The potential value of surrogate performance markers at caesarean section for the assessment of surgical competence.

OBJECTIVES: We hypothsised that surrogate markers of competence (procedure time and estimated surgical blood loss) could be of value when assessing competence for trainees learning to undertake lower segment caesarean section (LSCS). The study aim was to investigate differences in surrogate markers of surgical competence at LSCS between different training grades of primary surgeon and for different grades of surgical assistant; to assess the potential value of using these surrogate markers in overall assessments of surgical competence. STUDY DESIGN: Operating records for elective LSCS were reviewed from January 2007 to January 2015. Uncomplicated LSCS where a junior trainee (ST2/ST3) or a senior trainee (ST6+) was the primary surgeon were included. Inclusion criteria were LSCS with body mass index less than 35, singleton pregnancy, greater than 34 weeks' gestation, no more than one previous caesarean section and no low-lying placenta. Procedure time, estimated blood loss and the effect of the grade of surgical assistant (consultant or trainee) on these were compared overall for all surgeons at ST2 level, ST3 level and senior level (ST6+) using Student's t test and effect size calculation (Cohen test). RESULTS: During the study period 3099 uncomplicated LSCS were performed by 60 trainees: 1367 by ST2, 1085 by ST3 and 646 by senior trainees (ST6+). Mean procedure times and recorded estimated blood loss decreased significantly for each level of training (p < 0.05). The degree of experience of the surgical assistant was also associated with reduced procedure times and blood loss, this was significant for trainees in ST2 when assisted by a consultant (p < 0.05). CONCLUSIONS: Training progression is associated with a reduction in procedure time and estimated blood loss, which are both surrogate markers of competence at LSCS. Current objective structured assessments of technical competence for trainees (OSATS) do not take these metrics into account when assessing performance. An enhanced assessment of trainees undertaking LSCS is suggested, reviewing both objective structured assessments of technical performance (OSATS) and surrogate markers of performance recorded in a surgical logbook to provide a more comprehensive assessment of overall competence.

Healthcare reform in the USA, 2010: the rocky road ahead?

Historic legislation for healthcare reform in the United States was enacted in March 2010. Reforms in medical practice, payment for services, and access to care and insurance will be introduced by complex processes over time through 2019. The overriding goals of healthcare reform are cost containment and guaranteeing access to all Americans. The contentious political struggle that preceded the legislation is emblematic of the continuous struggle in American society to define who is worthy of services. Understanding the value framework for social and welfare provisions in American society is crucial to making sense of the piecemeal policy making characteristic of the development of healthcare over the past 50 years. Here some highlights of the reform and the complex organisation of American healthcare are discussed.

Medical pluralism in India: patient choice or no other options?

The maldistribution of biomedical services creates a dilemma for Indian patients. They encounter a bewildering array of medical services, ranging from qualified traditional medical practitioners to untrained, self-taught purveyors of medicines and cures. Research on Indian healthcare has decried the inefficient distribution of services in rural and urban areas. The studies discussed here reveal the ground reality of the consequences of limited choices for patients, characterised as "forced pluralism," with no state regulation of type of care, quality of care, or credentials of practitioners.