Use of the eLogbook in surgical training in the United Kingdom: A nationwide survey and consensus recommendations from the Association of Surgeons in Training.

INTRODUCTION: Accurate recording of operative cases is essential during training to demonstrate experience. However, indicative numbers delineating minimum desirable experience may incentivise exaggeration or misrepresentation of experience. This study aimed to determine perceptions of real-world eLogbook use among UK surgeons in training. MATERIAL AND METHODS: An anonymous online questionnaire was disseminated electronically using a pre-planned yield-maximisation strategy, incorporating regional champions, email and social media. Evaluation employed mixed methods in a combined interpretation of quantitative and qualitative data from the questionnaire. Recommendations for development of the eLogbook were itemised from respondents' free text items and a modified Delphi process, conducted within the Council of the UK national trainee representative body, the Association of Surgeons in Training, determined the strength of each recommendation. RESULTS: Analysis included 906 complete responses from training-grade surgeons (34.8% female) from all UK recognised specialties and all grades of training. More than two-thirds (68.5%) believed that overstatement or misrepresentation of case involvement occurs. A fifth (20.8%) reported witnessing trainees logging cases they had not actually participated in and almost a third (32.7%) had witnessed overstatement, yet few (15.1%) had raised such an issue with a supervisor. Most (85.2%) respondents had few or no eLogbook entries validated. More than a quarter of respondents felt pressure to overstate their involvement in cases (28.6%) and the number recorded (28.1%). Almost a third (31.5%) felt the required case number for completion of training was not achievable. Female trainees were less likely to feel well supervised (p = 0.022) and to perceive targets for completion of training were achievable (p = 0.005). Thematic analysis identified four key themes to explain logbook misuse: Pressure to achieve training milestones; eLogbook functionality issues; training deficiencies and probity. CONCLUSIONS: Inaccurate operative recording was widely reported, primarily in response to perceived pressure to achieve targets for career progression. Operative logbooks may not be as accurate as intended. Consensus recommendations are made for improvement in the eLogbook and its use.

Supporting doctors as healthcare quality and safety advocates: Recommendations from the Association of Surgeons in Training (ASiT).

BACKGROUND: As front-line healthcare staff, doctors in surgical training occupy a unique organisational space rotating through hospitals and services in which they witness first hand both good and bad practice. This puts trainees in a clear position to identify and raise patient safety issues, and to contribute to discussions regarding quality and safety improvement. However, there are a number of real and perceived barriers to trainees doing so. These include concerns about the impact on training assessments and career progression, and uncertainty about the appropriate route. METHODS: Paper-based survey of delegates attending the Association of Surgeons in Training (ASiT) conference (response rate 73%; 479/652). RESULTS: 288 (60%) of trainees reported previous concerns over practices and behaviour of colleagues that might pose risks to patient care including concerns over poor performance (n = 243; 84%), bullying (n = 45; 16%), alcohol and drug abuse (n = 15; 5%) and mental health problems (n = 8; 3%). However, 53% (n = 153) did not escalate these concerns. 178 (37%) of trainees also reported concerns over hospital policies, protocols or systems that might pose a risk to patient care, with 46% (n = 82) not escalating such concerns. Respondents highlighted fear of personal vilification or reprisal (n = 224; 47%), fear of impact on career (n = 206; 43%) and a lack of confidence in the process (n = 170; 36%) as barriers to whistleblowing. More senior trainees were significantly more likely to raise concerns than more junior grades (p < 0.0001). CONCLUSION: These results highlight worrying issues around reporting concerns, with trainees often "silent witnesses" to poor performance in healthcare. Adverse events must provide opportunities for learning to improve future outcomes. Herein, ASiT proposes 14 recommendations to improve protection for trainees in raising patient safety concerns. These include the creation of a positive workplace culture, promoting the active involvement of trainees in quality improvement discussions, with clear mechanisms for trainees to raise concerns.

Systematic review with meta-analysis of the impact of surgical fellowship training on patient outcomes.

