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Published Online 29 September 2016

Maximising learning opportunities in the time available for surgical training

Publication: The Bulletin of the Royal College of Surgeons of England
Volume 98, Number 9

Abstract

The results of a Health Education England Better Training Better Care pilot.
Better Training Better Care (BTBC) is a Health Education England (HEE) initiative to improve the quality of training and learning for the benefit of patient care by delivering the key recommendations from Sir John Temple’s Time for Training1 and Professor John Collins’ Foundation for Excellence.2 These include the recommendations that ‘service delivery must explicitly support training’ and to ‘make every moment count’.1
Technical skill acquisition is an essential part of surgical training, but there has been a gradual decline in the amount of operative training delivered, and discussion about the time needed to train a surgeon.3 Training opportunities have been lost owing to the reduction in hours for working, complexities of rotas and competing pressures on trainees’ time. There is ongoing debate about the impact of the European Working Time Directive (EWTD) on training4,5 and whether trainees have enough experience.6 Some of the reduction in operative training may be offset by innovative training methods and simulation, but workplace-based training in operative surgery is essential for competence progression to independent practice. Efforts to deliver more effective training within the time available are therefore of paramount importance.1
This study reports on one of the sixteen BTBC pilots selected by HEE. The aim of the pilot was to improve delivery of operative core surgical training by maximising learning opportunities using existing resources in the time available for training.

METHODS

The University Hospital of South Manchester (UHSM) made a successful bid to HEE to run a BTBC pilot with the trust board support. A postgraduate administrator (AS) in the Department of Postgraduate Medical Education was appointed to help develop and run the pilot. A clinical lead (DJ) and consultant champions for each surgical specialty within the trust were identified. Trainers were asked to protect a proportion of their operating lists for core surgical training (BTBC lists) with trust board support. The number varied between specialties and over time, but the aim was to protect approximately one in eight lists for each participating consultant surgeon for core surgical training.
Trainees were asked to include participation in the BTBC pilot in their Learning Agreements. BTBC lists were timetabled up to three months in advance. Assigned educational supervisors and clinical supervisors agreed these dates with their trainees. If a core surgical trainee (CST) was unable to attend a BTBC list, the opportunity was offered to another CST in the same specialty or occasionally to a trainee in a different specialty. The postgraduate administrator ensured that BTBC lists were identified, matched to CSTs and liaised with relevant hospital management to maintain support for the agreed lists.
Health Education North West (HENW) supported the project and received progress reports that were submitted to the Core Surgical Training Committee and Board of the School of Surgery. Reports were also sent to the pilot site trust board. The methodology and development of the BTBC pilot were approved and monitored by HEE.
A BTBC list was trainee-led from admission to discharge, with a consultant providing supervision throughout. The CST saw and examined the patients and completed the admission formalities before taking charge of the team brief and use of World Health Organization (WHO) checklist. Operations were completed with a consultant supervisor in the operating theatre, either scrubbed or unscrubbed. A workplace-based assessment (WBA) was completed on the Intercollegiate Surgical Curriculum Programme (ISCP) after each procedure or at the end of the list. Operations were designated as training cases when there was a consultant Supervised Trainer Scrubbed (STS) or a Supervised Trainer Unscrubbed (STU). A few procedures were performed as an Observation of Teaching (OOT), with a consultant trainer observing a specialist registrar acting as the STS and completing the WBA with a CST. Operations were recorded in trainee logbooks and the proportion of training cases (STS or STU) calculated as a proportion of the total number of cases entered during the study period. Operations performed without supervision or as an assistant were not considered as training cases for the purposes of this study. The clinical involvement of CSTs was identical to that for patients on non-BTBC lists and was viewed as a change in the organisation of practice and training, rather than a change in the nature of training.
Data for the pre-BTBC year (August 2011–July 2012) were compared with BTBC Year 1 (August 2012–July 2013) and BTBC Year 2 (August 2013–July 2014). Data between these groups were compared using a chi-squared test. For plastic surgery, data were only obtained for the first six months of the pre-BTBC year, owing to inconsistencies in staffing in the second half of that year.
In general surgery the time taken to complete an open inguinal hernia repair during BTBC Year 1 on a BTBC list was compared with the time taken on a non-BTBC list. These data were compared using a two-tailed Student t-test.
The educational value of the BTBC lists was assessed using a modified mini Surgical Theatre Educational Environmental Measure (miniSTEEM),7 omitting five questions not relevant to the evaluation of dedicated operative training lists.
Returns to theatre, readmissions, patient complaints and the Hospital Incident Reporting Service (HIRS) were monitored.
The project was subject to independent external evaluation by Matrix Knowledge on behalf of HEE.8

