Surgical Logbook Research Paper

7/28/2019 Surgical Logbook Research Paper

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C O M P A R I S O N O F S H O

S U R G I C A L L O G B O O K S

A G E N E R A T I O N A P A R T

RL Thomas ST3 in General Surgery, St Georges Hospital, London

N Karanjia Consultant Hepatopancreaticobiliary Surgeon, Royal Surrey County Hospital,

Guildford

There is current concern regarding

operative experience obtained by

senior house officers (SHOs) during

basic surgical training prior to

beginning registrar level.1,2

Anecdotally, working hours are

greatly reduced compared to 20

years ago. The reduction in

experience is attributed to the New

Deal, which was introduced by the

Department of Health in 1991 to

improve working conditions fordoctors, primarily through reduction

of working hours to 76 per week

maximum by 1996. In addition,

Calmanisation, ie the introduction of

the specialist trainee registrar grade

of training, and the recent

introduction of the European

Working Time Directive (EWTD)

have both had an effect on juniors

working hours.

Ann R Coll Surg Engl

(Suppl) 2009; 91:356359

Comparison of working patterns

We compared the general surgical

logbooks of two surgical SHOs from the

mid 1980s and the mid 2000s (20 years

apart) in the same training centre. The

first trainee appointed (surgeon A) had

full training in general surgery and is now

a professor of hepatobiliary surgery; the

second, (surgeon B) is a registrar-level

ST3 trainee in general surgery, equivalent

to first-year surgical registrar. Surgeon A

qualified in June 1983 and worked as anSHO in general surgery on two firms

during two periods: January 1986 to July

1986 (vascular, breast, endocrine and

general surgery) and July 1987 to January

1988 (upper gastrointestinal (GI),

colorectal and general surgery), a total of

12 months. During this period trainee A

followed a 1-in-2 on-call rota working for

two consultants for each six-month

period. In addition there was on each firm

a senior registrar and a registrar.

Surgeon B qualified in August 2003 and

worked in the same centre as an SHO in

general surgery between February 2006

and November 2007. During this time he

rotated through: hepatobiliary (three

months), breast (six months), colorectal

(seven months), upper GI (three months).

There was also a three-month period

spent as an intensive care clinical fellow.

During this basic surgical training scheme,

a roughly 1-in-6 partial-shift rota wasfollowed, compliant at band 2b with a

maximum of 48 hours per week. Surgeon

B worked a total of 19 months as a

general surgical SHO.

With regards to examinations, surgeon A

obtained primary FRCS in February 1985

and final FRCS in May 1987 (London)

after six months of general surgical SHO

posts, whereas surgeon B obtained MRCS

in October 2006 (intercollegiate/London)

after nine months of similar posts. See

Table 1 for a comparison of working

patterns for both surgeons.

Comparison of logbooks

The use of electronic logbooks is now a

requirement for all surgical trainees. The

logbook used by surgeon B is theAssociation of Surgeons of Great Britain

and Ireland (ASGBI) logbook available on

the Intercollegiate Surgical Curriculum

Project (ISCP) website: www.iscp.ac.uk.

This logbook allows a great deal of data

storage per operation, including American

Society of Anaesthesiology (ASA) grading,

National Confidential Enquiry into Patient

Outcome and Death (NCEPOD) rating,

time of operation and level of

supervision. It also allows the trainee to

revisit and edit the page to enter any

complications that may have occurred.

The named trainer can also be recorded

and there is a facility for free text to add

any additional, relevant information.

The electronic logbook also allows the

trainee to show activity for any periods in

the form of a spreadsheet and allows

consolidation of each type of operation

and levels of supervision for operations in

each specialy. In contrast, the logbook ofsurgeon A is unusual in that it exists at

all, logbooks being uncommon in surgery

until relatively recently. The form is a

Collins A5 notebook recording the names

and hospital number of each patient. A

note is made of other members of the

team, at that time constituting consultant,

DOI: 10.1308/147363509X475781
http://www.iscp.ac.uk/http://www.iscp.ac.uk/


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THE ROYAL C OLLEGE OF SU RGEONS OF ENGLAND B U L L E T I N

senior and junior registrars. There is no

mention of the level of supervision and

only operations performed by surgeon A

with trainer scrubbed or unscrubbed are

recorded. For each case, neither ASAgrading, nor NCEPOD rating, nor an

indication of the time of operation is

recorded.

Differing volumes of operative

experience

The numbers of operations from each

logbook were collated and compared.

Distinctions were made between pre and

post-membership/fellowship operating for

each surgeon. Hernia repairs, closure of

colostomy or ileostomy andcholecystectomy (open or laparoscopic)

have been used as examples of elective

surgery. Appendicectomy, abscess drainage

and laparotomy (right hemicolectomy,

perforated duodenal ulcer, adhesiolysis

and small bowel resection) have been

used to demonstrate volumes of

emergency operating. Total numbers of

emergency and elective operations

performed have also been recorded. For

the purposes of this comparison, the six-

month periods either side of obtaining

the MRCS/FRCS will be compared; this is

intended to give a direct comparison of

equivalent periods in each of the two

surgeons training.

