JRSM >
Volume 97, Number 4 >
Pp. 174-178
1 Imperial College London, Hammersmith Hospital, Du Cane Road, London W12
0NN
2 Social Sciences and Law, Oxford Brookes University, Oxford OX3 0BP
3 Radcliffe Infirmary, Oxford OX2 6HE
4 Academic Unit of Ophthalmology, Division of Immunity and Infection, University
of Birmingham, Birmingham B18 7QU
5 Department of Ophthalmology, Imperial College London, Charing Cross Campus,
London W6 8RP, UK
Correspondence to: Professor Alistair Fielder, Department of Ophthalmology,
Imperial College London, Room 9L02, Charing Cross Campus, St Dunstan's Road,
London W6 8RP, UK
E-mail:
a.fielder{at}imperial.ac.uk
 | SUMMARY |
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 TOP SUMMARY INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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| INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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This paper aims to describe the level of basic surgical training in one specialty, ophthalmology, in the light of the growing pressures on service provision in the NHS. Ophthalmology provides a good case example for examining the state of basic surgical training, since in this specialty surgical training is largely in relation to one procedure—phakoemulsification cataract surgery—and clear guidelines have been agreed by the Royal College of Ophthalmologists6 as to what constitutes a basic minimum standard of training. Cataract surgery is the most commonly performed operation in the UK and recent policy initiatives have stressed the need to increase the number of procedures performed in order to reduce waiting lists.7 In none of these has proper consideration been given to their potential impact on training junior doctors.8 Although this paper focuses on SHOs in ophthalmology, the findings are of relevance to other surgical specialties that must also provide training within the context of increased service pressures.
| METHODS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The questionnaire asked about laboratory training and facilities; theatre lists, surgical experience and supervision; and background and demographic details. Participants were asked their self-assessed ethnicity according to Office for National Statistics categories;9 other questions used the categories found in the Workforce Census for England.10 A final section invited free comments with regard to surgical training as an ophthalmic SHO. The operation most commonly performed by ophthalmologists, phakoemulsification cataract surgery, was used as the exemplar procedure throughout the questionnaire. To reduce reporting error, participants were asked to report their activities in the previous week and in the week before that; these were then averaged to give rates per week. Longer time frames were used as appropriate.
Participants
From the Directory of Training Posts in Ophthalmology, 2000-2001, we
identified 476 ophthalmology SHOs. Between November 2000 and October 2001,
numbered questionnaires were distributed to named individuals in each post. 10
questionnaires were subsequently excluded because the questionnaire was
returned undelivered or the hospital post was not recognized for surgical
training (e.g. it was designed for general practice vocational training only).
Individuals who did not respond within two months were sent a follow-up
questionnaire.
Statistical analysis
Questionnaire responses were entered onto a personal computer and analysed
by means of SPSS 11.0 for Windows. Statistical tests included chi-square tests
for categorical data, t-tests and Pearson's correlation coefficient
for interval data, and logistic regression for multivariate analysis. Logistic
regression is used when the outcome variable is dichotomous—in this case
whether or not the participant had completed 50 full phako procedures. Forward
and backward stepwise logistic regression was performed to identify the model
that best fitted the data.
| RESULTS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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96% (302/314) of participants had been present in their hospital for at least one of the two weeks before completing the questionnaire, of whom 301 had attended at least one operating session. The other 12 participants had been attending courses, on leave or ill for the previous two weeks. Analyses relating to activity in the previous two weeks were confined to the 302 participants who were present in their hospital for at least one of the two study weeks; data from all 314 were used in analyses relating to longer time periods.
Patient-based surgical training
Phakoemulsification cataract surgery is composed of several distinct steps
of increasing complexity, which the basic surgical trainee is expected to
master before performing a full procedure. 50% (151/302, 95% CI 44-56%) of
participants reported performing at least one part phako operation in the
previous two weeks; the mean number of part phako procedures performed per
week during this period was 0.789 (95% CI 0.6602-0.9178). Since starting as an
ophthalmic SHO in the UK, 91% (276/305, 95% CI 87-94%) of participants had
performed at least one part phako procedure.
44% (133/302, 95% CI 38-50%) of participants reported performing at least one full phako in the previous two weeks. The mean number of full phako operations performed per week was 0.741 (95% CI 0.605-0.8764%). SHOs working in a teaching hospital performed significantly more full phako operations in the previous two weeks than those working in a district general hospital (t=2.905, 297 df, P=0.004, mean difference 0.41, 95% CI 0.132-0.688).
Since starting as an ophthalmic SHO in the UK, 61% (192/314, 95% CI 56-67%) of participants had performed at least one full phako. The number performed was positively correlated to the length of time as an SHO in the specialty (r=0.262, P<0.01).
