Differential attainment in higher surgical training: scoping pan-specialty spectra.

INTRODUCTION: This study aimed to evaluate differential attainment during higher surgical training (HST; all specialties) related to three ethnic cohorts: White UK (WUKG), Black and Minority Ethnic UK Graduates (BMEUKG), and International Medical Graduates (IMG). METHOD: Anonymised records of 266 HSTs (126 WUKG, 65 BMEUKG, 75 IMG; 7 years) in a single UK Statutory Education Body were examined. Primary effect measures were Annual Record of Competency Progression Outcome (ARCPO) and Fellowship of the Royal College of Surgeons (FRCS) pass. RESULTS: ARCPOs related to ethnicity and specialty were similar with the exception of general surgery (GS) trainees, four of whom received ARCPO 4 (GS 4.9% (75% BME; p=0.025) vs all other 0%). ARCPO 3 was commoner in women (22/76, (28.9%) than men 27/190 (14.2%), OR 2.46, p=0.006). FRCS pass rates (WUKG vs BMEUKG vs IMG) were 76.9%, 52.9% and 53.9% respectively (p=0.064) but unrelated to gender (M 70.4% vs F 64.3%). On multivariable analyses: ARCPO 3 was associated with Female gender and Maternity Leave (OR 8.05, p=0.001); FRCS pass with ethnicity (OR 0.21, p=0.028) and Hirsch Indices of ≥5 (OR 11.17, p=0.001). CONCLUSION: Differential attainment was plain with BMEUKG FRCS performance almost a third poorer than WUKG, and women twofold more likely to receive adverse ARCPOs, with return from statutory leave independently associated with training extension. Focused counter measures targeted at non-operative technical skills (including academic reach), Keeping in Touch, Return to Work, and re-induction programmed support are urgently needed for trainees at risk.

Minimally-invasive cardiac surgery: a bibliometric analysis of impact and force to identify key and facilitating advanced training.

BACKGROUND: The number of citations an article receives is a marker of its scientific influence within a particular specialty. This bibliometric analysis intended to recognise the top 100 cited articles in minimally-invasive cardiac surgery, to determine the fundamental subject areas that have borne considerable influence upon clinical practice and academic knowledge whilst also considering bibliometric scope. This is increasingly relevant in a continually advancing specialty and one where minimally-invasive cardiac procedures have the potential for huge benefits to patient outcomes. METHODS: The Web of Science (Clarivate Analytics) data citation index database was searched with the following terms: [Minimal* AND Invasive* AND Card* AND Surg*]. Results were limited to full text English language manuscripts and ranked by citation number. Further analysis of the top 100 cited articles was carried out according to subject, author, publication year, journal, institution and country of origin. RESULTS: A total of 4716 eligible manuscripts were retrieved. Of the top 100 papers, the median (range) citation number was 101 (51-414). The most cited paper by Lichtenstein et al. (Circulation 114(6):591-596, 2006) published in Circulation with 414 citations focused on transapical transcatheter aortic valve implantation as a viable alternative to aortic valve replacement with cardiopulmonary bypass in selected patients with aortic stenosis. The Annals of Thoracic Surgery published the most papers and received the most citations (n = 35; 3036 citations). The United States of America had the most publications and citations (n = 52; 5303 citations), followed by Germany (n = 27; 2598 citations). Harvard Medical School, Boston, Massachusetts, published the most papers of all institutions. Minimally-invasive cardiac surgery pertaining to valve surgery (n = 42) and coronary artery bypass surgery (n = 30) were the two most frequent topics by a large margin. CONCLUSIONS: This work establishes a comprehensive and informative analysis of the most influential publications in minimally-invasive cardiac surgery and outlines what constitutes a citable article. Undertaking a quantitative evaluation of the top 100 papers aids in recognising the contributions of key authors and institutions as well as guiding future efforts in this field to continually improve the quality of care offered to complex cardiac patients.

Prognostic significance of competition ratios in surgical specialty training selection.

