'Thrown in at the deep end': a qualitative analysis into the transition from trainee to consultant during the COVID-19 pandemic and lessons for the future.

Background: Sustained crises such as the COVID-19 pandemic would be expected to impact the transition from trainee to consultant for anaesthetists or intensivists, but limited research exists on this important topic. This study aimed to examine the social context of this crucial career transition during the pandemic and post-pandemic periods. Methods: We conducted semi-structured interviews with anaesthetists and intensivists who became consultants after the first UK lockdown. Thematic analysis was used and data saturation was reached at 33 interviews. Results: The pandemic substantially impacted the transition to consultant role in various ways, including professional identity, clinical and non-clinical responsibilities, and wellbeing. Participants experienced identity confusion, self-doubt, and moral injury, resulting in intense emotional distress, feelings of guilt and helplessness, which persisted beyond the pandemic. They also felt unprepared for their consultant roles because of disruptions in training. The pandemic exaggerated the vulnerability of those transitioning to consultants, because of increased clinical uncertainties, and pressures of the growing backlog. Additionally, the pandemic impacted on the wellbeing of those transitioning to consultants, intensifying feelings of anxiety and stress. We also identified unique opportunities presented by the pandemic, which accelerated learning and encouraged post-traumatic growth. Our study identified practical solutions that may improve transition experience at individual, organisational, and national levels. Conclusions: Persistent crises significantly impact the transition from trainee to consultant. Our findings generated insights into the challenges of this critical career transition and staff wellbeing, and serve to inform approaches of ongoing support for those transitioning to consultants.

Functional and structural abnormalities after milligan hemorrhoidectomy: a comparison with healthy subjects.

BACKGROUND: Fecal incontinence is a rare but well-known adverse effect of hemorrhoidectomy. OBJECTIVE: The objective of this study was to identify possible reasons for incontinence after hemorrhoidectomy. DESIGN: We conducted a retrospective comparative study. SETTINGS: The study was performed in 1 university hospital and 1 general district hospital serving 2 counties in central Sweden. PATIENTS: In a cohort of 418 patients with consecutive Milligan hemorrhoidectomies, 40 reported fecal incontinence that was attributed to surgery. Of these, 19 patients agreed to participate. Fifteen age- and sex-matched patients from the same cohort who were operated on, but without symptoms of incontinence, were also studied, as was a third reference group of 19 age- and sex-matched persons serving as a population-based control group. INTERVENTION: All of the participants answered a bowel function questionnaire and underwent clinical evaluation, including rectoscopy, anal manometry, saline infusion test, and endoanal ultrasound. MAIN OUTCOME MEASURES: We evaluated anal resting and squeeze pressures, sphincter defects, and continence function. RESULTS: The symptomatic patients had higher incontinence scores than the control groups (p = 0.00002). The mean resting pressure at the high-pressure zone was also reduced in this group (p = 0.047). External sphincter injuries were detected in 4 (20%) of 19 subjects compared with none in the control group (p = 0.11). Saline infusion test in the patients reporting incontinence showed reduced ability to hold liquids compared with healthy controls (p = 0.004). LIMITATIONS: This study was limited by selection bias and limited numbers in the groups. CONCLUSIONS: In the group of patients reporting incontinence after hemorrhoidectomy, there was a proportion with sphincter defects and impaired sphincter function. These results indicate a need for cautious patient selection and improved or alternative surgical techniques.

Self vs expert assessment of technical and non-technical skills in high fidelity simulation.

BACKGROUND: Accurate assessment is imperative for learning, feedback and progression. The aim of this study was to examine whether surgeons can accurately self-assess their technical and nontechnical skills compared with expert faculty members' assessments. METHODS: Twenty-five surgeons performed a laparoscopic cholecystectomy (LC) in a simulated operating room. Technical and nontechnical performance was assessed by participants and faculty members using the validated Objective Structured Assessment of Technical Skills (OSATS) and the Non-Technical Skills for Surgeons scale (NOTSS). RESULTS: Assessment of technical performance correlated between self and faculty members' ratings for experienced (median score, 30.0 vs 31.0; ρ = .831; P = .001) and inexperienced (median score, 22.0 vs 28.0; ρ = .761; P = .003) surgeons. Assessment of nontechnical skills between self and faculty members did not correlate for experienced surgeons (median score, 8.0 vs 10.5; ρ = -.375; P = .229) or their more inexperienced counterparts (median score, 9.0 vs 7.0; ρ = -.018; P = .953). CONCLUSIONS: Surgeons can accurately self-assess their technical skills in virtual reality LC. Conversely, formal assessment with faculty members' input is required for nontechnical skills, for which surgeons lack insight into their behaviours.

