Please could you give a brief introduction to surgical training? At what point are trainees involved in operations?
Surgical training begins at an undergraduate medical student level where students are involved in operations to a minor degree, and educated using a combination of didactic and problem-based approaches.
Newly qualified doctors (often termed “house officers” in Europe and “residents” in North America) are involved to a degree in that period, but are mainly involved in ward level service provision.
Involvement in operations increases in a graduated manner, an approach for which we are always going to be indebted to William Halsted for introducing. North America and Europe differ in terms of the training thereafter.
In North America, residents enter a five year training program called residency during which they gain increasing exposure and involvement in surgical operations. During this period they go from “scrubbing into” operations and playing a limited role, to playing major roles as chief residents. They then undergo a specialist training period referred to as a fellowship, in which they are immersed in operations on virtually a daily basis and obtain enormous experience at performing operations. This is all done under close supervision.
Even after training and gaining a staff level position (i.e. consultancy in Europe) they are slowly introduced to increasingly complex procedures, rather than immediately starting on complex procedures as independent operators. Of course biologic diversity is such that realistically surgeons must aim to continue to learn on a lifelong basis.
Slight differences exist in Europe where the general pattern involves training as senior house officer for approximately two years, after which the trainee enters a higher specialist period of training lasting 4-6 years. Typically the trainee then undergoes a fellowship-style period of immersive training at the end of this period.
Although differences exist across European countries in respect of the precise duration of these intervals and the nomenclature utilized at each stage, the overall trend of graduated increases in intraoperative and perioperative responsibility is common to all programs.
At the University of Limerick, Graduate Entry Medical School we introduce medical students to operations as early as possible. A recent study of ours demonstrated that when students are embraced in an operating environment early in their undergraduate careers, this acts as catalyst for the generation of interest in surgery.
We have an intense postgraduate surgical training program that involves everybody from internship (equivalent to PGY 1 in the United States) “scrubbing up” and get involved in operations. With the support of the Royal College of Surgeons in Ireland and the local Health Service Executive, trainees are gradually advanced to a higher surgical training program in which they are primarily conducting operations, albeit in an entirely supervised manner. This is coupled with increasing perioperative responsibility such that the trainee surgeons are capable of bringing patients through the entire surgical care pathway, in as safe and efficacious manner as possible.
The overriding aim of the training program is to develop surgeons committed to upholding and delivering the highest standard of surgical care.
How did your research into the safety of trainee surgeons originate?
Operative surgery is primarily about achieving optimal outcomes in the safest manner possible. Thus, safety in training is always a primary concern and it follows that the safety associated with training future surgeons would stem from that.
Following my appointment as Chair of Surgery in the Graduate Entry Medical School (University of Limerick) I also became vice dean of postgraduate surgical education for the Royal College of Surgeons in the Mid-Western Region of Ireland. Both these positions meant that we develop a vision for surgical training for the Mid-Western region of Ireland.
Our vision is to continue contributing to the highest standard of surgical care internationally and in that context we developed a focus on the safety associated with resident/trainee involvement in surgery.
This was also a topic that was a source of much intensive discussion between the leader of the research project recently published (Dr Ravi Kiran), myself and the Chair of the Colorectal Surgical Department at the Cleveland Clinic (Professor Feza Remzi).
Thus it is crucial to get trainees involved in operations in a hands-on manner. This requires that they “scrub up” and get involved. If this is not achieved early on, then students, trainees, residents are distanced from the coal face of what it’s all about (the operative correction of a disease process) and thus loose interest in surgery in general. As this is essential it becomes important to formally confirm that trainee/resident involvement is in itself safe and not associated with increased rates of adverse outcomes.
Some might suggest that as the trainee’s activities are always controlled and directed by a supervisor that it goes without saying that they will be safe. That’s not necessarily the case when one considers the possibilities of unanticipated movements and the potential impact these could have.
The findings of this study are thus very reassuring as they now provide us mentors and surgical educators with a formal basis to continue to firstly involve trainees directly, and secondly to increase their activities (in a graduated manner) within operations.
What potential risks are there of having trainee surgeons involved in operations?
The main problem always lies in the possibility of unpredicted movements/maneuvers and activities. I have heard of procedures where simple activities such as inserting a port for laparoscopic surgery was followed by the port continuing into an organ/ blood vessel etc. These are incredibly rare events but could have catastrophic net results for the patient and have very harmful effects from an emotional perspective for the trainee.
Thus this study shows that overall, harmful events such as these do not occur at an increased frequency beyond the levels that occur in operations performed solely by trained surgeons.
There are additional risks that relate to the current climate in which health service demands are being met by provisions. Worldwide, contracting budgets and increasing infrastructural demands have meant that we have had to find ways of doing more with less. This is a problem everywhere but as with all problems and challenges it leads to opportunities.
Nevertheless it places pressures on systems and we have to operate more (aiming to ever improving safety outcomes). This means that the surgical educators must educate whilst at the same time meet the requirement of patients and the demands of process. This combination of factors places the educator under increasing pressure to achieve multiple goals and contemporaneously train the surgeons of the future.
How did you measure the safety of having trainee surgeons involved in operations?
The National Surgical Quality Improvement Program database was utilized to identify and group operations into those with and without resident/trainee involvement. Each group was then matched according to sex, age, specialty, surgical procedure and morbidity likelihood. In this manner the study ensured that both groups were comparable. The study then determined and compared the rate of complications occurring in both groups.
What did your results show?
The key finding was that the rate of complications associated with each group was comparable with exception of a slightly higher incidence of mild wound infections in the group with resident involvement. Thus, no difference was observed in the rate of major complications such as mortality (and several other events) between both group types.
How do your results compare with what was previously thought?