BACKGROUND: The number of surgeons entering fellowship training before independent practice is increasing. This may have a negative impact on surgeons in training. The impact of fellowship training on patient outcomes is not yet known. This review aimed to investigate the impact of fellowship training in surgery on patient outcomes. METHODS: A systematic review of the literature was conducted to identify studies exploring the structural and surgeon-specific characteristics of fellowship training on patient outcomes. Data from these studies were extracted, synthesized and reported qualitatively, or quantitatively through meta-analysis. RESULTS: Twenty-three studies were included. The mortality rate for patients in centres with an affiliated fellowship programme was lower than that for centres without (odds ratio 0.86, 95 per cent c.i. 0.84 to 0.88), as was the rate of complications (odds ratio 0.90, 0.78 to 1.02). Surgeons without fellowship training converted more laparoscopic operations to open surgery than those with fellowship training (risk ratio (RR) 1.04, 95 per cent c.i. 1.03 to 1.05). Comparison of outcomes for senior surgeons versus current fellows showed no differences in rates of mortality (RR 1.00, 1.00 to 1.01), complications (RR 1.03, 0.98 to 1.08) or conversion to open surgery (RR 1.01, 1.00 to 1.01). CONCLUSION: Fellowship training appears to have a positive impact on patient outcomes.

Surgical treatment of gastrointestinal stromal tumour of the rectum in the era of imatinib.

BACKGROUND: Gastrointestinal stromal tumours (GISTs) of the rectum often require radical surgery to achieve complete resection. This study investigated the management and outcome of surgery for rectal GISTs and the role of imatinib. METHODS: A cohort study was undertaken of patients identified from a database at one tertiary sarcoma referral centre over a continuous period, from January 2001 to January 2013. RESULTS: Over 12 years, 19 patients presented with a primary rectal GIST. Median age was 57 (range 30-77) years. Neoadjuvant imatinib was used in 15 patients, significantly reducing mean tumour size from 7·6 (95 per cent c.i. 6·1 to 9·0) to 4·1 (2·8 to 5·3) cm (P < 0·001). Nine of these patients underwent surgical resection. Imatinib therapy enabled sphincter-preserving surgery to be undertaken in seven patients who would otherwise have required abdominoperineal resection or pelvic exenteration for tumour clearance. Neoadjuvant imatinib treatment also led to a significant reduction in mean(s.d.) tumour mitotic count from 16(16) to 4(9) per 50 high-power fields (P = 0·015). Imatinib was used only as adjuvant treatment in two patients. There were three deaths, all from unrelated causes. Eleven of the 13 patients who underwent resection were alive without evidence of recurrence at latest follow-up, with a median disease-free survival of 38 (range 20-129) months and overall survival of 62 (39-162) months. CONCLUSION: The use of neoadjuvant imatinib for rectal GISTs significantly decreased both tumour size and mitotic activity, which permitted less radical sphincter-preserving surgery.

A cross sectional study of surgical training among United Kingdom general practitioners with specialist interests in surgery.

OBJECTIVES: Increasing numbers of minor surgical procedures are being performed in the community. In the UK, general practitioners (family medicine physicians) with a specialist interest (GPwSI) in surgery frequently undertake them. This shift has caused decreases in available cases for junior surgeons to gain and consolidate operative skills. This study evaluated GPwSI's case-load, procedural training and perceptions of offering formalised operative training experience to surgical trainees. DESIGN: Prospective, questionnaire-based cross-sectional study. SETTING/PARTICIPANTS: A novel, 13-item, self-administered questionnaire was distributed to members of the Association of Surgeons in Primary Care (ASPC). A total 113 of 120 ASPC members completed the questionnaire, representing a 94% response rate. Respondents were general practitioners practising or intending to practice surgery in the community. RESULTS: Respondents performed a mean of 38 (range 5-150) surgical procedures per month in primary care. 37% (42/113) of respondents had previously been awarded Membership or Fellowship of a Surgical Royal College; 22% (25/113) had completed a surgical certificate or diploma or undertaken a course of less than 1 year duration. 41% (46/113) had no formal British surgical qualifications. All respondents believed that surgical training in primary care could be valuable for surgical trainees, and the majority (71/113, 63%) felt that both general practice and surgical trainees could benefit equally from such training. CONCLUSIONS: There is a significant volume of surgical procedures being undertaken in the community by general practitioners, with the capacity and appetite for training of prospective surgeons in this setting, providing appropriate standards are achieved and maintained, commensurate with current standards in secondary care. Surgical experience and training of GPwSI's in surgery is highly varied, and does not yet benefit from the quality assurance secondary care surgical training in the UK undergoes. The Royal Colleges of Surgery and General Practice are well placed to invest in such infrastructure to provide long-term, high-quality service and training in the community.