BACKGROUND: A competition ratio (CR) indicates the ratio of total applications for a training post when compared with numbers of specialty posts available. This study aimed to evaluate CRs' influence on National Training Number (NTN) selection in a single UK Statutory Education Body. METHODS: Consecutive core surgical trainees numbering 154 (105 men, 49 women; median years since graduation: four) were studied over a 6-year period. Annual specialty specific CRs were obtained from Health Education England's website, and primary outcome measure was UK NTN appointment. RESULTS: Overall NTN appointment was 45.5%. Median CR was 2.36; range Oral & Maxillofacial Surgery 0.70 (2020) to Neurosurgery 22.0 (2020). Multivariable analysis revealed that NTN success was associated with: CR (OR 0.46, p=0.003), a single scientific publication (OR 6.25, p=0.001), cohort year (2019, OR 12.65, p=0.003) and Universal Annual Review of Competence Progression Outcome 1 (OR 45.24, p<0.001). CRs predicted NTN appointment with a Youden index defined critical ratio of 4.42; 28.6% (n=8) versus 49.2% (n=62), p=0.018. CONCLUSION: CRs displayed 30-fold variation, with CRs below 4.42 associated with twofold better NTN promotion, but strong clinical competence and academic reach again emerged as the principal drivers of career advancement.

Strategic organisational skills predict surgical training success.

INTRODUCTION: Surgical career progression is determined by examination success and Annual Review of Competence Progression (ARCP) outcome, yet data on organisational skills are sparse. This study aimed to determine whether organisational skills related to Core Surgical Training (CST) outcome. Primary outcome measures include operative experience, publications, examination success (Membership of the Royal College of Surgeons or the Diploma in Otolaryngology-Head and Neck Surgery (MRCS/DO-HNS)) and ARCP outcome. METHODS: The study was conducted prospectively at three consecutive CST induction boot camps (2017-2019) providing clinical and simulation training for 125 trainees. Arrival time at course registration was the selected surrogate for organisational skills. Trainees were advised to arrive promptly at 8:45 for registration and that the course would start at 9:00. Trainee arrival times were grouped as follows: early (before 8:45), on time (8:45-8:59am) or late (after 9:00). Arrival times were compared with primary outcome measures. SETTING: Health Education and Improvement Wales' School of Surgery, UK. RESULTS: Median arrival time was 8:53 (range 7:55-10:03), with 29 trainees (23.2%) arriving early, 63 (50.4%) on-time and 33 (26.4%) late. Arrival time was associated with operative experience (early vs late; 206 vs 164 cases, p=0.012), publication (63.2% vs 18.5%, p=0.005), MRCS/DO-HNS success (44.8% vs 15.2%, p=0.029), ARCP outcome (86.2% vs 60.6% Outcome 1, p=0.053), but not National Training Number success (60.0% vs 53.3%, p=0.772). CONCLUSIONS: Better-prepared trainees achieved 25% more operative experience, were four-fold more likely to publish and pass MRCS, which aligned with consistent desirable ARCP outcome. Timely arrival at training events represents a skills-composite of travel planning and is a useful marker of strategic organisational skills.

Trainee burnout: when does the fire start?

PURPOSE OF THE STUDY: Burnout is an increasingly recognised phenomenon in acute healthcare specialities and associated with depersonalisation, ill health and training programme attrition. This study aimed to quantify contributory physiological variables that may indicate stress in newly qualified doctors. STUDY DESIGN: Post Graduate Year 1 doctors (n=13, 7 f, 6 m) were fitted with a VivaLNK wellness device during four prior induction days, followed by their first 14 days work as qualified doctors. Minute-by-minute Heart Rate (HR), Respiratory Rate (RR), and Stress Index (SI) data were correlated with Maslach Burnout Inventories, Short Grit Scales (SGS) and clinical rota duties: Induction vs Normal Working-Day (NWD) versus On-call shift. RESULTS: In a total 125 recorded shift episodes, on comparing Induction versus NWD versus On-call shift work, no variation was observed in HR above baseline (25.47 vs 27.14 vs 24.34, p=0.240), RR above baseline (2.21 vs 1.86 vs 1.54, p=0.126) or SI (32.98 vs 38.02 vs 35.47, p=0.449). However, analysis of participant-specific temporal SIs correlated with shift-related clinical duties; that is, study participants who were most stressed during a NWD, were also more stressed during Induction (R2 0.442, p=0.026), and also during On-call shifts (R2 0.564, p=0.012). Higher SGS scores were inversely related to lower SIs (coefficient -32.52, 95% CI -45.881 to 19.154, p=0.001). CONCLUSION: Stress and burnout stimulus appear to start on day one of induction for susceptible PGY1 doctors, and continues into front-line clinical work irrespective of shift pattern. Short Grit Scale questionnaires appear an effective tool to facilitate targeted stress countermeasures.