Numerous previous studies have examined the relationship between trainee involvement and a putative increase in rates of postoperative complications. The results have been conflicting due to variations in cohort sizes and statistical stringency.
In addition, several of these studies addressed the question of trainee involvement somewhat indirectly by using proxy measures associated with trainees, rather than directly comparing two groups in the manner conducted in Dr Kiran`s study.
The National Surgical Quality Improvement Program (NSQIP) database provides an enormous resource of information that in turn enables investigators directly tackle questions that heretofore were inadequately addressed.
NSQIP transcends the limitations of small cohort studies by providing data on a very large cohort of patients, thereby enabling a matching of groups for several variables. The latter point is crucial as the multivariate nature of postoperative complications requires such an approach to unraveling causative factors.
What impact do you think your research will have on the teaching of trainee surgeons?
We hope that it will continue to increase surgeon willingness to embrace resident/trainee involvement in cases. The data indicate that this should remain the case if not increase into the future.
Given that the safety of future surgery lies in the hands of the current trainees it is a responsibility of surgeons to act as educators of trainees and in so doing safeguard the highest standards of process and outcome for the future.
How do you think the future of surgical training, and its safety, will progress?
I think it should evolve and continue to improve from here. We now have formal data to support the continued involvement of trainees, and, moreover an expansion of their activities in a supervised context.
There is now increasing interest in educational topics such as that detailed in Dr Kiran`s manuscript. This highlights a shift in the direction of surgical education that is welcome and we would hope it will continue to develop.
Do you have any plans for further research into this area?
Yes, we have several research programs underway in the Graduate Entry Medical School and the 4i Centre for Interventions in Inflammation, Infection and Immunity (4i) that aim to facilitate and improve the education of surgical trainees/residents.
A study by one of our recently qualified medical students, Dr Eoin McCarthy, developed and optimized a technique for rendering the surgeon`s own point of view, for all individuals in the operating theatre to observe. This has a transformative effect and is a dramatic departure from the traditional operating environment, where the surgeon alone (and possibly one or two assistants) were able to visualize the operation. With our new approach the surgeon’s point of view is rendered on a screen which all can view and follow.
An additional study has been conducted by a surgical trainee, Dr Peter Coyle, who is developing a surgical educational nexus which provides an incredibly powerful educational platform from which our students and surgical trainees will learn. Although there are several interwoven layers to the nexus, one of the major features involves the utilization of state of the art 3D animation technology to render structures and operations in 3D.
Further published studies by Dr Kevin Culligan have transformed our understanding of colorectal surgical anatomy and led to the formation of an alternative surgical nomenclature that could be safer and more informative that classic nomenclature (see below).
The 4i Centre for Interventions in Interventions in Infection, Inflammation and Immunity was recently established under the directorship of Professor Colum Dunne as the research vehicle of the Graduate Entry Medical School in University of Limerick. One of the aims of 4i is to investigate better ways to improve patient safety and outcomes as they journey through the patient care pathway. 4i is committed to investigating all aspects of patient safety, including methods to enhance the safety of surgical training in general.
Would you like to make any further comments?
The results are highly reassuring on numerous levels. Although we could not directly measure the level of activity of residents in later years, the results generally indicate that increasing resident involvement in a graduated manner is safe and should continue to be developed.
Where can readers find more information?
They can find more information on our study: https://www.news-medical.net/news/20120822/Trainee-surgeons-in-operations-is-safe-according-to-new-study.aspx
They can find more information about our additional studies:
- Culligan K, Remzi FH, Soop M, Coffey JC. Review of nomenclature in colonic surgery - Proposal of a standardised nomenclature based on mesocolic anatomy. Surgeon. 2012 Mar 27. PubMed PMID: 22459667.
- Culligan K, Coffey JC, Kiran RP, Kalady M, Lavery IC, Remzi FH. The mesocolon: a prospective observational study. Colorectal Dis. 2012 Apr;14(4):421-8; discussion 428-30. doi: 10.1111/j.1463-1318.2012.02935.x. PubMed PMID: 22230129.
They can find more information on the University of Limerick: http://www.ul.ie/
About Prof Calvin Coffey
Professor Coffey qualified in medicine from University College Cork in 1998. He underwent basic surgical training in Cork University Hospital after which he completed a PhD in operative cancer biology in 2004.
He then entered and completed higher surgical training with a short fellowship in minimally invasive (laparoscopic surgery) in Barcelona and a further intensive laparoscopic fellowship in the Department of Colorectal Surgery at the Digestive diseases Institute, The Cleveland clinic, Ohio.
He took up his current position as the Foundation Chair of Surgery at the Graduate Entry Medical School in University of Limerick, Ireland, where he is consultant colorectal/general surgeon with the Mid-western Regional Group of hospitals (Health Service Executive).
Subsequently he became secretary for the Irish Association of Coloproctology, Vice-Dean of Postgraduate Surgical Education of the Mid-Western region of Ireland, under the Royal College of Surgeons in Ireland, and deputy director of the 4i Centre for Interventions in infection, Inflammation and Immunity.
Professor Coffey has several national and international wards including the James IV Fellowship, The Millin Lecture and more recently was awarded an Enterprise Ireland / Cleveland Clinic feasibility award.
Author of over a 100 publications his clinical interests are colorectal cancer, laparoscopic and robotic colorectal surgery, inflammatory bowel disease and functional pelvic disorders.
His educational interests lie in generating modalities for undergraduate surgical education, developing simulator technologies and audiovisual technologies for postgraduate and consultancy level surgical training, and operative techniques in general.
His scientific interests are the application of computational bioinformatic techniques to surgical diseases, characterizing microbial ecology in surgical disease and in normality, better characterizing surgical anatomy and nomenclature.
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