Faking it? Simulation in the training of obstetricians and gynaecologists.

PURPOSE OF REVIEW: This paper discusses the use of simulation as a training tool in obstetrics and gynaecology. RECENT FINDINGS: Modern medical training and patient pressure for treatment by more experienced clinicians have contributed to a reduction in the training opportunities available to junior doctors. Advances in information technology have led to the successful introduction of simulator-based training in many safety-critical industries such as aviation and nuclear power. In this editorial we describe simulation devices that are available to obstetrics and gynaecology and explain how simulation can benefit the patient, trainee and educator. We also explore how simulation could be integrated into obstetrics and gynaecology training programmes. SUMMARY: At present simulation is very much underused as a training tool in medicine, and features little in the postgraduate training curriculum. In obstetrics and gynaecology simulation could be used as an educational tool to assist in (1) transfer of knowledge, (2) practising diagnostic and simple practical skills, (3) surgical skills training, (4) emergency drill training and (5) human factors and team training. Whereas simulation should not be perceived as a replacement for training with real patients, educators should embrace the opportunities that simulation provides and integrate it into current training programmes to maximize training opportunities and patient safety.

Bowel habits in hemorrhoid patients and normal subjects.

OBJECTIVES: Bleeding, pain, soiling, and prolapse are the classic symptoms in hemorrhoid disease, but the patients sometimes report a variety of other symptoms. Little is known about functional bowel symptoms in patients with hemorrhoids and few studies have previously addressed this subject. The aim of this study was to compare patients with hemorrhoids with a control population regarding functional bowel symptoms and anorectal complaints. METHODS: One hundred consecutive patients who participated in a randomized study on hemorrhoidectomy completed a validated questionnaire on bowel and anorectal functional symptoms. Two hundred age- and gender-matched population based control subjects, and 100 gender-matched consecutive patients undergoing an orthopedic procedure served as two control groups, and completed the same questionnaire. RESULTS: Bowel frequency was the same in all three groups, but only 37% of the patients described their bowel movements as normal, compared to 55 and 67% of the controls (p < 0.001). Up to 37% of the patients reported bloating, compared to 18 and 26% in the control groups. Abdominal pain associated with bowel evacuation was experienced by 34% of the patients but in 3 and 5% of the controls (p < 0.001). Excessive straining, feeling of incomplete evacuation, and repeated toilet visits were significantly more usual in the patients. Reduced feeling of well being and disturbed social life caused by bowel symptoms was often reported by patients but rarely in the control groups. CONCLUSIONS: Beside hemorrhoidal symptoms, many patients with Grade 3-4 hemorrhoids have concomitant functional bowel symptoms, possibly associated with the irritable bowel syndrome. This knowledge might be important while selecting therapy for patients with hemorrhoids.

Long-term results of haemorrhoidectomy.

OBJECTIVE: To assess the long-term functional results of Milligan-Morgan haemorrhoidectomy. DESIGN: Retrospective multicentre study. SETTING: One university hospital, one county hospital, and two community hospitals, Sweden. SUBJECTS: 507 of 556 patients who were operated on for haemorrhoids by the Milligan-Morgan technique between January 1987 and December 1995. INTERVENTION: A questionnaire was sent to all 507 patients, the questions in which focused on functional results and satisfaction. MAIN OUTCOME MEASURES: Patients' satisfaction and symptoms of anal incontinence after haemorrhoidectomy. RESULTS: 418 of the 507 responded (82%). Altogether 279 patients (67%) reported a successful result, while 139 patients (33%) reported impaired anal continence. 40 of the 139 patients (29%) claimed that the incontinence was a direct result of the haemorrhoidectomy. Female sex (p = 0.005) and an operation for hygienic problems (p = 0.02) were associated with a higher risk of incontinence. CONCLUSION: Impaired anal continence is common after Milligan-Morgan haemorrhoidectomy and a large proportion of affected patients relate their problems to the operation.