1

DOI: 10.1308/147363513X13500508920095

G e n e r a l s u r G e r y l o G b o o k s u r v e y

W allum Past Chairman1

s Hornby President2

G khera Past President2

e Fitzgerald Past President2

G Griffiths Past Chairman2

1General Surgery Specialist Advisory Committee2Association of Surgeons in Training

Ann R Coll Surg Engl(Suppl) 2013; 95: XX–XX

Application for a Certificate of Completion of Training (CCT) in general surgery includes assessment of a validated logbook. The content of a satisfactory logbook has long been an area of contention. The logbook allows trainees to record their operative experience and to show the level of supervision. It is tempting to set a specific number of procedures to be completed by the end of training. However, such a number must be evidence based rather than chosen subjectively.

In the initial phase of development of the Intercollegiate Surgical Curriculum Programme (ISCP), there was considerable discussion about indicative numbers for individual procedures. It was decided not to include such numbers, as the ISCP is a competence-based process and numbers were not simply definable. The ISCP clearly defines the technical skills expected of a trainee in operative surgery and how those skills should be assessed in the workplace in the detailed descriptions of the procedure-based assessments (PBAs). It has become apparent that there is potential for discrepancy between experience and competence assessment reflected in the content of logbooks presented to the general surgery specialist advisory committee (SAC) at the completion of training. A specific concern is that a trainee may be assessed as competent in a particular procedure but may not have learned the range of operative strategies needed to manage complex conditions requiring that procedure. The general surgery SAC and the Association of Surgeons in Training (ASiT) education committee have therefore surveyed the logbooks of those

completing general surgical training in the past two years (2010–2011) to understand the levels of experience gained, with a view to influencing future evaluation and provision of training.

MethodsLogbook consolidation sheets and the electronic logbooks of those general surgery trainees applying to the SAC for their CCT in 2010 and 2011 were reviewed anonymously. The logbook was designed by the Association of Surgeons of Great Britain and Ireland (ASGBI), and recorded the number of procedures performed by subspecialty and also the level of supervision. It was not mandatory for trainees to record whether or not a procedure was an emergency. In those recording their data electronically, procedures were documented according to Confidential Enquiry into Perioperative Deaths (CEPOD) status and it was therefore possible to assess emergency surgery experience from these data.

Logbooks were included for those who completed training without any periods of repeat or targeted training. Those whose logbooks were incomplete or included

Subspecialty Number of trainees

Breast 10 (1 trainee also endocrine interest)

Colorectal 20

Upper gastrointestinal 17 (1 trainee also transplant interest)

Vascular 9

Endocrine 1

Transplant 1

DISTRIBUTION OF SPECIAL INTERESTS

Table 1

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periods of out-of-training fellowships were excluded.

ResultsThe logbook consolidation sheets of 58 trainees were reviewed. Their special interests were not described explicitly but were apparent from the content. The distribution of special interests is shown in Table 1.

The average duration of training was 72 months (range: 58–87 months). Throughout training, trainees were involved with a median of 28 procedures (first quartile: 23) each month.

The total number of procedures in which trainees were involved (either assisting or performing) in general surgery and their own special interest is shown in Table 2. The largest absolute number of procedures was performed by colorectal trainees. This reflects partly the numbers of colonoscopies performed in addition to other procedures. The numbers for endocrine and transplantation surgery are expressed as a mean only because of the small number of trainees. The overall experience in general surgery of childhood was limited.

The number of cases in which trainees were involved that were not in their area of special interest but part of their training in general surgery was also estimated. The median number for breast surgery was low at 53 (range: 0–399). Not unexpectedly, the larger numbers were in upper gastrointestinal (GI) (196 [range: 43–643]) and colorectal surgery (280 [range: 88–662]). Non-vascular trainees were involved in a median of 126 vascular procedures (range: 11–377), principally varicose veins and access surgery. In view of the median number of procedures performed monthly, this experience could be achieved in a six-month attachment to a vascular unit.