Surgical curriculum concordance: requiem for the educational dream.

This study aimed to analyse the degree of relative variation in speciality-specific competencies required for Certification of Completion of Training (CCT) set by the UK Joint Committee for Surgical Training (JCST) 2021 curriculum. Regulatory body guidance related to operative and non-operative surgical skill competencies required for CCT were analysed and compared. Wide inter-speciality variation was demonstrated in the minimum number of logbook cases (median 815; range 54 to 2100), indexed operations (8; 5 to 24) and procedure-based assessments (35; 6 to 110). Academic competencies related to peer-reviewed publications, communications to learned societies and audits were aligned at zero, zero and three across specialities, respectively. Mandatory courses have been standardised with Advanced Trauma Life Support being the sole pre-requisite CCT for all. JCST certification guidelines have broadly standardised competency domains, yet large discrepancies persist regarding operative indicative numbers and assessments. This article serves as a definitive CCT guide regarding prevailing changes.

Gongs galore: phaleristic study of the relative risk of a healing art related New Year Honour.

OBJECTIVES: To compare proportional representation of healthcare specialty workers, in receipt of New Year Honours (NYHs) and examine system bias. DESIGN: Observational study of UK honours system including comparative analysis of proportional representation of the UK medical workforce. PARTICIPANTS: Recipients of NYHs from 2010 to 2019. MAIN OUTCOME MEASURES: Absolute risk of receiving an NYH, related to medical specialty, gender and geographical region. Relative risk (RR) of receiving an NYH for services to healthcare related to specialty. RESULTS: 11 207 NYHs were bestowed, with 368 (3.3%) awarded to healthcare professionals: 212 (57.6%) women, 156 (42.4%) men. The RR of a healthcare professional receiving an NYH was 0.76 (95% CI 0.68 to 0.84, p<0.001) when compared with the remaining UK workforce. Doctors received most NYHs (n=181), with public health, clinical oncology and general medicine specialties most likely to be rewarded (RR 20.35 (95% CI 9.61 to 43.08, p<0.001), 8.43 (95% CI 2.70 to 26.30, p<0.001) and 8.22 (95% CI 6.22 to 10.86, p<0.001)), respectively; anaesthetists received fewest NYHs (RR 0.52 (95% CI 0.13 to 2.10), p=0.305). Men were more likely to receive NYHs than women (OR 0.44, 95% CI 0.36 to 0.54; p<0.001). Two hundred and fifty-four NYHs (69.0%) were bestowed on residents of England (60, 16.3% London), 49 (13.3%) Scotland (p=0.003), 39 (10.6%) Wales (p<0.001) and 26 (7.1%) Northern-Ireland (p<0.001). CONCLUSIONS: Relative risk of receiving an NYH varied over 150-fold by specialty, twofold by gender and threefold by geographical location. Public health physicians are perceived to be the pick of the parade.

Trainee perspective of the causes of stress and burnout in surgical training: a qualitative study from Wales.

OBJECTIVES: Stress and burn-out among surgical trainees has been reported most prevalent in core surgical trainees (CST) and female trainees in particular. This study aimed to identify factors perceived by CSTs to be associated with stress and burnout in those at risk. DESIGN: An open-ended questionnaire was distributed to 79 CSTs and two researchers categorised responses independently, according to Michie's model of workplace stress. SETTING: A UK regional postgraduate medical region (Wales). PARTICIPANTS: Sixty-three responses were received; 42 males, 21 females. The response rate was 79.7%. RESULTS: Inter-rater reliability was good (k=0.792 (79.2%), p<0.001). The most common theme of Michie's model related to CST stress and burnout was career development, with most statements associated with curriculum, examination and academic demands required to attain a CST certificate of completion of training, and higher surgical national training number appointment. This was closely followed by those intrinsic to the job with recurrent discussion around the difficulties balancing work perceived to be service provision (ward work and on-calls), outpatient clinic and operative experience. Conversely, the most common themes relevant to stress and burnout among female trainees were associated with relationships at work (primarily the male-dominated nature of surgery), extraorganisational factors (family-work life balance) and individual characteristics (personality and physiological differences). CONCLUSION: CSTs' perceptions regarding the causes of National Health Service related stress and burnout are numerous, and these findings provide a basis for the development of targeted stressor counter-measures to improve training and well-being.