RESULTS

Consultant surgeons in general surgery, trauma and orthopaedics, breast surgery and plastic surgery provided BTBC lists for the duration of the study period and had consistent numbers of CSTs in post. A total of 139 protected BTBC lists were delivered during BTBC Year 1 and BTBC Year 2. Twenty-three planned lists did not take place or did not fulfil the criteria of a BTBC list for a variety of reasons. Otorhinolaryngology and urology did not participate at the start of the study period but have subsequently started to deliver BTBC lists so do not have equivalent data for analysis. Vascular surgery underwent changes in personnel that precluded inclusion in the study. Cardiothoracic surgery necessitated a different approach, owing to the complexity of the surgery performed, so is not included in this analysis.
There were significant improvements in both the absolute numbers and proportion of cases completed with supervised training (STS and STU) for general surgery, trauma and orthopaedics, breast surgery and plastic surgery (Table 1).
Table 1 Training operations (STS or STU) and non-training operations for different surgical specialties in the pre-BTBC year compared to BTBC Year 1
General surgery (4 CST posts)Non-training operationsTraining (STS and STU) operations
Pre-BTBC year640 (80%)163 (20%)
BTBC Year 1492 (67%)242 (33%)
Chi-squared test is 31.7, p< 0.01
Plastic surgery (3 CST posts)  
Pre-BTBC year170 (83%)35 (17%)
BTBC Year 1278 (62%)174 (38%)
Chi-squared test is 29.8, p< 0.01
Trauma and orthopaedics (2 CST posts)  
Pre-BTBC year21486(29%)
BTBC Year 1228156 (41%)
Chi-squared test is 10.5, p< 0.01
Breast (1 CST post)  
Pre-BTBC year547 (93%)43 (7%)
BTBC Year 1285 (78%)79 (22%)
Chi-squared test is 41.9, p< 0.01
BTBC lists were shown to be a strongly positive education experience, with an overall mini-STEEM score of 38 (>2 standard deviations above midpoint of 27).
None of the patients on a BTBC list in BTBC Year 1 required readmission or a return to the operating theatre. There were no complaints or patient safety incidents relating to a BTBC list recorded on the Hospital Incident Reporting System in BTBC Year 1.
It took longer to complete an open inguinal hernia repair on a BTBC list (n= 24) compared with the time taken on a non-BTBC list (n= 96) in BTBC Year 1. The mean recorded operating time in the theatre data system was 89 (range 60–121, standard deviation = 19) minutes on a BTBC list compared with 74 (range 38–131, standard deviation = 20) minutes on a non-BTBC list (t value is 3.29, p< 0.01). A similar number of open inguinal hernias were performed in the department in the pre-BTBC year (n= 111) and BTBC year 1 (n=120).
The improved delivery of training observed in BTBC Year 1 was sustained in BTBC Year 2 for general surgery, trauma and orthopaedics and plastic surgery (Table 2). Owing to the absence of a CST in breast surgery for BTBC Year 2, sustainability data were not obtained.
Table 2 Training operations (STS or STU) and non-training operations in the pre-BTBC year compared to BTBC Year 2
General surgery (4 CST posts)Non-training operationsTraining operations (STS or STU)
Pre-BTBC year640 (80%)163 (20%)
BTBC Year 2442 (66.5%)223 (33.5%)
Chi-square test is 32.9, p<0.01
Plastic surgery (3 CST posts)  
Pre-BTBC year170 (83%)35 (17%)
BTBC Year 2414 (61%)263 (39%)
Chi-squared test is 33.4, p<0.01
Trauma and orthopaedics (2 CST posts)  
Pre-BTBC year214 (71%)86(29%)
BTBC Year 2320 (62%)200 (38%)
Chi-squared test is 8.03, p< 0.01  

