Corresponding Author:
Gianni D. Angelini MD,
BHF Professor of Cardiac Surgery.
Level 7, Bristol Royal Infirmary,
Bristol, BS2 8HW.
Phone number: +441173423165
Email:
G.D.Angelini@bristol.ac.uk
Being able to perform surgery first-hand represents the backbone of
every training program and the key to successful development of the new
generation of skilful surgeons. In this issue of the Journal, Comanici
et al. presented a thorough systematic summary of the current evidence
on the outcomes of cardiothoracic operations performed by
trainees.1
Taking for granted the importance of training young surgeons, it is
paramount to identify and tackle any potential obstacles hindering the
surgical growth of a trainee.
Firstly, there is an ever-growing scrutiny on the performance of each
surgeon with publicly available reports on mortality and
morbidity.2 In the United Kingdom, public reporting
was systematically implemented by the Society for Cardio-Thoracic
Surgery in 2004 following the Bristol enquiry.3,4 The
benefits of public reporting are well-recognized and includes improved
transparency, higher accountability of healthcare providers and informed
patient’s choice. However, downsides should also be acknowledged.
Trainees may be direct innocent victims of public reporting due to the
tendency of surgeons to safeguard their publicly scrutinized outcomes.
Under the erroneous assumption that trainee-led cases can lead to worse
outcomes, surgeons may be hesitant to allow trainees to perform the
operation as first operators. This does not only reduce the absolute
number of cases performed by trainees but also limits surgical exposure
to only selected less complex procedures. Reports such as the one of
Comanici et al. are pivotal to provide compelling evidence that trainee
cases are not likely to negatively impact surgeons’ outcomes.
Secondly, the cohort of patients presenting for surgery is continuously
evolving and changing. Patients are now older, with a greater burden of
comorbidities and more advanced disease.5Traditionally, a trainee case is described as a low-risk case in which
there is ample space for education and supervision, however, sticking to
this paradigm would sharply reduce the number of eligible patients for
trainees given the increasing higher risk surgical population. However,
surgeons should not be discouraged to let trainee operate first-hand
also on high risk profile patients. There are previous reports that
focused on this issue and showed that regardless of the increased risk
of nowadays patients trainee cases have similar favourable outcome than
when performed by trainers and patients welfare is still preserved and
prioritized.1,6,7 Extension of training to complex
operations also facilitates the always challenging transition from
trainee to consultant position.
Thirdly, there is a subjective variability within surgeons when it comes
down to teaching regardless of the complexity of the patients. Surgeons
can have a different level of comfort in letting a trainee perform the
surgery and this can clearly reduce the opportunities for trainees
working with less self-confident surgeons. Also, training is an
educative experience above all and as such it should be acknowledged
that some surgeons may be more willing to teach or better at it than
others. Identifying these educational skills and rewarding them in their
professional career could help improve the quality and quantity of
training.
Another source of heterogeneity is related to how much a surgeon feels
the trainee needs to perform during the operation. This is clearly
reflected in the diverging definitions of a “trainee case” in
published reports. It would appear logical that the ideal definition is
a skin-to-skin operation, however, this does not always match the
educational needs of a trainee. Training should be based on a
skill-oriented program which progressively exposes the trainee to the
surgical steps (e.g., sternotomy, proximal than distal anastomosis of
coronary grafts) of each procedure until all the pieces are dexterously
performed and can be put together to perform the whole procedure.
Therefore, this definition should be approached pragmatically
considering that a skin-to-skin procedure can be suitable for senior
trainees, whereas smaller surgical bits more appropriate for junior
trainees.
Finally, a new problem is providing exposure to technique like minimal
access and robotic cardiothoracic surgery. The limits here are even more
impeding. These techniques and particularly robotic platforms and
expertise are not readily available in every cardiac unit, and the
volume of procedures is much lesser than conventional surgery. These
factors create a “training gap” difficult to fill. Simulation
curricula can in part fill this gap by means of wet labs and virtual
reality simulators which have been shown to provide proficient expertise
level.8 Considering the potentiality of minimal access
and robotic surgery in the future, surgical programs should start to
consider the implementation of means to train the surgeons of tomorrow
in these ever-evolving technologies.
Concluding, there is a substantial body of evidence in the literature
and well-summarized by Comanici et al. that support the safety of
surgical training. This should eradicate any remaining reluctance
towards trainee-led cases. Today’s well-trained doctors will be
tomorrow’s good surgeons, trainers and guarantor of patient welfare.