Mentorship in surgical training: current status and a needs assessment for future mentoring programs in surgery.

AIMS: Mentoring has been used extensively in the business world to enhance performance and maximise potential. Despite this, there is currently a paucity of literature describing mentoring for surgical trainees. This study examined the current extent of mentoring and investigated future needs to support this. METHODS: An electronic, 47-item, self-administered questionnaire survey was distributed via national and regional surgical mailing lists and websites through the Association of Surgeons in Training and Specialty Associations in the UK and Republic of Ireland. RESULTS: Overall, 565 fully completed responses were received from trainees in all specialties, grades and training regions. A total of 48.7 % of respondents reported that they have a surgical mentor, with no significant gender difference (p = 0.65). Of respondents, 52.5 % considered their educational supervisor and 45.5 % their current consultant as mentors. Modal duration of mentoring relationships was 1-2 years (24.4 %). A total of 90.2 % of mentors were in the same specialty, 60.7 % in the same hospital, and 88.7 % in the same training region. Mentors covered clinical and professional matters (99.3 %) versus pastoral and non-clinical matters (41.1 %). Mentoring was commonly face to face or via email and not documented (64.7 %). Of the 51.3 % without a mentor, 89.7 % would like a clinical mentor and 51.0 % a pastoral mentor (p < 0.001). Priority mentoring areas included career progression (94.9 %), research (75.2 %), clinical skills (66.9 %) and clinical confidence (58.4 %). A total of 94.3 % would be willing to act as a peer mentor. Only 8.7 % had received mentoring training; 83 % wish to undertake this. CONCLUSIONS: Less than half of surgical trainees identified a mentor. The majority want mentoring on professional topics during their training and would additionally be willing to peer-mentor colleagues, although few have received training for this. Despite an identified need, there is currently no structure for organising this and little national provision for mentoring.

Publication of surgeon specific outcome data: a review of implementation, controversies and the potential impact on surgical training.

Government-mandated publication of named surgeon-specific outcome data (SSD) has recently been introduced across nine surgical speciality areas in England. This move is the first time that such national data has been released in any country, and it promises to provide a significant advancement in health service transparency. Data is derived from nine preexisting national surgical audit databases. However, eight of these were not originally designed for this purpose, and there is considerable controversy surrounding data quality, risk adjustment, patient use and interpretation, and surgeons' subsequent case selection. Concerns also surround the degree to which these results truly reflect the individual consultant, or the wider hospital team and accompanying resources. The potential impact on surgical training has largely been overlooked. This paper investigated the background to SSD publication and controversies surrounding this, the potential impact on surgical training and the response to these concerns from medical and surgical leaders. As SSD collection continues to be refined, the most appropriate outcomes measurements need to be established, and risk adjustment requires ongoing improvement and validation. Prospective evaluation of changes in surgical training should be undertaken, as any degradation of will have both short and long-term consequences for patients and surgeons alike. It is important that the literature supporting the safety of supervised trainee practice is also promoted in order to counterbalance any potential concerns that might detract from trainee operating opportunities. Finally, it is important that outcomes data is communicated to patients in the most meaningful way in order to facilitate their understanding and interpretation given the complexities of the data and analysis involved.