General SurgeryThe index procedures that should be undertaken by all are identified in the general surgery curriculum as inguinal hernia repair, laparotomy for trauma, laparotomy for acute abdomen and Hartmann’s operation. Laparotomy for acute abdomen is not defined specifically in the ASGBI logbook. For

* Endocrine – 2 trainees; 1 endocrine, 1 breast and endocrine ** Transplant – 2 trainees – 1 renal and liver

* includes splenectomy** includes division of adhesions, palliative bypass, staging/diagnosis, postoperative complications and small bowel resection; excludes appendicectomy

Number of proceduresMean Median Range First quartile

General surgery 607 601 227–1,384 460

Breast surgery 902 962 474–1,272 670

Colorectal surgery 1,023 870 332–1,905 730

Upper gastrointestinal surgery Hepatopancreatobiliary Oesophagogastric

788 818 225–1,506 591357 324 184–604 235435 444 40–940 200

Vascular surgery 864 949 409–1,041 750

Endocrine surgery* 398

Transplant surgery** 250

General surgery in childhood 35 13 0–228 3

PROCEDURES IN whICh TRAINEES wERE INvOLvED (ASSISTING OR PERFORmING)

Table 2

Number of procedures

Mean Median range First quartile

Inguinal hernia surgery

90 86 19–214 60

Laparotomy for trauma*

5 4 0–20 2

Laparatomy for acute abdomen**

83 68 18–227 42

Hartmann’s operation

13 10 2–43 5

GENERAL SURGERy INDEx PROCEDURES PERFORmED By TRAINEES

Table 3

Number of procedures

Mean Median range First quartile

All trainees (n=14)

158 164 42–249 120

Gastrointestinal trainees (n=11)

179 182 70–249 143

EmERGENCy PROCEDURES PERFORmED By TRAINEES (CEPOD CLASSIFICATION)*

Table 4

* includes any procedure recorded as performed on a CEPOD list (eg laparotomy for acute abdomen and for trauma, segmental colectomy, Hartmann’s operation, surgery for acute peptic ulceration, cholecystectomy and surgery for acute abdominal vascular pathology)

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Number of procedures

Mean Median range First quartile

Image guided surgery(diagnostic/wide local excision)

69 57 17–134 37

mastectomy 66 12 31–92 51

Duct and nipple surgery

13 68 1–27 8

Sentinel node biopsy

95 90 16–169 70

Axillary clearance

64 58 42–112 45

myocutaneous flap 19 18 8–35 12

Implant-based reconstruction

19 18 0–48 3

Reduction mammoplasty

8 3 0–23 1

SPECIAL INTEREST ExPERIENCE IN BREAST SURGERy

Table 5

Number of procedures

Mean Median range First quartile

Anterior resection

40 38 14–96 28

Colonoscopy 238 203 0–707 90

Fistula surgery* 34 35 6–67 18

Segmental colectomy**

80 81 33–139 52

Haemorrhoidectomy 31 29 5–71 15

Prolapse surgery 8 6 2–18 4

SPECIAL INTEREST ExPERIENCE IN COLORECTAL SURGERy

Table 6

this analysis, laparotomy for acute abdomen included surgery for intestinal obstruction, peritonitis, palliative bypass and postoperative complications as well as other unspecified procedures. The general surgery index procedure experience is shown in Table 3. It is likely that some of the procedures were performed electively. Emergency experience (ie procedures recorded as performed according to the CEPOD classification of emergency or urgent) is shown in Table 4. These data are from the electronic logbooks of a group of trainees in the main cohort.

Special interest experience The total number of index procedures performed (supervisor scrubbed, supervisor unscrubbed, performed or training a junior colleague) according to the special interest of each trainee is shown in Tables 5–10. The data for upper GI surgery are presented separately for those with a general upper GI interest and an oesophagogastric (OG) or hepatopancreatobiliary (HPB) interest. Since there were only two trainees expressing interests in endocrine surgery or transplantation, their numbers are simply presented without analysis (Tables 9 and 10).

Non-special interest experienceTraining naturally exposes trainees to common procedures outside their own area of special interest. These include cholecystectomy, segmental colectomy and Hartmann’s operation (Table 11). Although not formally documented, the majority of cholecystectomies were laparoscopic.

EndoscopyExperience in endoscopy for surgical trainees has been variable for some time. Trainees have had the facility to record their endoscopy experience in the ASGBI logbook. however, this was at the same time as the Joint Advisory Group on GI Endoscopy (JAG) ePortfolio was being introduced. This may have created some limitations on the accuracy of the data on endoscopy. For those with an upper GI interest, the median number of oesophagogastroduodenoscopies performed was 58 (range: 0–477). For those with a declared oesophagogastric interest, the median number was 211 (range: 0–477). Colorectal trainees performed a median number of 203 colonoscopies (range: 0–707). In addition, upper GI trainees performed a median of 37 colonoscopies (range: 0–105) and colorectal trainees performed a median of 83 oesophagogastroduodenoscopies (range: 0–420).

Trainee supervisionTrainee supervision was estimated from the total number of procedures recorded as undertaken with the supervisor scrubbed, or present but unscrubbed. Overall, approximately 66% of all procedures were performed by trainees. The extent of supervision was variable, with an average of 65% of procedures being performed under supervision. For emergency procedures, 80% were performed by trainees, with 50% under supervision. The rates of supervision varied from 46% for laparotomies for acute abdomen to 67% for laparotomies for trauma.

