Authors' Response 2

Accurate and appropriate assessment of surgical trainees requires clear determination of the skills needed for surgical competence. This study was designed to identify those skills, rank them in order of importance and translate them into behavioural terms. A Delphi technique, using anonymous postal questionnaires, was used. All consultant surgeons in South-East Scotland were asked to identify the skills they expected of surgical trainees. Skills identified were then returned to all consultants for weighting. Differences among specialties in the importance of each item were identified using analysis of variance. The qualities identified fell into five domains: technical skills, clinical skills, interaction with patients and relatives, teamwork, and application of knowledge. Consultants from all specialties gave high weightings to the generic domains of clinical skills, teamwork, and interaction with patients and relatives. This study has identified the skills considered necessary by consultant surgeons in Scotland for a successful surgical career. Contrary to expectation, consultant surgeons value many generic skills more highly than technical skills, indicating that they value well rounded doctors, not just those with technical ability. The characteristics identified are being used to develop an assessment tool for use on basic surgical trainees.

The European Working Time Directive, the surgeon and training

Video assessment of basic surgical trainees' operative skills

IntroductionThe COVID-19 pandemic in the past few years led to major adjustments in the provision of healthcare. This study aimed to investigate trainees’ perception of impact of the pandemic on specialty training in Obstetrics & Gynaecology (O&G) in Hong Kong.MethodsA cross-sectional questionnaire survey was performed on all the O&G trainees and the young fellows of the Hong Kong College of Obstetricians and Gynaecologists (HKCOG). The questionnaires included 5 parts: demographic data, impact on clinical activities, redeployment, educational activities and career progression.ResultsA total of 104 questionnaires (92.9%) were received for final analysis. The majority of the participants had reductions in elective and emergency operations, as well as exposure to in-patient admissions and out-patient clinics in both obstetrics and gynaecology. The reduction was most significant in elective gynaecology operations. One-third (34.6%) of the participants had been redeployed to other departments, and educational activities were reduced during the pandemic. Around 58% of the trainees were concerned with the reduction in clinical exposure, and 78% worried they would not be able to log sufficient number of surgical procedures. Basic trainees were significantly more worried than higher trainees. Around half of the trainees had doubts or regrets about choosing to undergo O&G specialty training.ConclusionThe O&G trainees in Hong Kong perceived that the COVID-19 pandemic had significant negative impacts on their training. Many trainees were worried they would not be able to attain the required level of competence when they complete their specialist training.

Enhancing neonatal thoracoscopic surgical training with rabbit model

The objective of this work was to evaluate the safeguards implemented by surgical trainees to protect the confidentiality of electronic patient data through a structured questionnaire sent to Northern Ireland surgical trainees. A group of 32 basic and higher surgical trainees attending a meeting of the Northern Ireland Association of Surgeons-in-Training were invited to complete a questionnaire regarding their computer use, UK Data Protection Act, 1988 registration and electronic data confidentiality practices. Of these 32 trainees, 29 returned completed questionnaires of whom 26 trainees regularly stored sensitive patient data for audit or research purposes on a computer. Only one person was registered under the Data Protection Act, 1988. Of the computers used to store and analyse sensitive data, only 3 of 14 desktops, 8 of 19 laptops and 3 of 14 hand-held computers forced a password logon. Of the 29 trainees, 16 used the same password for all machines, and 25 of 27 passwords were less than 8 characters long. Two respondents declined to reveal details of their secure passwords. Half of all trainees had never adjusted their internet security settings, despite all 14 desktops, 16 of 19 laptops and 5 of 14 hand-helds being routinely connected to the internet. Of the 29 trainees, 28 never encrypted their sensitive data files. Ten trainees had sent unencrypted sensitive patient data over the internet, using a non-secure server. Electronic data confidentiality practices amongst Northern Ireland surgical trainees are unsafe. Simple practical measures to safeguard confidentiality are recommended.

