June Issue.indd

Registrar operating experience over a 15-year period: More, less or more or less the same?

G. Morris-Stiff, E. Ball, J. Torkington*, M.E. Foster, M.H. Lewis, T.J. Havard
Department of Surgery, Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, CF72 8XR, Rhonda Cynon Taf, *Department of Surgery, Llandough Hospital, Penlan Road, Penarth, Vale of Glamorgan, CF64 2XX

Correspondence to: T. Harvard, Department of Surgery, Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, CF72 8XR, Rhonda Cynon Taf

Background: Concerns have been raised on the effects that recent changes in junior doctor work patterns may have on the breadth and depth of operative exposure achieved during specialist registrar training. This study aimed to determine whether there was any justification for these concerns by assessing whether there have been significant changes in either the number of cases or the case mix operated upon by registrars over the course of the past fifteen years. Methods: A retrospective review of theatre records was undertaken, looking at the caseload of the registrars working for the same two consultant surgeons at one district general hospital in four one-year periods (1986-7; 1991-2; 1998-9; 2001-2). The number, subspecialty, and time of each operation were recorded. Results: Whilst operating experience for the first three periods of the study was static, the most recent assessment point has demonstrated a significant reduction in trainee routine operative experience and also a small reduction in the emergency workload performed by both firms. There was also a significant change in the elective case mixes corresponding to consultant sub-specialisation during this period. In addition, there were notable changes in the nature of the emergency workload and a reduction in the number of cases performed after midnight. Conclusion: SpRs trained during the Calman era appear to be gaining less operative experience than their predecessors in both the elective and emergency settings. With further changes in working patterns currently being implemented, major changes to SpR programmes are required if surgeons are to be adequately trained

INTRODUCTION
During the 1990s, changes in the philosophy of the provision of medical education and in the delivery of clinical care had the effect of dramatically changing the nature of postgraduate surgical training. Two of the most important changes were the introduction of the Calman Specialist Registrar (SpR) training grade (often termed Calmanisation) and the implementation of the New Deal on Junior Doctors Hours.^1,2 In addition, during the same time period, reports from CEPOD lead to a recommendation that out of hours emergency operating (after midnight) be minimised and that the number of unsupervised operations performed by registrars be dramatically reduced.³ The net effect of these changes has been a reduction in the number of years spent in surgical training together with a reduction in the intensity of on-call rotas with a subsequent reduction in emergency operative experience.

A previous study within our region reported that the mean post-registration training time of the current consultant cohort was 11.5 years, which included on-call rotas varying between one in one and one in four.⁴ This compares to a proposed duration of surgical training of nine years, three years in basic surgical training (BST) and six years in higher surgical training (HST) with a recommended on-call rota of one in five. As a result, 83% consultants felt that trainees of the Calman era would be inadequately trained and 64% feared that many future trainees would become ‘Junior Consultants’ in particular with regard to their competency in dealing with major emergencies. These fears have also been expressed on a National level.^5-6

The aim of this study was to ascertain whether there was any justification for these concerns by assessing whether there have been significant changes, in either the number of routine or emergency cases or the case mix operated upon by registrars, over the past 15 years.

METHODS
A retrospective review of theatre records was undertaken, looking at the caseload of the registrars working for the same two consultants at one district general hospital in four, one-year periods (1986-7; 1991-2; 1998-9; 2001-2), spanning a 12-year period. The periods were chosen as they had 100% data collection for all operations performed by each of the two firms.

The number of operations and subspecialty for each operation was recorded, as was the time of day that each procedure was performed. Procedures were also classified as to whether they were emergency or routine operations.

RESULTS
The number of elective and emergency operations performed by registrars attached to the two surgical firms over the four periods of study are sumarised in Figure 1. The primary findings of the study are that in the most recent period of assessment, the number of routine procedure performed by registrars on both teams was significantly reduced. This reduction was approximately 35% in the case of consultant A’s registrar and 44% for consultant B’s registrar. The number of emergency operations was relatively constant throughout the period of the study with a slight tailing off in numbers during the most recent assessment.