DISCUSSION

This study shows that by protecting a small proportion of operating lists for core surgical training, it was possible to deliver and maintain significant improvements in the operative training delivered to core surgical trainees (CSTs). This was achieved using the existing resources and personnel within normal working hours and was shown to be a strongly positive educational experience.
The trainees at UHSM were already receiving supervised training in accordance with the ISCP. The BTBC pilot delivered more organised as opposed to ad hoc training lists, resulting in better use of the learning opportunities in the time available. The levels of supervised training in the pre-BTBC year at the BTBC pilot site have not been compared to other trusts, so it is not known if the data from the BTBC pilot site were representative of the delivery of training elsewhere. The intervention of protecting a proportion of existing lists for operative training, however, had a significant enough impact to improve the delivery of training. It is possible that CST posts elsewhere may already be delivering high levels of supervised training but, if not, protecting a proportion of existing service lists for training is a simple intervention to adopt.
There was a reduction in the proportion of operations when a CST assisted a consultant. Assisting or observing a more senior surgeon is a recognised part of learning, but such involvement may be of limited educational value. Prioritising the allocation of CSTs to BTBC lists meant they attended fewer operations where they fulfilled a service commitment with no formal training.
Better training has been shown, but better care was more difficult to demonstrate. Studies have previously shown that in selected patients with appropriate supervision outcomes are satisfactory.9 The procedures performed by CSTs are associated with a low morbidity, so it was unlikely that a significant change in morbidity would be observed. As a surrogate marker of care, none of the patients on BTBC list required a return to theatre or readmission. None of the procedures resulted in a patient complaint or safety incident on the Hospital Incident Reporting System (HIRs).
It was perhaps not surprising to find that operations performed by supervised CSTs took slightly longer to complete, reinforcing the need to make time for training.10 The significance of the additional time taken for training in terms of service delivery is unclear as the throughput for the measured operation (open inguinal hernia repair) was maintained. The additional time taken may not have been sufficient to reduce overall productivity. There may have been some natural bias to populate BTBC lists with suitable cases and thereby maintain throughput of such index cases. It was noted that once established some waiting lists were soon depleted of suitable cases.
The appointment of a Postgraduate Administrator to provide support for the pilot was essential. The administrator’s determination and efforts ensured that both trainers and trainees delivered BTBC lists. Even the most committed consultants on occasion needed encouragement to fulfil their commitment to agreed BTBC lists.
BTBC lists comprised only a minority of a trainee’s timetabled training. The emphasis on delivering these lists may have resulted in an overall increase in commitment to CSTs, which motivated the wider delivery of training to these trainees – although this effect is difficult to measure.
Trust board support was vital to demonstrate the importance attached to the delivery of training. The results of the BTBC pilot have been presented to the trust board, who continue to support the initiative and have agreed to embed the principle of this BTBC pilot for operative training as part of service delivery.
A healthcare system such as the NHS has a responsibility to train the next generation of surgeons to deliver safe patient care. Trusts receive funding for training through a nationally agreed educational tariff,11 but this is usually absorbed into the organisation and is not evident at the point of delivery. Trusts have robust targets to meet relating to service delivery but do not have similar targets for their educational responsibilities. This study shows that service delivery can support the delivery of operative surgical training as proposed in Time for Training.1 It would be feasible to develop educational targets for the delivery of training that could be monitored as part of the commissioning arrangements for service provision by liaison between Local Education Training Boards (LETBs) and commissioners. This would embed training as part of service delivery. An alternative approach would be to separate training and service delivery, which may be feasible but would require a more radical reorganisation of the workforce.
This pilot has been identified by HEE in BTBC Phase 2 as suitable for adoption following independent assessment by Matrix Knowledge on behalf of HEE .8 Further details about the business case and ‘Top Tips’ to adopt this BTBC pilot are available online.12
In conclusion, this study shows that it is feasible to increase the delivery of operative surgical training using existing resources and within the time available for work and training. This BTBC pilot shows that service delivery can support training by trying to make every moment count1 and is a model that is transferable to other medical specialties.