The Leaning Tower of Pasta: Lessons in Team Performance and Creativity From a Core Surgical Training Boot Camp Design Challenge.

AIMS: Unity of effort is an important component of strategic leadership and management theory associated with Core Surgical Training (CST) outcome. The aim was to determine the impact of team diversity on task completion: a creative design challenge, during CST Boot camp. METHODS: Attendees (n = 44) at a single Statutory Education Body's CST Boot camp were stratified into teams related to specialty theme, and set a design challenge as described by Peter Skillman, to build the tallest free-standing tower out of spaghetti (20 pieces), tape (1 m), and string (1 m), with a marshmallow on top in 18 minutes. Primary outcome measure was tower height. RESULTS: Five teams (50%) completed the task with the tallest tower measuring 70 cm (median 51, range 0-70). Median satisfaction with the simulation exercise was 4 (2-5) on a scale of 0 to 5, with 5 corresponding with highest satisfaction. Successful task completion was associated with team surgical specialty (p = 0.032), ethnicity ratio (p = 0.010,), and gender ratio (p = 0.003), respectively. On multivariable analysis, only team gender ratio was independently associated with tower height (Hazard ratio 0.515, 95% confidence interval 0.350-0.759, p = 0.001). CONCLUSION: Modern leadership theory emphasizes the important dynamic relationship between individual team members, the team, and task completion. General surgery themed teams with a gender mix were most successful in completing the design challenge; whether relative simulation performance predicts strategic organizational skill and career progression will be the next question.

Prognostic significance of serum inflammatory markers in esophageal cancer.

BACKGROUND: The aim of this study was to assess the relative prognostic value of biomarkers to measure the systemic inflammatory response (SIR) and potentially improve prognostic modeling in patients undergoing potentially curative surgery for esophageal adenocarcinoma (EC). METHODS: Consecutive 330 patients undergoing surgery for EC between 2004 and 2018 within a regional UK cancer network were identified. Serum measurements of haemoglobin, C-reactive protein, albumin, modified Glasgow Prognostic Score (mGPS), and differential neutrophil to lymphocyte ratio (NLR) were obtained before surgery, and correlated with histopathological factors and outcomes. Primary outcome measures were disease-free (DFS) and overall survival (OS). RESULTS: Of 330 OC patients, 294 underwent potentially curative esophagectomy. Univariable DFS analysis revealed pT, pN, pTNM stage (all p < 0.001), poor differentiation (p = 0.001), vascular invasion (p < 0.001), R1 status (p < 0.001), perioperative chemotherapy (p = 0.009), CRP (p = 0.010), mGPS (p = 0.011), and NLR (p < 0.001), were all associated with poor survival. Multivariable Cox regression analysis of DFS revealed only NLR [Hazard Ratio (HR) 3.63, 95% Confidence Interval (CI) 2.11-6.24, p < 0.001] retained significance. Multivariable Cox regression analysis of OS revealed similar findings: NLR [HR 2.66, (95% CI 1.58-4.50), p < 0.001]. CONCLUSION: NLR is an important SIR prognostic biomarker associated with DFS and OS in EC.

Biosensors, Biomarkers and Biometrics: a Bootcamp Perspective.