Figure 1: Elective and emergency operating experience for the two firms during the assessment points of the study

The effects of sub-specialisation on the operative casemix of consultants A and B are illustrated in Figures 2 and 3. Consultant A has seen a significant increase within the field of specialist interest, namely vascular surgery, and a compensatory decrease in the percentage of gastrointestinal and breast operations performed (Figure 2).

Figure 2: Distribution of casemix for consultant A demonstrating increased subspecialisation within vascular surgery

Similarly for consultant B, who has a gastrointestinal interest, the number of cases within this field have increased, whereas the number of vascular and breast cases have decreased (Figure 3). For both consultants, the general surgical procedures have remained relatively static. The combination of these two factors means that there is adequate ‘bread and butter’ general surgery to teach specialist registrars during their generic period of training and also enough subspecialist experience during their latter years on the rotation.

Figure 3: Distribution of casemix for consultant B demonstrating increased subspecialisation within colorectal surgery

There were no real changes in the nature of the emergency workload with similar numbers of laparotomies, appendicectomies and abscesses treated at the four assessment points. There was, however, a change in the indication for laparotomy with more peptic ulcer-related complications in the earlier years of the study than in the latter period, whilst the number of laparotomies for adhesive obstruction have increased.

There was a significant reduction in the percentage of operations performed after midnight, from 30% in 1986-7 to 19% in 1991-2, 10% in 1998-9, and 4% in 2001-2, in accordance with CEPOD guidelines.

DISCUSSION
When this study was initially conducted and presented at the Association of Surgeons meeting in 2001, the primary finding of the study was that Calmanisation did not appear to have affected the number of operations performed annually by registrars in training.⁷ However, the most recent assessment has shown that this is no longer the case and current trainees who have trained entirely in the new era perform significantly fewer operations per year than their predecessors. There are numerous reasons for this.

One of the main reasons for the drop in experience is a chronic shortage in healthcare expenditure. There are inadequate ward beds, high care facilities and insufficient nurses to cover the available beds leading to frequent cancellations of admissions and operations.

The reduced operative experience is not entirely the result of Calmanisation but, if the number of years spent in training is reduced in an environment where there are fewer operations performed per annum, then the overall trainee operative experience will be significantly impaired.

Whilst there is a body of evidence that demonstrates that emergency workloads, both operative and non-operative, have increased significantly over the past two decades, the total number of emergency operations has remained relatively static and if anything has decreased.⁸ There are two main reasons for this finding. Firstly, the CEPOD report of 1997 recommended that emergency surgery should not be performed after midnight unless the operation was felt to be a life-saving procedure and, thus, in the best interest of the patient. Secondly, the increased number of admissions is effectively cancelled out by the reduced frequency of on-call duties of current registrars.

This study is only the second to address the issue of variation in registrar operative experience over time. A previous publication by Boyle and Bentley (1996) studied registrar operative experience over an eight year period. They concluded that there have been no significant changes in either emergency or routine operative experience since the introduction of Calmanisation. This article included the time period surveyed by our initial three point study and, thus, may suffer the same changes should the data be updated.

A previous published survey that examined the training of current surgical consultants within the region demonstrated a significantly longer postgraduate training than experienced by the Calman trainees.⁴ The mean duration of training of current consultant appointees was 11.5 years, compared with a proposed period of nine years (three BST and six HST). Even when dedicated periods of off-service research are considered, two years in the old system and one year for Calman trainees, there is still a discrepancy of 1.5 years of clinical surgery. As a consequence of the reduced duration of training, 83% consultants felt that trainees of the future would be “Junior Consultants,” in particular with regard to their competency in dealing with major procedures and emergencies outside of their area of specialist interest. These concerns were particularly voiced in specialities with low caseloads of technically difficult surgery.

This discrepancy is more important for surgeons than for our physician colleagues as with increasing experience comes increasing complexity and increasing independence. This is in contrast to physicians where there is less acute intervention as they progress up the career ladder.