Surgical training in primary care: consensus recommendations by the Association of Surgeons in Training.

Health service reconfigurations may result in increasing numbers of minor surgical procedures migrating from secondary care in hospitals to primary care in the community. Procedures may be performed by General Practitioners with a specialist interest in Surgery, or secondary care Surgeons who are sub-contracted to perform procedures in the community. Surgical training in such procedures, which are currently hospital based, may therefore be adversely affected unless surgical training also takes advantage of these opportunities. There is potential for surgical trainees to benefit from training in the community setting. ASiT supports the development of formal surgical training in the community setting for junior surgical trainees, providing high standards of patient care and training provision are ensured. Anticipated problems relating to the migration of surgical services to the community relate to the availability and quality assurance of training opportunities in primary care, its funding, including exposure to issues of indemnity cover for trainees, and also the release of surgical trainees from hospital duties in order to attend these training opportunities. These consensus recommendations set out a framework through which both patient care and training remain at the forefront of these continued service reconfigurations.

Mentoring during surgical training: consensus recommendations for mentoring programmes from the Association of Surgeons in Training.

Mentoring has been present within surgical training for many years, albeit in different forms. There is evidence that formal mentoring can improve patient outcomes and facilitate learning and personal growth in the mentee. The Association of Surgeons in Training (ASiT) is an independent educational charity working to promote excellence in surgical training. This document recommends the introduction of a structured mentoring programme, which is readily accessible to all surgical trainees. A review of the available evidence--including an ASiT-led survey of its membership--highlights the desire of surgical trainees to have a mentor, whilst the majority do not have access to one. There is also limited training for those in mentoring roles. In response, ASiT have implemented a pilot mentoring scheme, with surgical trainees acting both as mentors and mentees. Based on the existing literature, survey data and pilot experience, ASiT formalises in this document consensus recommendations for mentoring in surgical training.

Association of Surgeons in Training conference: Belfast 2014.

The Association of Surgeons in Training (ASiT) is a professional body and registered charity working to promote excellence in surgical training for the benefit of junior doctors and patients alike. ASiT is independent of the National Health Service (NHS), Surgical Royal Colleges, and specialty associations and represents trainees in all ten surgical specialties. ASiT was delighted to welcome all four surgical Royal College Presidents and over 650 delegates to Belfast for ASiT 2014. With a theme of Marginal Gains, the conference programme explored collaboration, simulation training and human factors, complimented by debates including the Shape of Training Review (ShOT), several focussed parallel sessions and ten subsidised pre-conference training courses. Almost £4000 was awarded by the incoming President, Mr Vimal Gokani, to delegates across more than 30 prizes for delegates who presented the highest scoring academic work from over 1200 submitted abstracts.

Intraoperative bleeding and haemostasis during pelvic surgery for locally advanced or recurrent rectal cancer: a prospective evaluation.

BACKGROUND: This study aimed to prospectively quantify the frequency of serious bleeding during pelvic surgery for locally advanced or recurrent rectal cancer and review the surgical methods used to control this. METHODS: Consecutive cases of pelvic surgery for curative resection of locally advanced or recurrent rectal cancer were prospectively evaluated over a nine-month period. The procedures undertaken included multivisceral resections, sacrectomies or ultra-low anterior resections. Multivisceral resections were defined as pelvic exenterations, extra-levator abdominoperineal resections (ELAPER) and recurrent anterior resections. The primary endpoint was the proportion of patients sustaining major blood loss, defined as ≥1,000 ml. The secondary endpoint was the blood transfusion rate. Haemostatic adjunct use was recorded. RESULTS: Twenty-six patients underwent surgery, comprising 11 pelvic exenterations, 3 ELAPERs, 1 recurrent anterior resection, 5 abdominosacral resections and 6 ultra-low anterior resections. The median intraoperative blood loss was 1,250 ml with 53.8 % of the patients sustaining a loss ≥1,000 ml. Fifty per cent of patients required a blood transfusion within 24 h, and one or more haemostatic adjuncts were necessary in 50 % of the cases. Adjuncts used included a fibrinogen/thrombin haemostatic agent in 38.5 % of patients, temporary intraoperative pelvic packing in 11.5 % of patients and preoperative internal iliac artery embolization in 7.7 % of patients. CONCLUSIONS: This patient group is at a high risk of intraoperative haemorrhage, and such patients are high consumers of blood products. Haemostatic adjunct use is often necessary to minimize blood loss. We describe our local algorithm to assist in the assessment and intraoperative management of these challenging cases.

