.

There remains, however, a concern regarding a number of SHOs who must be considered to have obtained inadequate operative experience after 12 months in general surgery. Such apparent deficits in SHO training must be addressed, as failure to do so will produce a cohort of inexperienced specialist registrars requiring increased consultant support. With the time available for training reduced by 60%⁸ and the long hours with maximal clinical exposure a thing of the past, the emphasis in SHO training today must be qualitative rather than quantitative. SHOs need to gain experience more quickly and efficiently and consultants must be prepared to play a pivotal role. The establishment of formal benchmarks of competency and levels of supervision to be achieved at key stages of SHO training should be an early goal. Once these are in place regular assessment of each unit should be instigated. Those units that consistently fail to meet these training targets should then have training recognition withdrawn.

CONCLUSION

This paper has demonstrated that all general surgical units in South East Scotland have adequate training opportunities for SHOs, but some are not fulfilling their potential. The way forward, as always, is a compromise. On the one hand, the service commitments must be met and on the other hand we must produce competent surgeons within the contracted training time available. What is needed is a commitment in every unit to reorganise and restructure the working environment to optimise those existing training opportunities. Failure to do so will have disastrous consequences on our future surgeons and any further reduction in hours of work should be accompanied by improvements in training.

REFERENCES

1. The Working Group on Specialist Medical Training. Hospital Doctors: Training for the Future. The report of the Working Group on Specialist Medica l Training (The Calman Report) London: Department of Health 1993
2. Downe R. Patterns of Hospital Medical Staffing: Interim Report. Junior Doctors’ Hours. London: British Postgraduate Federation 1989
3. Campling EA, Devlin HB, Hale RW, Lunn JN. The Report of the National Enquiry into Perioperative Deaths 1991/1992. London: The Royal College of Surgeons of England 1993
4. UK Health Depts, Joint Consultants Committee and Chairman of Regional Health Authorities. Hospital Medical Staffing:Achieving a Balance-Plan for Action. London: Department of Health 1993
5. Sharp RJ, Wellwood J.The training implications of day-case surgery. Br J Hosp Med 1996; 55(8): 472-5
6. Crofts TJ, Griffiths JM, Sharma S, Wygrala J, Aitken RJ. Surgical training- an objective assessment of recent changes for a single health board. BMJ 1997; 314(7084): 891-5
7. Savage PE. Competence assessment of senior house officers in general surgery. Ann R Coll Surg Engl 1995; 77(5 Suppl): 246-7
8. Bulstrode C, Holsgrove G. Education for educating surgeons. BMJ 1996; 312(7027): 326-7

Copyright date: 5th July 1999

Correspondence: Mr S Paterson-Brown, University Department of Surgery, Royal Infirmary, Lauriston Place, Edinburgh EH3 9YW, UK

©1999 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.,44; 5: 324-7