There are a number of possible solutions to this problem. One common proposal is for a period of post-CCST speciality training in nationally recognised posts. It is envisaged that these posts would be in centres of national or international repute and would be so designed that there would be no direct competition with existing specialist registrars for operating experience. Another attractive option would be an overseas sabbatical in recognised posts where there would be an opportunity to gain experience in the management of a small number of select conditions within the area of specialist interest.

There are also two distinct options that would contravene current guidelines. Firstly, for surgeons to opt out of the junior doctors deal on hours and the European Working Time Directive. This would allow surgeons to gain increased exposure to emergency surgery within a shorter period of time and, thus, ‘catch-up’ on the 1.5 years of surgical skills acquisition time which has been lost. Secondly, would be to increase the duration of training and reintroduce the concept of senior registrars or ‘speciality registrars’.

One significant change in the operative experience of the surgical registrars during the period of the study is the move towards sub-specialisation. The workloads of the two consultants studied revealed that both had shown significant changes in their case mix in favour of their areas of subspecialty interest, thus, making the posts more attractive for subspecialty training during years four to six years of higher surgical training. However, both also continued to perform a number of general surgical procedures, thus, satisfying the requirements of more junior trainees. As such, both posts were eminently suitable for postgraduate training at all levels of experience.

A further significant finding was that in keeping with the wishes of CEPOD, operating after midnight had been drastically reduced over the duration of the study. This has lead to an improved degree of supervision of complex emergency procedures by surgical trainees.

In conclusion, the study would suggest that SpRs in the Calman era are currently operating on less routine cases per year than their predecessors. The ‘out-of-hours’ workload is at present comparable, since despite the new rotas being less onerous, there has been a significant increase in the numbers of patients being admitted and treated as emergencies over the past two decades. Unless processes are put in place quickly to ensure otherwise, the implementation of the EWTD in 2009 may have a further detrimental effect on surgical training and leave future trainees without the cumulative operative experience of their predecessors.

REFERENCES
1. Calman KC. Hospital doctors: training for the future. The report of the working group on specialist medical training. London: HMSO, 1993.
2. NHS management executive. Junior doctors, the new deal. Working arrangements for hospital doctors and dentists in training. London: Department of Health, 1991.
3. Buck K, Devlin HB, Lunn JN. Report of a confidential enquiry into perioperative deaths (CEPOD). London: Nuffield Provincial Hospitals trust and King’s fund, 1987.
4. Morris-Stiff G, Clarke D, Torkington J, Bowrey DJ, Mansel R. Training in the Calman era: what the consultants have to say. Ann R Coll Surg Engl 2002; 84 (Suppl): 345-47.
5. Collins REC. Surgeons and the new deal - good deal or raw deal? Ann R Coll Surg Engl 1995; 77 (Suppl): 297-98.
6. Kirk RM. Teaching the craft of operative surgery. Ann R Coll Surg Engl 1996; 78 (Suppl): 25-28.
7. Ball E, Morris-Stiff G, Torkington J, Havard T. Calmanisation, consultant expansion, subspecialisation and the changes in operative experience over a 12 year period. British Journal of Surgery 2001; 88 (Suppl 1): 79-80.
8. Capewell S. The continuing rise in emergency admissions. BMJ 1996; 312: 991-92.
9. Boyle NH, Bentley PG. Trends in surgical registrar operative experience over the last eight years. Ann R Coll Surg Engl 2001; 83 (Suppl 2): 46-50.

Applications are invited for research grants (formally known as General Research Pump Priming Grants) for up to £6,000, from surgical trainees and recently appointed consultants who are Fellows/Members of the College in good standing.

Applications are invited from practitioners of surgery or dental surgery who have made a signi.cant contribution to the clinical and/or scienti.c basis of surgery. The courtesy title of Professor will be accorded to the individuals for the duration of the College year in which their lectures are delivered. Applicants must be Fellows/Members of the College, in good standing.

Awards & Grants Secretary
The Royal College of Surgeons of Edinburgh
Nicolson Street
Edinburgh
EH8 9DW

Tel: 0131 527 1618; Fax: 0131 527 1667
Email: h.walker@rcsed.ac.uk
www.rcsed.ac.uk/education