ORIGINAL ARTICLE

Higher surgical training opportunities in the general hospitalsetting; getting the balance right

I. Robertson • O. Traynor • W. Khan •

R. Waldron • K. Barry

Received: 29 November 2012 / Accepted: 25 February 2013

� Royal Academy of Medicine in Ireland 2013

Abstract

Background The general hospital can play an important

role in training of higher surgical trainees (HSTs) in Ireland

and abroad. Training opportunities in such a setting have

not been closely analysed to date.

Aims The aim of this study was to quantify operative

exposure for HSTs over a 5-year period in a single

institution.

Methods Analysis of electronic training logbooks (over a

5-year period, 2007–2012) was performed for general

surgery trainees on the higher surgical training programme

in Ireland. The most commonly performed adult and pae-

diatric procedures per trainee, per year were analysed.

Results Standard general surgery operations such as

herniae (average 58, range 32–86) and cholecystectomy

(average 60, range 49–72) ranked highly in each logbook.

The most frequently performed emergency operations were

appendicectomy (average 45, range 33–53) and laparotomy

for acute abdomen (average 48, range 10–79). Paediatric

surgical experience included appendicectomy, circumci-

sion, orchidopexy and hernia/hydrocoele repair. Overall,

the procedure most commonly performed in the adult set-

ting was endoscopy, with each trainee recording an average

of 116 (range 98–132) oesophagogastroduodenoscopies

and 284 (range 227–354) colonoscopies.

Conclusions General hospitals continue to play a major

role in the training of higher surgical trainees. Analysis of

the electronic logbooks over a 5-year period reveals the

high volume of procedures available to trainees in a non-

specialist centre. Such training opportunities are invaluable

in the context of changing work practices and limited

resources.

Keywords Higher surgical training � eLogbook � General

hospital � Operative exposure � Consultant supervision �Emergency surgery

Introduction

Debate continues regarding the content and duration of

surgical training. It is acknowledged that a substantial

exposure to common elective and emergency general sur-

gical conditions is optimal during training, and recent

publications have highlighted the importance of the

broadly trained physician or generalist [1]. Changes in

clinical practice may impact negatively on the ability of

surgical training programmes to ensure that designated

trainees are provided with sufficient exposure to the gen-

erality of common surgical conditions. The implementation

of the European Working Time Directive (EWTD) [2] has

been of particular concern to programme directors and

surgical trainees alike. Centralisation of cancer services

may also act to render general hospital training less

attractive, given the tendency of higher surgical trainees to

declare a subspecialty interest early in training [3].

Concern has been expressed regarding the limited

operative experience obtained by trainees during basic

surgical training [4]. Little information is available

regarding the quality of operative experience obtained by

higher surgical trainees (HSTs), particularly in the general

hospital sector. It is expected that significant changes to

I. Robertson (&) � W. Khan � R. Waldron � K. Barry

Department of Surgery, Mayo General Hospital, Castlebar,

Co Mayo, Ireland

e-mail: irobertson@me.com

O. Traynor

National Surgical Training Centre, Royal College of Surgeons

in Ireland, 123 St. Stephen’s Green, Dublin 2, Ireland

123

Ir J Med Sci

DOI 10.1007/s11845-013-0932-z

Irish postgraduate surgical training programmes will be

introduced in July 2013 with emphasis on a continuum of

basic and higher surgical training over an 8-year period.

Against this background, we propose that the general

hospital sector provides an ideal opportunity for higher

surgical trainees to develop operative skills in a supervised

and ‘training-friendly’ environment during the early years

of higher surgical training.

Methods

Mayo General Hospital (MGH) is a general hospital, which

serves a rural catchment population of 130,000 in the west

of Ireland. Our institution contains 325 beds across multi-

ple specialties including general surgery, medicine, pae-

diatrics, obstetrics, gynaecology, orthopaedics, intensive

care and a 24-hour accident and emergency department. In

June 2010, 43 inpatient beds in this institution were ring-

fenced specifically and exclusively to general surgery

patients receiving elective and emergency care. This

change in practice improved overall efficiency in terms of

increased day of surgery admission rates with associated

cost-efficiency, reduced cancellation rates for elective

surgical procedures and reduced surgical site infection

rates [5, 6].

Three consultant surgeons, staff of the department of

surgery at Mayo General Hospital, each having a team of

one registrar, two basic surgical trainees and two interns.

The higher surgical trainee (assigned to two consultant

trainers by the training committee of the Royal College of

Surgeons in Ireland) attends five theatre sessions per week.

The other two registrars (assigned to one trainer only)

attend three theatre sessions per week.

The electronic logbook of each higher surgical trainee

working at Mayo General Hospital over the last 5 years

(2007–2012) was interrogated. Particular attention was

paid to the more common elective and emergency general

surgical procedures performed. The level of supervision

was also assessed and classified as either Performed (P) or

Supervised (S). A subset analysis of paediatric operative

exposure was also completed. Each logbook was verified

against the theatre registers to ensure accuracy.