There are clear discrepancies in operative

experience between now and 20 years

ago in both elective and emergency

operating. Of the elective case numbers

compared, the number of cases 20 years

ago has fallen by over three-quarters

(80 vs 18, see Table 2). For inguinal hernia

repair the operations carried out has

fallen by 82%. The largest differences lie in

comparisons made after obtaining the

FRCS or MRCS diploma. Surgeon A

performed 32 post-FRCS hernia repairs

whereas surgeon B performed only 6,

82% fewer than 20 years ago. This

difference is also reflected in the number

of cholecystectomies performed 20 years

apart, the contemporary figure being

reduced by a factor of 95%.

These discrepancies may be partly

explained by the introduction of

laparoscopic techniques for both

cholecystectomy and hernia repair. It may

also be explained by the fact that both

surgeons worked in a hospital that is now

a major training centre for laparoscopic

surgical training with associated reduced

junior trainee opportunities.

Furthermore, surgeon A performed seven

common bile duct explorations as an

SHO whereas surgeon B performed

none.

With regards to emergency operating the

differences are similar and again weighted

in favour of surgeon A (see Table 3).

Surgeon A performed a total of 70

appendicectomies as an SHO compared

TABLE 1

COMPARISON OF WORKING PATTERNS BETWEEN SURGEONS A AND B

Surgeon A Surgeon B

Time in general surgery (months) 12 19

Specialities (months) Vascular/breast: 6 Hepatobiliar y: 3Upper GI/Colorectal: 6 Breast: 6

Colorectal: 7Upper GI: 3

Type of rota On call Partial shift

On calls 1:2 1:6

Hours per week (approx) 100120 48 (approx)

Banding n/a 2B

MRCS or FRCS May 1987 October 2006

Time pre-membership 6 months 9 monthsTime post-membership 6 months 10 months

TABLE 2

COMPARISON OF ELECTIVE OPERATING

Surgeon A (19851987) Surgeon B (20062007)

Pre-FRCS Post-FRCS TOTAL Pre-MRCS Post-MRCS TOTAL

Inguinal hernia 3 32 35 5 1 6

Femoral hernia 2 2 4 0 0 0

Other hernia 1 4 5 6 3 9

Closure of stoma 0 5 5 0 2 2

Cholecystectomy 2 22 24 0* 1** 1

Common bile duct exploration 0 7 7 0 0 0

Total 8 72 80 11 7 18

(only shown where performed with trainer scrubbed or unscrubbed, first and second assistant cases not shown)

*Assisted at 15 laparoscopic cholecystectomies**Assisted at 17 laparoscopic cholecystectomies


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to 4 for surgeon B, a difference of over

90%. The numbers pre and post-

membership were similar for both

surgeons. For incision and drainage of

abscesses, the figures were more similar

(12 vs 7). There are further differences

with regards to exploratory laparotomy,

right hemicolectomy, duodenal ulcer

oversew, adhesiolysis and small bowel

resection, perhaps not normally

considered as SHO operations. Surgeon

A performed 6 laparotomies in total as an

SHO, compared with only 1 for surgeon

B. The numbers themselves are low for

both surgeons though again reflect a

significant difference in experience

between the two eras.

Discussion

Surgical training has undergone a number

of changes in recent years. Since the

introduction of the EWTD in 2000, junior

doctors hours of work have decreased.

Since August 2004 the limit has been 56

hours per week and in August 2009 the

limit has been reduced to 48 hours per

week.3

This is very different from the 1980s

when junior doctors were often expected

to provide up to 100 hours per week,

with the result that the quality of training

and quantity of experience was high,

involving a great deal of exposure at SHO

level and beyond. During this time of

course, trainees were able to take

advantage of a wide range of training

opportunities as well as private study

time while at work. Prior to

Calmanisation and the EWTD a surgical

trainee could work approximately 30,000

hours between SHO and consultant

level.4 This has fallen to an estimated

8,000 hours and is thought likely to fall

further to 6,000 hours as the EWTD

takes full effect.4

There is evidence that the directive and

the New Deal have been detrimental to

the training of surgeons.1,2 Gurjar

showed that pre-Calman, the percentage

of cases in which a basic surgical trainee

(ie SHO) was the principal surgeon was

32%, rising to over 35% early inCalmanisation but falling to under 20% in

the post-Calman era (20012002).2 More

specifically, the rate of completed

appendicectomy during this period fell

from 60% to under 40%.