References

1.
Temple J. Time for Training. May 2010. http://hee.nhs.uk/healtheducationengland/files/2012/08/Time-fortraining-report.pdf [last accessed 8 September 2016]
2.
Collins J. Foundation for excellence. An evaluation of the Foundation Training Programme. October 2010. www.agcas.org.uk/assets/download?file=2053&parent=793 [last accessed 8 September 2016]
3.
Jackson GP, Tarpley J. How long does it take to train a surgeon? BMJ 2009; 339: b4260.
4.
Royal College of Surgeons of England. The implementation of the working time directive, and its impact on the NHS and health professionals. Report of the independent working time regulations taskforce to the Department of Health. March 2014. https://www.rcseng.ac.uk/policy/documents/wtd-taskforcereport-2014 [last accessed 8 September 2016]
5.
Fitzgerald JEF, Caesar BC. The European Working Time Directive: A practical review for surgical trainees. Int J Surg 2012; 10: 399–403.
6.
Thomas C, Griffiths G. Abdelrahman T et al. Does UK surgical training provide enough experience to meet today’s training requirements? 11 May 2015. http://careers.bmj.com/careers/advice/Does_UK_surgical_ training_provide_enough_experience_to_meet_today%E2%80%99s_training_requirements%3F
7.
Nagraj S, Wall D, Jones E. The development and validation of the mini-surgical theatre educational environment measure. Med Teach 2007; 6: e192–197.
8.
Health Education England and NHS Employers. Better Training Better Care. 2015. https://hee.nhs.uk/our-work/hospitals-primary-community-care/learning-be-safer/bettertraining-better-care-btbc [last accessed 8 September 2016]
9.
Kelly M, Bhangu A, Singh P et al. Systemic review and meta-analysis of trainee versus expert surgeonperformed colorectal resection. BJS 2014; 101: 750–759.
10.
Wilson T, Sahu A, Johnson DS, Turner PG. The effect of trainee involvement on procedure and list times: A statistical analysis with discussion of current issues affecting orthopaedic training in UK. The Surgeon 2010; 8: 15–19.
11.
UK Government. Education and training tariffs. Tariff guidance for 2015–16. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/411897/Tariff_guidance.pdf [last accessed 16 September 2016]

Information & Authors

Information

Published In

cover image The Bulletin of the Royal College of Surgeons of England
The Bulletin of the Royal College of Surgeons of England
Volume 98Number 9October 2016
Pages: 418 - 422

History

Published online: 29 September 2016
Published in print: October 2016

Authors

Affiliations

Zeiton Moez
Specialist Registrar in Trauma – Orthopaedics
Department of Surgery, University Hospital of South Manchester, Southmoor Road, Manchester
Coe P
Registrar in Surgery
Department of Surgery, University Hospital of South Manchester, Southmoor Road, Manchester
Derbyshire LF
Specialist Registrar in Urology
Department of Surgery, University Hospital of South Manchester, Southmoor Road, Manchester
Haque A
Consultant in General and Colorectal Surgery
Department of Surgery, University Hospital of South Manchester, Southmoor Road, Manchester
Pollard JS
Specialist Registrar in Urology
Department of Surgery, University Hospital of South Manchester, Southmoor Road, Manchester
Siddiqui A
Postgraduate Administrator
Department of Postgraduate Education, University Hospital of South Manchester
Bell A
Core Surgical Teaching Coordinator, Health Education North West
Department of Postgraduate Education, University Hospital of South Manchester
Jones D
Consultant General and Colorectal Surgeon
Department of Surgery, University Hospital of South Manchester, Southmoor Road, Manchester

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