Results

The nine most frequently recorded adult surgical proce-

dures and the four most frequently performed paediatric

procedures for each of the trainees were identified and

analysed. The total number of training procedures per-

formed by HSTs within this subset over the 5-year study

period was 3,550.

Cholecystectomy and hernia repair were the most fre-

quently performed elective procedures under general

anaesthesia with an average of 60 (range 49–72) chole-

cystectomies and 58 (range 39–86) hernia repairs per

trainee. Herniae included inguinal, femoral, epigastric and

umbilical categories. Significant exposure to major bowel

resections, including right and left hemicolectomy, anterior

resection and abdominoperineal resection, was achieved.

The average number of colectomies completed per trainee

was 36 (range 29–46). The only vascular procedure per-

formed at Mayo General Hospital is varicose vein surgery,

and each trainee performed an average of 15 (range 7–24)

cases within the year.

In the emergency setting, an average of 48 (range

10–79) laparotomies for acute abdomen and 45 (range

33–53) appendicectomies were completed by each trainee.

As expected, the most commonly performed procedure was

endoscopy. This accounted for 20 % of the procedural

workload of each trainee. On average, 116 (range 98–132)

oesophagogastroduodenoscopies (OGDs) and 284 (range

227–354) colonoscopies were performed by each trainee

(Table 2). Variation of training workload observed for

adult procedures may be attributed to a number of factors

including seasonal theatre closures, patterns of consultant

leave and the conflicting demands of providing parallel

elective and emergency general surgical services on a one-

in-three call rota.

In paediatric surgery, the most frequently performed

procedures were open appendicectomy (average 14, range

7–15), circumcision (average 7, range 3–17), hernia/hyd-

rocoele repair (average 8, range 1–17) and orchidopexy

(average 5, range 2–8) (Table 2). All paediatric procedures

were supervised, and the level of supervision (performed or

supervised) for each adult procedure is outlined in Table 1.

Discussion

Mayo General Hospital has a longstanding institutional focus

of providing well-structured operative training for HSTs, and

there has been a consistently high level of consultant super-

vision for all trainees attending Mayo General Hospital, as

outlined in Table 1. The recent introduction of several key

healthcare policies at our institution is likely to have played a

major role in the maintenance of high volume operative

workload for higher surgical trainees (working across two

services and attending five theatre sessions per week), despite

such impediments as financial constraints, the EWTD and a

national policy of centralisation of cancer services. We

believe that the successful introduction of ring-fenced inpa-

tient beds, pre-operative assessment clinics (PACs) and day of

surgery admission (DOSA) in June 2010 were instrumental in

protecting training opportunities for HSTs. A recent study

Ir J Med Sci

123

evaluated the impact of these departmental policies and

showed that such changes in clinical practice were associated,

collectively, with a significant increase in the composite

(including general surgery, orthopaedics and gynaecology)

DOSA rate from 56 to 85 %, surpassing the national target of

75 % [5]. A subset analysis of general surgery admissions was

performed as part of this study, and the number of patients

admitted as DOSA increased from a median of 5 per month to

a median of 42 per month. This facilitated a continued high-

volume of elective general surgery procedures to be per-

formed. The commonest elective procedures performed at our

institution include laparoscopic cholecystectomy, haemor-

rhoidectomy, inguinal hernia repair, varicose veins surgery

and diagnostic laparoscopy. This is reflected in the elogbooks

of the higher surgical trainees attached to our institution over

the last 5 years. Coordinated changes in clinical practice and

admission policies have helped to maintain valuable, high-

volume training opportunities in financially challenging

times.

Future trends in surgical training are likely to reflect the

demand for well-trained hospital generalists who can cope

with a high volume of non-cancer surgical procedures and an

onerous on-call rota. This is currently being driven in Ireland

by the centralisation of cancer services into eight units and

also by the advent of the austerity era. A recent study from our

institution has quantified the impact of the National Cancer

Strategy on surgical workload with a significant increase in the

numbers of benign procedures performed [7]. The concept of a

hospital generalist has re-emerged in medical practice, and a

recent paper outlined how hospital medicine in the US and

acute medicine in the UK are the fastest growing specialties in

their respective countries [8]. The number of hospitalists in the

US has risen from a few hundreds 15 years ago to 30,000

today and, around 70 % of US hospitals now employ hospi-

talists [8, 9]. The number of acute physicians in the UK is

smaller, with approximately 600 employed throughout the

country. However, the acute medicine field grew by 63 %

between 2002 and 2007, making it the fastest growing spe-

cialty in Britain [10]. Several studies have shown that hospi-

talists significantly reduce length of stay and costs without

harming quality and patient satisfaction [9, 11–13]. A corre-

sponding rise in the numbers of surgical hospitalists is likely to

emerge in Ireland and the UK over the coming years.

