Enhanced Stress Resilience Training for UK Surgical Trainees; Effect and Evolution Evaluated.

INTRODUCTION: Core Surgical Training (CST) programs are associated with high burnout. This study aimed to assess the influence of Enhanced Stress Resilience Training (ESRT) over a 2-year period in a single UK Statutory Education Body. METHOD: CSTs participated in 5-weeks of formal ESRT to address work stressors. The primary outcome measure was career progression related to curriculum metrics and National Training Number (NTN) appointment. Secondary measures related to burnout using validated psychological inventories. RESULTS: Of 42 CSTs, 13 engaged fully with ESRT (31.0%; male 8, female 5, median age 28 year.), 11 engaged partially, and 18 did not. ESRT engagement was associated with better NTN appointment (ESRT 8/13 (61.5%) vs. not 1/18 (5.6%), p = 0.025), less burnout [aMBI; mean 5.14 (SD ± 2.35) vs. 3.14 (±2.25), F 6.637, p = 0.002, ηp2=0.167], less stress [PSS-10; 19.22 (±5.91) vs. 15.79 (±5.47), F 8.740, p < 0.001, ηp2=0.200], but more mindfulness [CAMS-R; 19.22 (±5.91) vs. 20.57 (±2.93), F 3.201, p = 0.047, ηp2=0.084]. On multivariable analysis, Improving Surgical Training (run-through CST) program (OR 5.2 (95% CI 1.42-28.41, p = 0.022), MRCS pass (OR 17.128 (95% CI 1.48-197.11, p = 0.023) and ESRT engagement (OR 13.249, 95% CI 2.08-84.58, p = 0.006) were independently associated with NTN success. DISCUSSION: ESRT was associated with less stress and burnout, better mindfulness, and most importantly 13-fold better career progression.

Effect of intraoperative botulinum toxin injection on delayed gastric emptying and need for endoscopic pyloric intervention following esophagectomy: a systematic review, meta-analysis, and meta-regression analysis.

The aim of this study was to evaluate the effect of intraoperative botulinum toxin (BT) injection on delayed gastric emptying (DGE) and need for endoscopic pyloric intervention (NEPI) following esophagectomy. In compliance with Preferred Reporting Items for Systematic reviews and Meta-Analyses statement standards, a systematic review of studies reporting the outcomes of intraoperative BT injection in patients undergoing esophagectomy for esophageal cancer was conducted. Proportion meta-analysis model was constructed to quantify the risk of the outcomes and direct comparison meta-analysis model was constructed to compare the outcomes between BT injection and no BT injection or surgical pyloroplasty. Meta-regression was modeled to evaluate the effect of variations in different covariates among the individual studies on overall summary proportions. Nine studies enrolling 1070 patients were included. Pooled analyses showed that the risks of DGE and NEPI following intraoperative BT injection were 13.3% (95% confidence interval [CI]: 7.9-18.6%) and 15.2% (95% CI: 7.9-22.5%), respectively. There was no difference between BT injection and no BT injection in terms of DGE (odds ratio [OR]: 0.57, 95% CI: 0.20-1.61, P = 0.29) and NEPI (OR: 1.73, 95% CI: 0.42-7.12, P = 0.45). Moreover, BT injection was comparable to pyloroplasty in terms of DGE (OR: 0.85, 95% CI: 0.35-2.08, P = 0.73) and NEPI (OR: 8.20, 95% CI: 0.63-105.90, P = 0.11). Meta-regression suggested that male gender was negatively associated with the risk of DGE (coefficient: -0.007, P = 0.003). In conclusion, level 2 evidence suggests that intraoperative BT injection may not improve the risk of DGE and NEPI in patients undergoing esophagectomy. The risk of DGE seems to be higher in females and in early postoperative period. High quality randomized controlled trials with robust statistical power are required for definite conclusions. The results of the current study can be used for hypothesis synthesis and power analysis in future prospective trials.