Protected teaching time or cases on surgical lists
During the previous two weeks at least some time or cases
protected for surgical teaching on at least one surgical list was reported by
77% (233/302), 95% CI 72-82%) of participants. 15% (45/302, 95% CI 11-19%) of
participants reported that on at least one surgical list all time or
cases had been protected for surgical teaching. Those who reported at least
some protected surgical teaching time in the previous two weeks performed more
full phakos per week than those who did not (t=2.69, 135 df,
P<0.01, mean difference 0.387, 95% CI 0.102-0.672).
Surgical supervision
75% (228/302, 95% CI 71-80%) of participants had performed at least one
surgical procedure (part or full phako) in the previous two weeks. Of these,
79% (180/228, 95% CI 74-84%) had been supervised by a consultant, and 35%
(79/228, 95% CI 28-41%) had been supervised by a specialist registrar or staff
grade surgeon. 5% (12/228, 95% CI 2-8%) had performed cataract surgery without
supervision.
Threshold for completing SHO training
The Royal College of Ophthalmologists guidelines specify that SHOs are
expected to have carried out 50 intraocular procedures by the end of their
second year of training. Only 42% (40/96, 95% CI 32-52%) of participants who
had completed 2 or more years as an SHO met this requirement.
Table 2 shows that those
meeting the target are more likely to have been SHOs for longer
(
2=48.25, 2 d.f., P<0.001), more likely to be men
than women (2=8.95, 1 df, P=0.003) and more likely to
be in a teaching hospital than a non-teaching hospital
(2=15.36, 1 df, P<0.001); there are no differences
by self-ascribed ethnicity or where they qualified. These five variables were
entered into a logistic regression (forward and backward stepwise); the model
with the best fit included length of time as an SHO, gender and hospital type
(model 2 =52.88, 3 df, P<0.001). This shows that
the length of time participants had been an SHO cannot fully explain whether
or not they had performed 50 or more full phakos; both their gender and the
type of hospital where they currently work make a significant
contribution.
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| DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The findings of this survey raise questions as to whether SHOs are getting the opportunities that are essential to learn their craft.11 While virtually all SHOs had attended theatre lists in the previous two weeks, they performed very little surgery; the mean number of full phakos performed was less than one a week and a quarter had had no surgical experience at all in the previous two weeks. In the context of this limited activity, the high level of consultant supervision—while reassuring for trainees and patients alike—cannot be taken as reflecting a major commitment to training on their part. The low levels of protected surgical teaching time in theatre may also indicate a limited commitment to training; in the previous two weeks almost a quarter of SHOs had no protected teaching time or cases, and only 15% had one fully protected operating list. With so little protected time or so few cases, SHOs struggle to gain adequate practical experience. Thus, less than half of those who should have completed basic specialist training (that is, those with more than 25 months' training) had actually performed the minimum number of full phakos required by the College. Difficulties in gaining adequate hands-on experience have been reported in other surgical specialties, where low levels of consultant supervision are common12,13 and where the need to meet targets (such as cancer waiting list objectives) or the demands of higher specialist training take priority over basic surgical training for SHOs.8,14,15
While in general surgery SHOs may gain greater experience working in district general hospitals than in teaching hospitals,16 in ophthalmology basic surgical training seems especially problematic in district general hospitals. The reason is not clear. Perhaps in district general hospitals there is a greater focus on achieving service targets and less recognition of the requirement to train young surgeons. With the further proliferation of diagnostic and treatment centres, some outside the NHS, that are dedicated to increased throughput,17 the tension between service and training may worsen. By providing rapid treatment for substantial numbers of patients requiring routine surgery, diagnostic and treatment centres are likely to make it more difficult for SHOs to get adequate surgical training even within the context of teaching hospitals.
Whatever the constraints on basic surgical training in ophthalmology, they do not disproportionately affect SHOs from ethnic minorities or those who trained outside the UK. A high proportion of SHOs in ophthalmology are in these categories but studies amongst other groups of junior doctors have yielded similar reassurance.18,19 By contrast women, a minority in ophthalmology as in other surgical specialties,9 are clearly disadvantaged with regard to basic surgical training. The reasons are not obvious, although studies of junior doctors in other specialties have suggested that women are more likely to be bullied than men20 and to feel inadequately trained for clinical tasks.18 The experience of women in basic surgical training clearly warrants further attention.
Overall, the study found that, in the context of a health service preoccupied by the need to meet growing demands to improve service provision and to address rising patient expectations, even a well organized, clearly described and straightforward programme of basic specialist training has not succeeded in ensuring adequate surgical training for SHOs. If this continues, it may prove difficult to train sufficient new surgeons to an adequate standard to meet the increasing demands an ageing population will bring. Minor improvements can be made on the ground, but surgical training is unlikely to improve substantially until NHS policies on service provision recognize and take into account the requirements for training new surgeons. This is not an issue for ophthalmology alone but for all surgical specialties.
| Acknowledgments |
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| REFERENCES |
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