The current design of the higher surgical training pro-

gramme in the Republic of Ireland consists of a 6-year

training scheme. Candidates choose jobs based on a

matching system and ultimately select a sub-specialty

interest, usually at the end of their training. However, the

format of training may need to be revised if we are to

produce a more broad-based general surgeon competent in

both adult and paediatric elective and emergency surgery in

parallel with subspecialists. In this scenario, the general

hospital will have a pivotal role to play in the training of

future surgeons and higher surgical trainees perception of

the value of time spent in the general hospital setting will

need to be adjusted. Calmanisation (the 6-year SpR training

programme) has already reduced the operative exposure of

trainees at registrar level, so closer evaluation of the train-

ing opportunities available in general hospitals must be

considered by relevant postgraduate training bodies [14].

Provision of paediatric surgery in the general hospital

setting continues to attract debate. A recent survey of HSTs

in Ireland revealed that the majority of those surveyed were

opposed to mandatory paediatric surgical training and

would not be willing to provide paediatric surgery as a

consultant. In addition, the trainees surveyed were of the

opinion that general paediatric surgery (GPS) should be

provided by paediatric surgeons in the future [15]. While

centralisation of paediatric surgery in Ireland may occur

eventually, there is a continuing need to provide GPS

outside of specialist centres. We continue to provide GPS

at Mayo General Hospital and a recent audit from this

Table 1 Adult procedures

Procedure Trainee 1 Trainee 2 Trainee 3 Trainee 4 Trainee 5 Average Level of supervision (%)

S P

Cholecystectomy 49 54 56 72 68 60 100 0

Hernia repair 39 60 32 86 71 58 63 37

Laparotomy for acute abdomen 23 10 60 70 79 48 100 0

Colectomy 29 30 46 37 36 36 100 0

Varicose veins 11 13 7 18 24 15 88 12

Haemorrhoidectomy 11 12 18 17 9 13 100 0

Appendicectomy 51 33 44 42 53 45 47 53

OGD 128 106 132 98 115 116 41 59

Colonoscopy 271 227 354 323 244 284 78 22

S supervised by consultant, P performed without consultant supervision

Bold values indicate average and supervision

Ir J Med Sci

123

institution demonstrated that 4,255 surgical procedures

were performed in 3,981 paediatric patients over a 5-year

period, accounting for 7.4 % of total surgical workload

[16]. This represents a potential training opportunity in the

general hospital setting for HSTs who may wish to avail of

paediatric surgical training (Table 2).

Emergency surgery will remain a core function of

general surgeons over the coming years and appropriately

trained surgeons will be required to deliver safe and

competent emergency care. Training of surgeons in general

hospitals may represent better value for money for the

Health Service Executive (HSE) in Ireland considering that

emergency general surgery forms a major part of the

workload of a general surgeon. The results of our study

indicate that high-volume emergency general surgical

training can be provided to HSTs in non-cancer centres. A

consensus statement released by the Association of Sur-

geons of Great Britain and Ireland (ASGBI) in 2007 on the

future of emergency surgery recognised that emergency

general surgery is a huge clinical service with approxi-

mately 1,000 Finished Consultant Episodes per 100,000

population/year [17, 18]. It also states that emergency

general surgery is one of the most common reasons for

admission to a surgical bed in the UK and that the patient

workload of an emergency general surgeon far exceeds that

of any of the general surgical specialty associations or

societies. This emergency surgery workload is predicted to

increase with an aging population.

Although the accuracy of each elogbook in this study

was verified against theatre registers, it is worth noting that

such logbooks have been criticised in the literature for the

high percentage of inaccuracies recorded. A study of 13,755

operations entered onto the elogbook platform by HSTs

over a 1-year period found that 12.5 % of the data required

either correction or exclusion from the database prior to

analysis [19]. However, a separate study in the US looking

at the logbooks of vascular surgery trainees found that

trainees may be under-reporting cases by a factor of up to

20 % [20].

Conclusions

The general hospital will continue to play an important role

in the training of higher surgical trainees. This study has

shown that high volume operative experience in common

elective and emergency general surgical procedures is

available to HSTs in the general hospital setting. The re-

organisation of cancer services in Ireland, gradual intro-

duction of the European Working Time Directive and

decreasing hospital budgets have not impacted negatively

on the operative workload of HSTs at our institution. We

postulate that several factors, including successful imple-

mentation of ring-fenced inpatient beds, pre-operative

assessment clinics (PACs) and a policy of increased day of

surgery admissions (DOSA) have been instrumental in

protecting training opportunities at MGH. The introduction

of similar departmental policies in designated training units

throughout Ireland may help to provide protected training

opportunities for HSTs in the future.

Conflict of interest None.

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Table 2 Paediatric procedures

(all supervised by consultant)

Average values are highlighted

in bold

Procedure Trainee 1 Trainee 2 Trainee 3 Trainee 4 Trainee 5 Average

Orchidopexy 2 3 8 6 4 5

Open appendicectomy 15 14 7 19 13 14

Circumcision 9 3 8 16 17 11

Hernia/hydrocoele 1 2 10 17 8 8

Ir J Med Sci

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