Supervision of complex procedures was naturally high. Approximately 50% of all breast reconstructions were undertaken by trainees, with 84% under supervision. In contrast, 59% of axillary clearance operations were performed by trainees, with 68% under supervision. Colorectal trainees performed 61% of anterior resections, with 95% under supervision.

* includes advancement flap, drainage seton or other treatment (high fistula-in-ano) and lay-open technique (low fistula-in-ano) ** includes right, left, transverse and sigmoid colectomy

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Number of procedures

Mean Median range First quartile

Oesophagogastroduodenoscopy Oesphagogastric interest

129189

58211

0–4770–477

021

Anti-reflux surgery Oesophagogastric interest

1726

830

0–605–60

310

Gastrectomy* Oesophagogastric interest

1116

1016

0–323–32

311

Oesophagogastrectomy Oesophagogastric interest

1725

1420

0–504–50

116

Obesity surgery Oesophagogastric interest

2730

1522

0–1240–80

013

Acute peptic ulcer 11 10 1–28 6

Cholecystectomy** 166 132 60–373 110

Exploration of common bile duct 5 2 0–27 0

Liver resection Hepatopancreatobiliary interest (2)

540

0 0–4733–47

Pancreatic necrosectomy Hepatopancreatobiliary interest (2)

29

0 0–152–15

Pancreatic resection Hepatopancreatobiliary interest (2)

433

0 0–4917–49

SPECIAL INTEREST ExPERIENCE IN UPPER GASTROINTESTINAL SURGERy

Table 7

* includes D2 subtotal and total gastrectomy as well as distal, subtotal and total gastrectomy ** predominantly laparoscopic cholecystectomy

Similarly, 49% of oesophagectomies were performed by trainees, with 97% under supervision. In vascular surgery, 66% of abdominal aortic aneurysm repairs were undertaken by trainees, with 85% and 76% of procedures supervised for bifurcated and tube grafts respectively. In endocrine surgery, only 34% of adrenalectomies were performed by trainees, with 95% under supervision. Finally, 68% of liver transplant implantation procedures were undertaken by trainees, all under supervision.

DiscussionThis review of the logbooks of general surgical trainees completing training in 2010–2011 has defined the volume of experience achieved during the six years of higher surgical training. The nature of the process and analysis was highly dependent on the accuracy of the documentation by each trainee. The figures for overall activity, general elective and emergency experience, and special interest experience allow a benchmark to be set. It is proposed that this benchmark should be, as a minimum, the first quartile and this should be the indicative number for a specific procedure.

The determination of such a benchmark has several applications. First, it establishes the level of experience a trainee should reach by the end of training. Second, it allows a longitudinal assessment by training programme directors to determine the progress being made by an individual trainee, highlighting where experience is appropriate and, more importantly, where it is limited so that this can be addressed in future trainee posts. Third, it demonstrates to trainees what is expected of them as they progress through training. Finally, the benchmark can be used to set the expected level for those applying for entry on to the General medical Council specialist register through the route of Certificate of Equivalence of Specialist Registration.

This analysis represents a snapshot of the experience of one cohort of trainees. A limitation has been identifying the amount of emergency experience. This was particularly apparent for emergency laparotomies as it was not mandatory to record the urgency of a procedure in the ASGBI logbook. The data from the consolidation sheets show lower rates of emergency procedures than

in the electronic logbooks. It is likely that emergency procedures will have been recorded as specific operations in logbooks, hence the discrepancy. From these combined data, it is therefore recommended that trainees should complete a minimum of 100 emergency laparotomies by the end of training. The transfer from the ASGBI logbook to the Faculty of Health Informatics electronic logbook in 2011 has enhanced recording of operative experience and this will allow more contemporaneous analysis of activity in the future.

Trainees must be careful in filling in their logbooks to ensure key metrics such as the level of urgency of a procedure are recorded. This is essential for the assessment of both trainee and training unit with regard to the level of emergency exposure. Failure to complete logbooks accurately will, ultimately, lead to erroneous benchmarks.