Neuro- and cognitive diversity in surgery and allied professions: celebrating difference and optimising performance.

Neurotypicality (NT) and neurodiversity (ND) are two terms used to describe separate ways of thinking and experiencing the world. The prevalence of ND within surgery and allied professions is poorly studied or understood but is likely to be significant and increasing. If our aim is to be truly inclusive, ND's effects on teams and our willingness and ability to adapt adequately must improve.

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.

A retrospective cohort study of differential attainment, COVID and chaos: taking the difference out of a terrible trinity.

BACKGROUND: This study aimed to evaluate core surgical training (CST) differential attainment related to coronavirus disease 2019 (COVID-19), gender and ethnicity. The hypothesis was that COVID-19 adversely influenced CST outcomes. METHODS: A retrospective cohort study of 271 anonymised CST records was undertaken at a UK Statutory Education Body. Primary effect measures were Annual Review of Competency Progression Outcome (ARCPO), Membership of the Royal College of Surgeons (MRCS) examination pass and Higher Surgical Training National Training Number (NTN) appointment. Data were collected prospectively at ARCP and analysed with non-parametric statistical methods in SPSS. RESULTS: CSTs numbering 138 completed training pre-COVID and 133 peri-COVID. ARCPO 1, 2 and 6 were 71.9% pre-COVID versus 74.4% peri-COVID ( P =0.844). MRCS pass rates were 69.6% pre-COVID versus 71.1% peri-COVID ( P =0.968), but NTN appointment rates diminished (pre-COVID 47.4% vs. peri-COVID 36.9%, P =0.324); none of the above varied by gender or ethnicity. Multivariable analyses by three models revealed: ARCPO was associated with gender [m:f 1:0.87, odds ratio (OR) 0.53, P =0.043] and CST theme (Plastics vs. General OR 16.82, P =0.007); MRCS pass with theme (Plastics vs. General OR 8.97, P =0.004); NTN with the Improving Surgical Training run-through programme (OR 5.00, P <0.001). Programme retention improved peri-COVID (OR 0.20, P =0.014) with pan University Hospital rotations performing better than Mixed or District General-only rotations (OR 6.63, P =0.018). CONCLUSION: Differential attainment profiles varied 17-fold, yet COVID-19 did not influence ARCPO or MRCS pass rates. NTN appointment fell by one-fifth peri-COVID, but overall training outcome metrics remained robust despite the existential threat.

Personal protective equipment-induced systemic hypercapnic hypoxaemia: translational implications for impaired cognitive-clinical functional performance.

BACKGROUND: Personal protective equipment (PPE) adversely affects pulmonary gas exchange and may result in systemic hypercapnic hypoxaemia and headache. This study aimed to determine what extent PPE affects cerebral symptoms, global cerebral blood flow, and cognitive functional performance. METHODS: Higher surgical trainees participated in a randomized, repeated-measures, crossover study, completing 60 min of laparoscopic surgical simulation in both standard operating attire and type 3 PPE. Measurements were collected at baseline and after 60 min of simulation. The primary outcome measure was headache. Headache was examined using the validated visual analogue scale (VAS) and Environmental Symptoms Questionnaire C (ESQ-C), global cerebral blood flow with duplex ultrasonography, and visuospatial and executive gross/fine motor function with grooved peg board (GPB) and laparoscopic bead (LSB) board tasks. RESULTS: Thirty-one higher surgical trainees (20 men, 11 women) completed the study. Compared with standard operating attire, PPE increased headache assessment scores (mean(s.d.) VAS score 3.5(5.6) versus 13.0(3.7), P < 0.001; ESQ-C score 1.3(2.0) versus 5.9(5.1), P < 0.001) and was associated with poorer completion times for GPB-D (61.4(12.0) versus 71.1(12.4) s; P = 0.034) and LSB (192.5(66.9) versus 270.7(135.3) s; P = 0.025) tasks. Wearing PPE increased heart rate (82.5(13.6) versus 93.5(13.0) beats/min; P = 0.022) and skin temperature (36.6(0.4) versus 37.1(0.5)°C; P < 0.001), but decreased peripheral oxygen saturation (97.9(0.8) versus 96.8(1.0) per cent; P < 0.001). Female higher surgical trainees exhibited higher peripheral oxygen saturation across all conditions. No differences were observed in global cerebral blood flow as a function of attire, time or sex. CONCLUSION: Despite no marked changes in global cerebral blood flow, type 3 PPE was associated with increased headache scores and cerebral symptoms (VAS and ESQ-C) alongside impaired executive motor function highlighting the clinical implications of PPE-induced impairment for cognitive-clinical performance.