Early this year, Dr. Leung Lap Chi, a fellow of our college, passed away slightly more than a year after fighting against colon cancer. Not only is it a big loss to the surgical profession, we have one less plastic surgeon working in the public institutes of Hong Kong. Surgery has always been a profession infamous for hard work and demanding hours. Surgeons are expected to perform all the time but many a time people would ignore the issue of whether the surgeons are tired or not. Many surgical colleagues who have come through the hardship of training and service of the old system are now advocates of working hour restrictions for surgeons and surgical trainees. The main argument for restriction is that surgeons are in many ways similar to pilots and there is a lot of evidence and study showing that exhaustion and tiredness after long hours of work can result in deterioration of psychomotor skills. The technical and dexterity skills that are called for in accomplishing high quality surgical procedures are reduced after long hours of work (for example, after on-call duty for a whole day). However, quality of service or operation is something very difficult to assess. No one can really guarantee that surgeons do better surgery after cutting down their working hours. The Colleges and Associations in the United Kingdom are busy working out how to maintain the training programs and standards of surgeons' performance. The real strike is yet to come because how to manage the provisions on surgical service after the implementation of the European working hour directive in 2009 remains a big issue. Interestingly, there seems to be no such plan as to lengthen the training period for surgical specialties. Perhaps it is politically too sensitive to even raise that issue for proper debate. What happens to the local scene? While the Hospital Authority has announced its plan to cut down the work-hour for public doctors irrespective of the subspecialties, the College of Surgeons of Hong Kong has a plan to revise the curriculum of surgical training, at least at the level of the basic surgical training. In future, the working time of our higher trainees would likely be reduced and the number of operations they have would logically be reduced as well. As the assessment of training is linked to the number of operations trainees and trainers might be forced to be dishonest about the operative exposure when they are filling in their log-books and assessment records. If our College is turning a blind eye to this potentially disastrous deterioration in the quality of training, what can the surgical profession do? Some innovative ideas and action plans are desperately needed here. At the time of writing this editorial, various stakeholders were busy trying to restructure the training in plastic surgery in Hong Kong. The crisis situation was precipitated as a result of the reduction in the number of recognized training units as well as trainers remaining in the Hospital Authority. Although some surgeons may think this is just an isolated event and they are getting on with their lives pretty well, no one can be sure that this is not the first crack in the dam.

BackgroundMajor advances in management of common pleural diseases have taken place in the past decade. However, pleural diseases are often managed by physicians of diverse training background and research on implementation of new knowledge is scanty. We aim to evaluate the practice pattern in pleural medicine among physicians in Hong Kong, for identification of possible gaps for clinical service improvement.MethodsThe Hong Kong Thoracic Society undertook a cross-sectional questionnaire survey in 2019, targeting clinicians of various subspecialties in internal medicine and levels of experience (basic and higher trainees, specialists) from twelve regional hospitals of diverse service scopes throughout Hong Kong. Respondents were selected by non-probability quota sampling. The questionnaire tool consisted of 46 questions covering diagnostic and therapeutic aspects of common pleural diseases. The responses were anonymous, and analysed independently using SPSS statistics software.ResultsThe survey collected 129 responses, 47(36%) were from clinicians specialized in respiratory medicine. Majority of the respondents (98%) managed pleural diseases, including performing pleural procedures in their practice. Fifty-five percent of all the respondents had not received any formal training in transthoracic ultrasonography. A significant proportion of clinicians were unaware of pleuroscopy for investigation of exudative pleural effusion, indwelling pleural catheter for recurrent malignant pleural effusion, and combined intra-pleural Alteplase plus DNase for treatment of pleural infection (30%, 15% and 70% of non-respiratory clinicians respectively). Significant heterogeneity was found in the management of pleural infection, malignant pleural effusion and pneumothorax among respiratory versus non-respiratory clinicians. Contributing factors to the observed heterogeneity included lack of awareness or training, limited accessibility of drugs, devices, or dedicated service support.ConclusionSignificant heterogeneity in management of pleural diseases was observed among medical clinicians in Hong Kong. Continuous medical education and training provision for both specialists and non-specialists has to be strengthened to enhance the implementation of advances, improve quality and equity of healthcare provision in pleural medicine.

