Unsupervised surgical training: questionnaire study

BMJ 1997; 314 doi: (Published 21 June 1997) Cite this as: BMJ 1997;314:1803
  1. Janet A Wilson, professora
  1. a Department of Otolaryngology Head and Neck Surgery, University of Newcastle, Freeman Hospital, Newcastle upon Tyne NE7 7DN
  • Accepted 16 January 1997


Most surgeons have anecdotal awareness of trainees carrying out, unsupervised, operations which they have never previously performed. This is the first formal attempt to quantify this variant of surgical “training.”

Methods and results

Questionnaires were sent to 451 trainee surgeons and young consultants in the United Kingdom. Replies were received from 276 (61%): 144/230 (63%) members of the Association of Surgeons in Training and 132/221 (60%) otolaryngologists from the Association of Otolaryngologists in Training and the Young Consultant Otolaryngologists Head and Neck Surgeons.

Respondents were asked to indicate whether they had ever undertaken a surgical procedure for the first time “without your trainer being present in the theatre”; to specify any such procedure; to “asterisk any where you can recall your senior not being present in the hospital at the time”; and to select the statement that most closely reflected their attitude to this practice. Consultants were asked to indicate the number of different procedures they had performed for the first time since appointment.

Experience of first time unsupervised procedures was significantly commoner among general than otolaryngological surgeons (86% v 66%; χ2=14.7, P<0.001) (table 1). Senior house officers undertook submandibular gland excision, femoral hernia, Mayo repair, testicular torsion, partial gastrectomy, splenectomy, and cholecystectomy with the “senior” absent from the hospital. Registrars' unsupervised hepatobiliary procedures included triple bypass for pancreatic carcinoma, common bile duct exploration, choledochoduodenostomy, “hot” cholecystectomy, laparotomy for liver trauma, and a Whipple's procedure. Registrars also reported 20 large bowel resections, six aneurysm repairs, a renal transplant, and a mesenteric embolectomy; senior registrars' procedures included axillary clearance, elective aneurysm surgery, oesophagectomy, distal pancreatectomy, mastectomy, open prostatectomy, horseshoe nephrectomy, and gastroplasty for morbid obesity. Otolaryngologists performed 34 major head and neck procedures (laryngectomy, pharyngolaryngectomy, parotidectomy, thyroidectomy, radical neck dissection, hemiglossectomy, free tissue transfer), 27 major nose and sinus procedures (including 3 external rhinoplasties, 3 lateral rhinotomies, 2 total maxillectomies, 5 orbital decompressions, and l4 arterial ligations for epistaxis), and 34 major ear procedures.

Table 1

Procedures performed, unsupervised, for the first time by trainee surgeons and young consultants

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Of 17 general surgical consultant respondents, five had performed a procedure not seen during training and seven had performed procedures only assisted at in training. Most reported only one such operation, but one of the group included “all majors” in this category. The greater the interval since qualification in the 84 otolaryngological consultants (1981 to 1994), the greater the number of first time consultant procedures. Sixty one (73%) had performed procedures not seen during training (45% had performed 1-4; 11% 5-9; 9% 10-19; and 7% 20-50 procedures); 41 had performed operations only observed as trainees.


The results are based on the responses of a large sample, collected anonymously; they are in line with reports that two thirds of all procedures by surgical trainees are unassisted.1 2

Many first time unsupervised procedures are undertaken as out of hours emergencies (one reason for the smaller numbers in otolaryngology). Most responsible trainers (and members of the public) will agree with the view of the trainees that unsupervised first time surgery is not ideal training. Preservation of training status for a unit should require returning a much more complete dataset than is currently available for audit of training.1 Surgical log books should include a more formal evaluation of procedures that appear for the first time in the absence of a senior assistant.

As the specialist registrar grade is introduced, assessors must be aware of the risk of excessive “first time” surgery for young consultants. Some of this experience in otolaryngology was the result of surgical advance–33 procedures were functional endoscopic sinus surgery, which is new in Britain. Conversely, the 38 head and neck procedures that respondents performed but had never previously seen supports the urgent need for specialist head and neck training modules.


I thank the organisers and members of the Association of Surgeons in Training, the Young Consultant Otolaryngologists Head and Neck Surgeons, and the Association of Otolaryngologists in Training for their cooperation and their honesty.


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