Introduction: Competitive physical performance is routinely monitored by wearable technology (biosensors), yet professional healthcare is not, despite high prevalence of trainee stress and burnout, notwithstanding the corresponding risk to patient safety. This study aimed to document the physiological stress response of UK Core Surgical Trainees (CSTs) during simulation training. Methods: CSTs (n=20, 10 male) were fitted with Vital Scout Wellness Monitors (VivaLNK, Campbell, California, USA) for an intensive 3-day training bootcamp. In addition to physiological parameters, CST demographics, event diaries and Maslach Burnout Inventory scores were recorded prospectively during exposure to three scenarios: interactive lectures, clinical skills simulation and non-technical (communication) training. Results: Baseline heart rate (BHR, 60 bpm (range 39-81 bpm)) and baseline respiratory rate (14/min (11-18/min)) varied considerably and did not correlate (rho 0.076, p=0.772). BHR was associated with weekly exercise performed (66 bpm (<1 hour) vs 43 bpm (>5 hour), rho -0.663, p=0.004). Trainee response (standardised median heart rate vs BHR) revealed heart rate was related proportionately to lectures (71 bpm, p<0.001), non-technical skills training (79 bpm, p<0.001) and clinical skills simulation (88 bpm, p<0.001). Respiratory rate responded similarly (p<0.001 in each case). Heart rate during clinical skills simulation was associated with emotional exhaustion (rho 0.493, p=0.044), but maximum heart rate was unrelated to CSTs' perceived peak stressors. Discussion: Stress response, as derived from positive sympathetic heart rate drive varied over two-fold, with a direct implication on oxygen uptake and energy expenditure, and highlighting the daily physical demands placed upon clinicians.

Economic cost-utility analysis of stage-directed gastric cancer treatment.

BACKGROUND: Gastric cancer (GC) treatment levies substantial financial burden on health services. Potentially curative surgery with or without chemotherapy is offered to patients with locoregional disease. This study aimed to examine treatment costs related to life-years gained in patients having potentially curative treatment (gastrectomy) and those receiving best supportive care (BSC). METHODS: Some 398 consecutive patients with GC were classified according to treatment modality (116 BSC, 282 gastrectomy). Cost calculations for 1 year's treatment from referral were made according to network diagnostic, staging and treatment algorithms. Primary outcome was overall survival (OS). RESULTS: GC median survival after BSC was 8 months, costing €5413, compared with gastrectomy median survival of 34 months, costing €22 753 for 1 year's treatment: cost per life-year gained €9319. Cost incurred for stage I GC was €22 434, stage II €23 498, stage III €22 445, and stage IV €22 032. Based on these values, the cost per quality adjusted life-year (QALY) for BSC for stage I GC was -€8335 stage II -€8952, stage III -€11 317, and stage IV -€25 669. CONCLUSION: Potentially curative treatment that included gastrectomy improved OS four-fold compared with BSC and was cost-effective at national thresholds of readiness to pay per QALY.

The Glasgow Microenvironment Score associates with prognosis and adjuvant chemotherapy response in colorectal cancer.

BACKGROUND: The Glasgow Microenvironment Score (GMS) combines peritumoural inflammation and tumour stroma percentage to assess interactions between tumour and microenvironment. This was previously demonstrated to associate with colorectal cancer (CRC) prognosis, and now requires validation and assessment of interactions with adjuvant therapy. METHODS: Two cohorts were utilised; 862 TNM I-III CRC validation cohort, and 2912 TNM II-III CRC adjuvant chemotherapy cohort (TransSCOT). Primary endpoints were disease-free survival (DFS) and relapse-free survival (RFS). Exploratory endpoint was adjuvant chemotherapy interaction. RESULTS: GMS independently associated with DFS (p = 0.001) and RFS (p < 0.001). GMS significantly stratified RFS for both low risk (GMS 0 v GMS 2: HR 3.24 95% CI 1.85-5.68, p < 0.001) and high-risk disease (GMS 0 v GMS 2: HR 2.18 95% CI 1.39-3.41, p = 0.001). In TransSCOT, chemotherapy type (pinteraction = 0.013), but not duration (p = 0.64) was dependent on GMS. Furthermore, GMS 0 significantly associated with improved DFS in patients receiving FOLFOX compared with CAPOX (HR 2.23 95% CI 1.19-4.16, p = 0.012). CONCLUSIONS: This study validates the GMS as a prognostic tool for patients with stage I-III colorectal cancer, independent of TNM, with the ability to stratify both low- and high-risk disease. Furthermore, GMS 0 could be employed to identify a subset of patients that benefit from FOLFOX over CAPOX.

Prognostic significance of low muscle volume in patients undergoing surgery for oesophageal cancer.