Systematic review and meta-analysis of trainee- versus expert surgeon-performed colorectal resection.

BACKGROUND: The aim of this meta-analysis was to compare short-term and oncological outcomes following colorectal resection performed by surgical trainees and expert surgeons. METHODS: Systematic literature searches were made to identify articles on colorectal resection for benign or malignant disease published until April 2013. The primary outcome was the rate of anastomotic leak. Secondary outcomes were intraoperative variables, postoperative adverse event rates, and early and late oncological outcomes. Odds ratios (ORs), weighted mean differences (WMDs) and hazard ratios (HRs) for outcomes were calculated using meta-analytical techniques. RESULTS: The final analysis included 19 non-randomized, observational studies of 14,344 colorectal resections, of which 8845 (61.7 per cent) were performed by experts and 5499 (38.3 per cent) by trainees. The overall rate of anastomotic leak was 2.6 per cent. Compared with experts, trainees had a lower leak rate (3.0 versus 2.0 per cent; OR 0.72, P = 0.010), but there was no difference between experts and expert-supervised trainees (3.2 versus 2.5 per cent; OR 0.77, P = 0.080). A subgroup of expert-supervised trainees had a significantly longer operating time for laparoscopic procedures (WMD 10.00 min, P < 0.001), lower 30-day mortality (OR 0.70, P = 0.001) and lower wound infection rate (OR 0.67, P = 0.040) than experts. No difference was observed in laparoscopic conversion, R0 resection or local recurrence rates. For oncological resection, there was no significant difference in cancer-specific survival between trainees and consultants (3 studies, 533 patients; hazard ratio 0.76, P = 0.130). CONCLUSION: In selected patients, it is appropriate for supervised trainees to perform colorectal resection.

Outpatient management of biliary colic: a prospective observational study of prescribing habits and analgesia effectiveness.

BACKGROUND: Uncomplicated biliary colic presents a significant health and financial burden to hospitals and primary care services alike. There is little guidance on the correct analgesia to use on an outpatient basis. This study aimed to evaluate the effectiveness of oral analgesics on biliary colic pain and to explore the prescribing habits of community doctors. METHODS: Consecutive patients with ultrasound proven symptomatic gallstones completed a questionnaire recording demographics and symptomatology. Pain was assessed using a visual analogue scale (VAS) based on the Biliary Symptom Score (BSS) to evaluate the effectiveness of various analgesic agents. Local General Practitioners were also surveyed to establish prescribing practices. RESULTS: Co-Codamol had the highest mean effectiveness VAS score (6.5/10). Patients with increased BMI, short symptom duration and a BSS >70 were most likely to suffer from severe pain. Patients in a subgroup with severe pain were most likely to have their pain reduced by NSAID analgesia compared to no NSAID (OR 2.20, p = 0.027). This effect remained significant upon multivariable regression (OR 2.52, p = 0.018) in a model containing age and NSAIDs. There was wide variation in the prescribing practice of GPs and hospital doctors. CONCLUSIONS: The range of drugs prescribed for biliary colic is extensive with little evidence base. In this study NSAIDs were the most effective analgesia for patients with severe pain. In the absence of contraindications to their use, physician education or guidance emphasizing the benefits of NSAIDs may potentially reduce symptomatic hospital presentation and admissions for biliary colic.

Emergency cross-cover of surgical specialties: consensus recommendations by the Association of Surgeons in Training.