The review has identified a number of areas that need further consideration. In the development of the curriculum, each subspecialty association education committee recommended a series of

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Number of procedures

Mean Median range First quartile

Abdominal aortic aneurusm – bifurcated graft

11 12 5–23 5

Abdominal aortic aneurysm – tube graft

35 21 11–90 13

Carotid endarterectomy 55 44 26–119 33

Infrainguinal bypass* 90 94 48–154 61

‘Re-do’ vascular surgery 9 4 0–29 2

Varicose vein surgery 85 82 41–170 59

Vascular access 20 15 0–49 1

SPECIAL INTEREST ExPERIENCE IN vASCULAR SURGERy

Table 8

*includes femoral-crural bypass, femoral-distal bypass, femoral endarterectomy, femoral-femoral crossover, femoral-popliteal bypass (above knee and below knee) and ilio-femoral bypass

Number of proceduresMean range

Thyroidectomy 152 118–186

‘Re-do’ thyroidectomy 5 5–6

Parathyroidectomy 67 56–77

Adrenalectomy 11 9–13

SPECIAL INTEREST ExPERIENCE IN ENDOCRINE SURGERy (2 TRAINEES)

Table 9

Number of proceduresMean range

Kidney transplant 67 24–111

Liver implantation 7 0–13

Liver recipient hepatectomy 4 0–8

SPECIAL INTEREST ExPERIENCE IN TRANSPLANTATION SURGERy (2 TRAINEES: 1 RENAL, 1 LIvER)

Table 10

index procedures, defined as standard operations that all trainees with that special interest should undertake. The figures for these show variation, with low numbers for certain specialist procedures. This raises the question of whether such numbers are acceptable experience for a trainee at the end of training and also whether the current index procedures are appropriate.

The totality of experience shows a consistent range, with a median of 28 procedures a month. The current Joint Committee on Surgical Training quality indicators for training posts in general surgery recommend a minimum of three operating lists per week. Although the number of cases per list varies according to the complexity of the procedures, the current median total equates to 2–3 cases per list. Since two-thirds of cases are performed by trainees, it is crucial that these cases are used to the fullest extent for training. The introduction of simulation may help with operative experience in the sense that basic skills are mastered outside the operating theatre. yet there is a strong argument to increase the proportion of cases performed by trainees, with at least part of every procedure being undertaken by a trainee.

Experience in gastrointestinal endoscopy has been variable, reflecting the access of surgical trainees to endoscopy lists. This survey has shown a wide range of practice, confirming anecdotal reports of limited experience. Both upper GI surgery and coloproctology include endoscopy as

index procedures in the curriculum. In order to increase experience, the SAC has recommended to training programme directors that trainees’ experience in endoscopy is carefully reviewed annually and targeted if necessary. There will shortly be a direct link between the ISCP and the JAG ePortfolio, which will enable trainees to record their data and thereby facilitate the annual review of competence progression.

Progression through operative training is reflected in the level of supervision a trainee receives. In the early phases, the

presence of the trainer provides not only instruction but also the experience of a good assistant. with trainee progression, the ability to perform technical aspects improves and the ability to make decisions according to changes in circumstances develops with less involvement of the trainer. Eventually, the competent trainee is able to perform the procedure unsupervised.

The level of supervision documented in the review reflects this progression, with 66% of procedures performed under supervision. In complex surgery,

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Special interest Procedure Number of procedures

Mean Median range First quartile

Colorectal surgery Cholecystectomy 96 90 24–212 62

Gastrectomy 2 1 0–5 0

Upper gastrointestinal surgery

Segmental colectomy 33 31 16–52 21

Hartmann’s operation 11 10 2–37 6

Breast surgery Cholecystectomy 56 58 28–81 38

Segmental colectomy 26 24 12–63 17

Hartmann’s operation 3 3 2–10 2

ExPERIENCE IN INDEx PROCEDURES OUTSIDE SPECIAL INTEREST

Table 11

the majority of procedures are done under supervision and this is undoubtedly associated with the value of an experienced assistant. however, there is a potential negative aspect. If all procedures are carried out under supervision, the first procedure not supervised may be when the trainee undertakes his or her first list as a newly appointed consultant. There is an argument for competence assessment in complex surgery illustrating the level of complexity. This also prompts the question about the level of support and mentorship provided for newly appointed consultants.

ConclusionsThe ISCP has developed as a competence-based process. It has determined the skills and attributes required to practise as a consultant. Nevertheless, although the skills to perform an operation competently have been defined, the experience to manage all presentations requiring a particular procedure is more difficult to stipulate. This review has identified the median number of procedures undertaken by trainees. It also proposes an indicative minimum

number from the first quartile of numbers performed. The unknown measure is the number of procedures required to achieve competency as described in the PBA. Analysis of ISCP and eLogbook data should allow this to be determined. In addition, due allowance for complexity of a procedure and the associated clinical problem is planned to be built into the PBA, thereby resolving the tension between experience and competence.