Simultaneously the proportion of non-

career grade surgeons performing

emergency operations rose sharply from

under 15% pre-Calman to over 40% post-

Calman. These changes have also been

reflected in outpatient clinic experience in

a similar fashion.1 Furthermore, these data

were echoed for inpatient operations

where of the 458 procedures carried out

during a study there was a fall of 34% in

the proportion in which an SHO was

present after the implementation of the

full-shift rota. Perhaps surprisingly, the

number of emergency operations at

which an SHO was present was

unchanged.1 What is perhaps most

disconcerting is that in this study the

full-shift rota was found to be compliant

at 52 hours per week significantly

more than the current limit of 48 hours

in effect from August 2009.

In a similar study analysing SHO operating

over an eight-year period between

February 1997 and February 2005,

elective operating experience for SHOs

fell by 31% in ENT, 65% in general and

vascular surgery, and 68% in urology.5 This

was despite the numbers of SHOs in the

specialties remaining unchanged duringthe period studied. For our operative

examples for surgeons A and B the fall

was 77%, which is in keeping with data in

the other studies.

Proposed solutions?

There is compelling evidence that the

introduction of dedicated consultant-led

training lists can ameliorate the erosion of

operating opportunities, as recently

demonstrated by Beaton.6 This study

demonstrated that during a six-month

period in which operative training lists

were arranged for SHOs or house officers

the average number of inguinal hernia

repairs performed by SHOs rose from 1 to

5 (range 115), appendicectomies rose

from 2 to 6 (range 119) and total

TABLE 3

COMPARISON OF EMERGENCY OPERATING, APENDICECTOMIES AND ABSCESS DRAINAGE

Surgeon A (19851987) Surgeon B (20062007)

Pre-FRCS Post-FRCS TOTAL Pre-MRCS Post-MRCS TOTAL

Appendicectomy 38 32 70 3 1 4

Abscess drainage 7 5 12 6 1 7

Laparotomy: right hemi 0 3 3 0 1 1

Laparotomy:

DU oversew 0 1 1 0 0 0

Laparotomy:

adhesiolysis 0 1 1 1 0 1

Laparotomy:

SB resection 1 3 4 0 0 0

Total 46 45 91 10 3 13

(Only cases performed with supervisor scrubbed or unscrubbed shown)


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operative experience from 47 to 74 (range

30149). The institution of the supervised

training list restored basic surgical training

experience to pre-Calman levels while

preserving rota compliance.

In addition to this there is early evidence

that surgical training in treatment centres

may provide a valuable source of elective

theatre experience for trainees as shown

by Macleod in an encouraging recent

study.7 Similarly, the issue of surgical

training and the EWTD is being

addressed by the realisation that surgical

education must undergo radical changes

in order to maintain high standards of

trainees through maximising availableopportunities. An example of this has

been demonstrated by Allum and

Markham, whereby the new surgical

curriculum laid out in the ISCP

(www.iscp.ac.uk) can be incorporated

into a pattern of training for junior

surgical trainees.8

During this model, specialist trainee

registrar years 2 and 3 would rotatethrough emergency surgery, general

surgery and day surgery for varying

lengths of time essentially following a

modular system. At more advanced

levels, ie specialist trainee/registar years 5

to 8, the model would be maintained,

giving a progressive advancement in the

level of the trainee according to the

landmarks of the ISCP while exposing the

trainee to scheduled emergency surgery.

The bulk of the time at these stages

would be in subspecialty training predominantly elective activity although

it would appear that dedicated, supervised

training lists are vital in ensuring a good

level of experience is obtained by the

trainee.

References1. Marron CD, Byrnes CK, Kirk SJ. An EWTD-compliant

shift rota decreases trainining opportunities. Ann R Coll

Surg Engl (Suppl) 2005; 87: 24648.

2. Gurjar SV, McIrvine AJ. Working time changes: a raw

deal for emergency operative training. Ann R Coll Surg(Suppl) 2005; 87: 14041.

3. Department of Health. HSC 2003/001 - Protecting staff;

delivering services: implementing the European Working

Time Directive for doctors in training. London: Crown

copyright; January 2003.

4. Chikwe J, de Souza AC, Pepper JR. No time to train

the surgeons. BMJ 2004 Feb 21; 328: 41819.

5. Varley I, Keir J, Fagg P. Changes in caseload and the

potential impact on surgical training: a retrospective

review of ones hospital experience. BMC Medl Educ

2006 Jan 18; 6: 6.

6. Beaton C, Hopper AN, Morgan MA et al. Influence of

targeted basic surgical training lists on SHO operative

experience in the EWTD era. Ann R Coll Surg Engl(Suppl) 2007; 89: 21416.

7. Macleod S, Black J. Surgical training in a treatment

centre. Ann R Coll Surg Engl (Suppl) 2005; 87: 31617.

8. Allum WH, Markham NI. Surgical training and EWTD

can it be done? Ann R Coll Surg Engl (Suppl) 2007; 89:

2069.
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Surgical Logbook Research Paper