Background: Subspecialization in general surgery is being encouraged by various surgical societies. The aim of this study was to view attitudes of Royal Australasian College of Surgeons (RACS) trainees to subspecialization in surgery, in particular, breast ­surgery. Methods: A postal questionnaire survey of registered RACS basic and advanced surgical trainees was conducted in February 2002. Trainees were asked to nominate their preferred specialty and to indicate the level of support and interest for subspecialty training in breast surgery. Trainees indicating breast surgery as their preferred career choice were then asked to nominate their reasons for choosing breast surgery, preferred options for cross-specialty training and for vocation specifications such as a continuing ‘on-call’ responsibility. Results: Trainees returned 291 of 1049 (28%) completed questionnaires. One hundred and sixty-nine trainees felt that the concept of breast subspecialization in general surgery was reasonable (58%). For all respondents, the most popular specialty choices were plastic surgery (15.8%), orthopaedics (15.5%) and general surgery (15.4%). Breast surgery was chosen by 14 of 291 (4.8%) respondents as their first specialty preference and a further 25 respondents as their second specialty preference. Of 189 trainees who did not choose breast surgery as their preferred specialty, 45% stated repetitive stress, escalating litigation or demanding patients as deterrent factors. Only 36% of trainees interested in breast surgery were interested in undertaking after hours ‘on-call’ work as a consultant, although 36 of 39 (92%) were interested in other forms of general or subspecialty elective surgical operating (i.e., endocrine surgery, surgical oncology) after completion of their training. According to trainees with an interest in breast surgery, the two most important aspects requiring inclusion in the proposed provisional training program were breast reconstruction (38%) and breast screen assessment (34%). Conclusion: Breast surgery is an unpopular subspecialty for RACS trainees. Breast surgery is likely to experience increasing ­problems with recruitment unless the skill base is reviewed and revised in line with the aspirations and needs of today's trainees.

Assessing the educational environment in the operating room—a measure of resident perception at one Canadian institution

Aim The COVID-19 pandemic has brought innumerable challenges to surgical training, especially with regard to theatre opportunities for core surgical trainees. This study aims to evaluate the implementation of training-oriented key performance indicators (KPIs) in supporting trainees to meet the Joint Committee on Surgical Training (JCST) quality indicators for core surgical training. Method A six-month long closed-loop quality improvement project. Two KPIs were developed following discussion with trainees and departmental leads, evaluation of the rota, and review of the JCST quality indicators: theatre/normal-working-day-attendance (T/A) ratio and missed-theatre-sessions/normal-working-day-attendance (M/A) ratio. Our calculations projected a T/A ratio of 1.00 and M/A ratio of 0.20 to be fully compliant with the JCST quality indicators. Data were collected prospectively from eight trainees, who provided feedback on training opportunities and allocation equitability. Results Following implementation of the KPIs, there was a significant increase in the mean T/A ratio from 0.70 (range=0.55–0.82) to 1.00 (range=0.95–1.17) (p=0.03), and a significant decrease in the mean M/A ratio from 0.55 (range=0.45–0.70) to 0.20 (range=0.11–0.22) (p=0.01). There were significant improvements in trainee satisfaction with training opportunities from 50% to 85% (p=0.02) and allocation equitability from 66% to 95% (p=0.01). Conclusions The development and implementation of training oriented KPIs led to increased allocation and fewer missed theatre sessions, enabling trainees to meet the JCST quality indicators. Furthermore, our data demonstrate smaller variances between trainees, thus, highlighting greater equitability of training opportunities. These findings are supported by the improved trainee satisfaction with training opportunities and allocation equitability reported.

