Training in large bowel cancer surgery: observations from three prospective regional United Kingdom audits

Methods and results

The audits covered 1990–4. The number of resections undertaken by trainees, and the proportion of these supervised by a consultant, were determined. A supervised resection was one in which the operation note named the consultant as the assistant. These audits did not record observational supervision. Right hemicolectomy and anterior resection for rectal and rectosigmoid cancers were considered to be representative of operations undertaken by junior and senior trainees. The current number of specialist registrar posts is 21 in Lothian and Borders, 50 in Wessex, and 125 in Trent and Wales.

Altogether, 7282 elective and 1594 emergency resections were performed (table); trainees performed 2772 (39.8%) of the elective and 1089 (65.2%) of the emergency resections. A consultant was present at 63.7% (5653) of all resections (54.9% (4874) as the surgeon and 8.8% (779) as assistant to a trainee). Consultants supervised 20.2% (779/3861) of the resections performed by trainees.

Of the 2275 right hemicolectomies performed, trainees undertook 1300 (57.1%), and a consultant assisted in 198 (15.2%) of these. Of 1849 elective anterior resections performed for rectosigmoid and rectal cancers, trainees undertook 571 (30.9%), and a consultant assisted in 197 (34.5%) of these.

Comment

This study shows that trainee surgeons performing colorectal cancer surgery are receiving insufficient consultant supervision. The audits cover almost a fifth of the UK population and are probably representative of national colorectal cancer surgery. The absolute number of supervised resections likely to be undertaken by a typical trainee seems low. In these audits, however, consultant supervision was determined from the operation note, which documented only direct, not indirect, involvement. The importance of also recording when trainees operate independently but with their consultant immediately available is now recognised.2 United States residents undertaking a one year colorectal fellowship would expect to perform over 100 large bowel resections,3 far more than an equivalent trainee in Britain.

As these data were recorded before the introduction of specialist training they might not be considered representative of current practice.4 Currently, however, no other equivalent data on training exist. In Edinburgh during 1994–7 general surgery performed with consultant supervision increased by 5% but operations performed by trainees fell by 8% (unpublished data). This decrease is in addition to the loss resulting from the shortened specialist training period. There will be a further 14% drop if junior doctors are restricted to 48 hours‘ work a week.

A core aim of surgical training is consultant supervision during emergency surgery, but such supervision was lacking in these audits. It can no longer be acceptable that inadequately supervised trainees care for critically ill patients. The national confidential inquiry into postoperative deaths suggests that this acknowledged deficiency still has not been addressed.5 If consultants are to increase their direct supervision of emergency surgery they will have to be relieved of other commitments, and other logistical difficulties, such as theatre availability, will have to be addressed.

Quality of training is an essential part of patients‘ care. The provision of sufficient protected training time should become a priority when quality protocols are developed. Substantial potential exists to increase the number of operations performed by supervised trainees, although it will require additional resources.