In recent years, working time restrictions and a restructuring of postgraduate surgical training have resulted in increased reliance on emergency cross-cover (ECC)--the provision of emergency care by a doctor trained or training in a different specialty to that which they are requested to assess or manage. There are increasing concerns surrounding the provision of ECC, particularly regarding appropriate supervision of trainees and in turn their competence, experience and confidence in dealing with surgical problems of outside their own specialty. Surgical training has failed to keep pace with workforce changes and in this document we outline the key principles of providing safe ECC. In particular this includes the medico-legal implications of providing such cover outside a surgical trainee's normal area of practice, particularly without previous experience or means for regular skills practice and up-dating. We report the findings of an ASiT snapshot survey that demonstrates concerns surrounding existing cross-cover arrangements. Variable access to senior support, together with varied willingness to provide this, and a paucity of specific training opportunities for trainees required to provide cross-cover were highlighted. These have the potential to promote variability in patient care and resource use by those providing care outside of their usual specialty. This document provides consensus recommendations to address these issues, including clarification of curricula and improved provision of training for, and supervision of, trainees who are expected to deliver cross-cover.

Developing future surgical workforce structures: a review of post-training non-Consultant grade specialist roles and the results of a national trainee survey from the Association of Surgeons in Training.

The optimal workforce model for surgery has been much debated historically; in particular, whether there should be a recognised role for those successfully completing training employed as non-Consultant grade specialists. This role has been termed the 'sub-consultant' grade. This paper discusses historical and future career structures in surgery, draws international comparisons, and presents the results of a national trainee survey examining the post-Certificate of Completion of Training (CCT) non-consultant specialist grade. Junior doctors in surgical training (i.e. pre-CCT) were invited to participate in an electronic, 38-item, self-administered national training survey. Of 1710 questionnaires submitted, 1365 were appropriately completed and included in the analysis. Regarding the question 'Do you feel that there is a role in the surgical workforce for a post-CCT non-consultant specialist ("sub-consultant") grade in surgery?', 56.0% felt there was no role, 31.1% felt there was a role and 12.8% were uncertain. Only 12.6% of respondents would consider applying for such a post, while 72.4% would not and 15.0% were uncertain. Paediatric (23.3%), general (15.7%) and neurosurgery (11.6%) were the specialties with the highest proportions of trainees prepared to consider applying for such a role. For both questions, there was a significant gender difference in responses (p < 0.0001, Chi-square test) with female trainees more likely to consider applying. Overall 50.8% of respondents felt that the introduction of a post-CCT non-consultant specialist grade would impact positively upon service provision, however, only 21.6% felt it would have a positive impact on patient care, 13.9% a positive impact on surgical training, 11.1% a positive impact on the surgical profession and just 7.9% a positive impact on their surgical career. This survey indicates that the introduction of a 'sub-consultant' grade for surgeons who have completed training would be unpopular, with the majority believing it would be to the detriment of both patient care and surgical training. Changes to surgical career structures must be made in the interests of patient safety and quality, and on this basis ASiT supports the continued provision of primarily Consultant-delivered care.

Prognostic significance of extramural vascular invasion in T4 rectal cancer.

AIM: Extramural vascular invasion (EMVI) has been proposed as an adverse prognostic indicator in colorectal cancer, although its use remains both variable and controversial. This study aimed to determine the survival effect of EMVI in T4 rectal cancer. METHOD: Patients undergoing surgery with curative intent for primary T4 rectal cancer between 1971 and 2011 were included from two prospectively collected rectal cancer databases. The main end-point was 3-year survival. RESULTS: From 1142 patients undergoing resection of rectal cancer during the study period, 126 (11.0%) had T4 rectal cancer and were included in the study group. Sphincter preservation was performed in 61 (48%) and a pathologically negative resection margin (R0) was achieved in 104 patients (82.5%). EMVI was present in 51 patients (40.5%) and was an independent predictor of positive lymph node status (adjusted odds ratio 2.66, P = 0.013). Considering all patients, EMVI was associated with reduced overall survival (P = 0.007) and disease-free survival (P = 0.002), but not local recurrence-free survival (P = 0.198). In only those undergoing R0 resection, EMVI predicted reduced disease-free survival with positive nodal status (P = 0.021); it did not predict survival with negative nodal status. CONCLUSION: Overall, EMVI was a strong prognostic marker of survival. However, after complete surgical resection in patients with node-negative disease, EMVI did not predict local recurrence.