<h2>Abstract</h2><h3>Objectives</h3> The Accreditation Council for Graduate Medical Education (ACGME) reduced core surgical requirements during integrated vascular surgery residency from 24 months to 18 months in 2018. The aim of this study is to assess the impact of this reduction on integrated vascular residents' operative experience. <h3>Methods</h3> A retrospective analysis of public ACGME case logs was performed for the five years following requirement reduction (post-reduction era, 2018-2022) for all integrated vascular surgery residents. Trends were evaluated for mean number of surgeon chief and junior cases over four categories (general surgery open, general surgery laparoscopic, vascular surgery open, and vascular surgery endovascular) in three anatomic regions (head/neck, thoracic, and abdominal) using linear regression. The overall mean for the post-reduction era were compared to overall mean from the five years before the reduction (pre-reduction era, 2013-2017) using t-tests. <h3>Results</h3> In the post-reduction era, the mean number of cases logged per year by integrated residents in all categories was 260. General surgery cases consistently accounted for 34-38% of total operative volume (p=0.88) with a mean of 95 cases. Operative experience by anatomic region demonstrated no significant changes except for a decrease in vascular open head/neck cases (54 to 43 cases, p=0.009) and an increase in endovascular thoracic cases (17 to 20 cases, p=0.003). General surgery open and laparoscopic cases in all three anatomic categories remained stable. When comparing case means between pre-reduction and post-reduction eras, there were no significant changes in total operative volume, total open cases (including open abdominal aortic aneurysm repair), or the proportion of general surgery versus vascular surgery cases. However, there was a minor decrease in general surgery laparoscopic means in the post-reduction era (50 to 45 cases, p=0.047) with concomitant minor increases in general surgery open thoracic and open abdominal cases. <h3>Conclusions</h3> This study demonstrates that reducing core surgery requirements for integrated vascular residents from 24 to 18 months did not negatively impact operative volume. The decrease in general surgery laparoscopic cases between the pre- and post-reduction eras suggests a sensible shift towards more relevant general surgery cases for the vascular surgery resident. Thus, a further reduction in general surgery requirements to 12 months may be a feasible option without compromising surgical training quality.

Traditional surgical training faces challenges related to sustainability, cost, and ethical considerations. Limited access to resources, ethical concerns about cadaver-based learning, limited availability of surgical cases, and the high costs associated with hands-on training impede the effectiveness and accessibility of surgical education. Despite these challenges, the need for direct tactile experience remains critical, as it fosters the development of essential motor skills and tactile abilities vital for surgical practice. However, advancements in immersive technologies such as virtual reality (VR), augmented reality (AR), and haptics offer a promising solution to address these challenges. VR and AR technologies offer realistic, controlled environments where learners can visualise anatomical structures and practice surgical procedures without risks. The integration of haptic feedback in these immersive simulations further enriches the learning process by adding the sense of touch and physical interaction, aiding in mastering critical surgical skills. The incorporation of immersive technologies in surgical training presents an opportunity to address the constraints of conventional methods. These technologies offer the possibility of creating platforms that replicate real-life surgical scenarios, allowing learners to hone their skills and build confidence in a safe and controlled environment. Moreover, immersive learning offers an ethical alternative to cadaver-based training and extends access to training materials irrespective of geographical limitations. Such an approach allows for step-based training, where students may begin acquiring skills through immersive learning, then move to special surgical simulators, and finally to patients. This article deals with the impact of immersive technologies such as VR, AR, and haptics on reshaping conventional surgical training, by focusing specifically on basic surgical skills. Targeting educators, medical experts, and involved parties, the article aims to stimulate additional exploration and adoption of immersive technologies to elevate surgical competencies and patient care standards.

To Editor, The use of cadavers as educational tools in medical science and technology is unparalleled.Cadavers serve as an essential foundation for learning and practicing the fundamentals of medicine, offering a student-centered, problem-oriented approach to education.Beyond imparting knowledge and skills, cadavers play a crucial role in fostering emotional connections to humanity, nurturing gratitude and responsibility, and a respectful attitude of service.A cadaver is a vast repository of diverse tissues, organs, and systems that offer a myriad of gross anatomical variations.It serves as the cornerstone for comprehending the embryological origins of congenital defects, microanatomical variations, unusual histopathological findings, and subtle yet significant structural differences.Cadavers donated by individuals with various diseases provide invaluable insights for preclinical students, enabling them to grasp the fundamentals and their applications in clinical, diagnostic, or therapeutic challenges within medicine and surgery. 1 In the domain of preclinical medical studies, cadavers prove invaluable for hands-on basic surgical training procedures, serving as a peerless model.They act as an invaluable simulation resource for advanced practice and postgraduate learning, and help students imbibe competencies and fortify their theoretical knowledge by providing opportunities for virtual practice.Cadavers serve as the basis for various surgical training skills, reinforcing the importance of human anatomy in careful diagnostic or therapeutic approaches.This includes procedures such as the use of intramuscular or intravenous injectables, venesection, skin suturing, collection of specimens through biopsies, endotracheal intubation,

Changes to Training Practices during a Pandemic - The Experience of the Irish National Trauma & Orthopaedic Training Scheme