Face validity of a virtual reality simulation platform to improve competency in endoscopy: a prospective observational cohort study.

Background and study aims Virtual reality endoscopic simulation training has the potential to expedite competency development in novice trainees. However, simulation platforms must be realistic and confer face validity. This study aimed to determine the face validity of high-fidelity virtual reality simulation (EndoSim, Surgical Science, Gothenburg), and establish benchmark metrics to guide the development of a Simulation Pathway to Improve Competency in Endoscopy (SPICE). Methods A pilot cohort of four experts rated simulated exercises (Likert scale score 1-5) and following iterative development, 10 experts completed 13 simulator-based endoscopy exercises amounting to 859 total metric values. Results Expert metric performance demonstrated equivalence ( P  = 0.992). In contrast, face validity of each exercise varied among experts (median 4 (interquartile range [IQR] 3-5), P  < 0.003) with Mucosal Examination receiving the highest scores (median 5 [IQR 4.5-5], P  = 1.000) and Loop Management and Intubation exercises receiving the lowest scores (median 3 [IQR 1-3], P  < 0.001, P  = 0.004), respectively. The provisional validated SPICE comprised 13 exercises with pass marks and allowance buffers defined by median and IQR expert performance. Conclusions EndoSim Face Validity was very good related to early scope handling skills, but more advanced competencies and translation of acquired clinical skills require further research within an established training program. The existing training deficit with superadded adverse effects of the COVID pandemic make this initiative an urgent priority.

Hospital compound-level endoscopy training quality performance: scoping the spectrum.

Background and study aims This study aimed to assess the quality of endoscopy training in a UK Statutory Educational Body compared with Joint Advisory Group on Gastrointestinal Endoscopy Training standards (JETS). Methods A total of 28,298 training procedures recorded by 211 consecutive cross-specialty trainee endoscopists registered with JETS in 18 hospitals during 2019 were analyzed. Data included trainer and trainee numbers, training list frequency, procedures, direct observation of procedural skills (DOPS) completion, and key performance indicators. Results Annual median training procedures per hospital were 1395 (interquartile range (IQR) 465-2365). Median trainers and trainees per unit were 11 (6-18) and 12 (7-16), respectively, (ratio 0.8 [0.7-1.3]). Annual training list frequency per trainee was 13 (10-17), 35.0 % short of Joint Advisory Group (JAG) standard (n = 20, P = 0.001, effect size -0.56). Median points per adjusted training list were 11 (5-18). Median DOPS per trainee and trainer were three (1-6) and four (1-7) respectively; completing 0.2 DOPS (0.1-0.4) per list and amounting to six (2-12) per 200 procedures: fewer than half of the JAG standard (20 per 200) (P < 0.001, -0.61). Esophagogastroduodenoscopy median KPI: J maneuver 94 % (90-96), D2 intubation 93 % (91-96); Colonoscopy KPI: cecal intubation 82 % (72-90), polyp detection rate 25 % (18-34). Compound hospital score ranged from nine to 26 (median 17 [14-20]). Conclusions Important performance disparity emerged with three-fold variation in compound hospital training quality and most units underperforming compared with JAG standards. Trainees and training program directors should be aware of such metrics to improve quality endoscopy educational programs and consider formal adjuncts to optimize training.

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.

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.

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.

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.

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.