BACKGROUND & AIMS: This study aimed to determine the prognostic significance of low muscle volume (LMV) Bioelectrical Impedance Analysis (BIA), defined skeletal muscle index (SMI, Kg/m2 male ≤8.75, female ≤5.75) in patients undergoing potentially curative surgery for Oesophageal Cancer (OC). METHODS: A prospective study of 122 patients diagnosed with OC [median age 65 yr, 104 male, 65 neoadjuvant therapy] who underwent preoperative BIA (Maltron Bioscan 920). Primary outcome measure was Overall Survival (OS). RESULTS: LMV was identified in 11 (9.0%) of patients, which was associated with low lean muscle mass (27.3 vs. 31.1 kg, p = 0.012), low body fat (8.8 vs.19.3 kg, p < 0.001), and greater total body water (72.2 vs. 62.2%, p = 0.001), and more open & close laparotomies (36.4 vs. 8.1%, p = 0.012). Median and 5-year OS was 16 months and 18.2% in LMV patients, compared with 51 months and 52.4% in non-sarcopenic patients (p = 0.002). On multivariable analysis of pre-operative variables, only LMV (HR 2.75; 95% CI 1.33-5.66, p = 0.006) was associated with OS. CONCLUSION: BIA is an important prognostic indicator in OC and focused pre-habilitation consequently has strong potential.

Targeting Wnt Signaling for the Treatment of Gastric Cancer.

The Wnt signaling pathway is evolutionarily conserved, regulating both embryonic development and maintaining adult tissue homeostasis. Wnt signaling controls several fundamental cell functions, including proliferation, differentiation, migration, and stemness. It therefore plays an important role in the epithelial homeostasis and regeneration of the gastrointestinal tract. Often, both hypo- or hyper-activation of the pathway due to genetic, epigenetic, or receptor/ligand alterations are seen in many solid cancers, such as breast, colorectal, gastric, and prostate. Gastric cancer (GC) is the fourth commonest cause of cancer worldwide and is the second leading cause of cancer-related death annually. Although the number of new diagnoses has declined over recent decades, prognosis remains poor, with only 15% surviving to five years. Geographical differences in clinicopathological features are also apparent, with epidemiological and genetic studies revealing GC to be a highly heterogeneous disease with phenotypic diversity as a result of etiological factors. The molecular heterogeneity associated with GC dictates that a single 'one size fits all' approach to management is unlikely to be successful. Wnt pathway dysregulation has been observed in approximately 50% of GC tumors and may offer a novel therapeutic target for patients who would otherwise have a poor outcome. This mini review will highlight some recent discoveries involving Wnt signaling in GC.

Histological phenotypic subtypes predict recurrence risk and response to adjuvant chemotherapy in patients with stage III colorectal cancer.

Histological 'phenotypic subtypes' that classify patients into four groups (immune, canonical, latent and stromal) have previously been demonstrated to stratify survival in a stage I-III colorectal cancer (CRC) pilot cohort. However, clinical utility has not yet been validated. Therefore, this study assessed prognostic value of these subtypes in additional patient cohorts along with associations with risk of recurrence and response to chemotherapy. Two independent stage I-III CRC patient cohorts (internal and external cohort) were utilised to investigate phenotypic subtypes. The primary endpoint was disease-free survival (DFS) and the secondary endpoint was recurrence risk (RR). Stage II-III patients, from the SCOT adjuvant chemotherapy trial, were utilised to further validate prognostic value and for exploratory analysis assessing associations with adjuvant chemotherapy. In an 893-patient internal cohort, phenotypic subtype independently associated with DFS (p = 0.025) and this was attenuated in stage III patients (p = 0.020). Phenotypic subtype also independently associated with RR (p < 0.001) in these patients. In a 146-patient external cohort, phenotypic subtype independently stratified patients by DFS (p = 0.028), validating their prognostic value. In 1343 SCOT trial patients, the effect of treatment type significantly depended on phenotypic subtype (pinteraction = 0.011). Phenotypic subtype independently associated with DFS in stage III patients receiving FOLFOX (p = 0.028). Furthermore, the immune subtype significantly associated with better response to FOLFOX compared to CAPOX adjuvant chemotherapy in stage III patients (p = 0.013). In conclusion, histological phenotypic subtypes are an effective prognostic classification in patients with stage III CRC that associates with risk of recurrence and response to FOLFOX adjuvant chemotherapy.