Financial impact of surgical training on hospital economics: an income analysis of 1184 out-patient clinic consultations.

INTRODUCTION: In many countries healthcare commissioning bodies (state or insurance-based) reimburse hospitals for their activity. The costs associated with post-graduate clinical training as part of this are poorly understood. This study quantified the financial revenue generated by surgical trainees in the out-patient clinic setting. METHODS: A retrospective analysis of surgical out-patient ambulatory care appointments under 6 full-time equivalent Consultants (Attendings) in one hospital over 2 months. Clinic attendance lists were generated from the Patient Access System. Appointments were categorised as: 'new', 'review' or 'procedure' as per the Department of Health Payment by Results (PbR) Outpatient Tariff (Outpatient Treatment Function Code 104; Outpatient Procedure Code OPRSI1). RESULTS: During the study period 78 clinics offered 1184 appointments; 133 of these were not attended (11.2%). Of those attended 1029 had sufficient detail for analysis (98%). 261 (25.4%) patients were seen by a trainee. Applying PbR reimbursement criteria to these gave a projected annual income of £GBP 218,712 (€EU 266,527; $USD 353,657) generated by 6 surgical trainees (Residents). This is equivalent to approximately £GBP 36,452 (€EU 44,415; $USD 58,943) per trainee annually compared to £GBP 48,732 (€EU 59,378; $USD 78,800) per Consultant. This projected yearly income off-set 95% of the trainee's basic salary. CONCLUSION: Surgical trainees generated a quarter of the out-patient clinic activity related income in this study, with each trainee producing three-quarters of that generated by a Consultant. This offers considerable commercial value to hospitals. Although this must offset productivity differences and overall running costs, training bodies should ensure hospitals offer an appropriate return. In a competitive market hospitals could be invited to compete for trainees, with preference given to those providing excellence in training.

Clinical fellowships in surgical training: analysis of a national pan-specialty workforce survey.

BACKGROUND: Fellowship posts are increasingly common and offer targeted opportunities for training and personal development. Despite international demand, there is little objective information quantifying this effect or the motivations behind undertaking such a post. The present study investigated surgical trainees' fellowship aims and intentions. METHODS: An electronic, 38-item, self-administered questionnaire survey was distributed in the United Kingdom via national and regional surgical mailing lists and websites via the Association of Surgeons in Training, Royal Surgical Colleges, and Specialty Associations. RESULTS: In all, 1,581 fully completed surveys were received, and 1,365 were included in the analysis. These represented trainees in core or higher training programs or research from all specialties and training regions: 66 % were male; the mean age was 32 years; 77.6 % intended to or had already completed a fellowship. Plastic surgery (95.2 %) and cardiothoracic (88.6 %) trainees were most likely to undertake a fellowship, with pediatrics (51.2 %), and urology (54.3 %) the least likely. Fellowship uptake increased with seniority (p < 0.01) and was positively correlated (p = 0.016, r = 0.767) with increasing belief that fellowships are necessary to the attainment of clinical competence, agreed by 73.1 %. Fellowship aims were ranked in descending order of importance as attaining competence, increasing confidence, and attaining subspecialist skills. CONCLUSIONS: Over three-quarters of trainees have or will undertake a clinical fellowship, varying with gender, specialty, and seniority. Competence, confidence, and subspecialty skills development are the main aims. The findings will influence workforce planning, and perceptions that current training does not deliver sufficient levels of competence and confidence merit further investigation.