DOI: 10.

1308/147363513X13500508920095

G e n e r a l s u r g e ry logbook survey
W Allum Past Chairman1 S Hornby President2 G Khera Past President2 E Fitzgerald Past President2 G Griffiths Past Chairman2

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General Surgery Specialist Advisory Committee Association of Surgeons in Training

Application for a Certificate of Completion of Training (CCT) in general surgery includes assessment of a validated logbook. The content of a satisfactory logbook has long been an area of contention. The logbook allows trainees to record their operative experience and to show the level of supervision. It is tempting to set a specific number of procedures to be completed by the end of training. However, such a number must be evidence based rather than chosen subjectively.

In the initial phase of development of the Intercollegiate Surgical Curriculum Programme (ISCP), there was considerable discussion about indicative numbers for individual procedures. It was decided not to include such numbers, as the ISCP is a competence-based process and numbers were not simply definable. The ISCP clearly defines the technical skills expected of a trainee in operative surgery and how those skills should be assessed in the workplace in the detailed descriptions of the procedure-based assessments (PBAs). It has become apparent that there is potential for discrepancy between experience and competence assessment reflected in the content of logbooks presented to the general surgery specialist advisory committee (SAC) at the completion of training. A specific concern is that a trainee may be assessed as competent in a particular procedure but may not have learned the range of operative strategies needed to manage complex conditions requiring that procedure. The general surgery SAC and the Association of Surgeons in Training (ASiT) education committee have therefore surveyed the logbooks of those

completing general surgical training in the past two years (20102011) to understand the levels of experience gained, with a view to influencing future evaluation and provision of training. Methods Logbook consolidation sheets and the electronic logbooks of those general surgery trainees applying to the SAC for their CCT in 2010 and 2011 were reviewed anonymously. The logbook was designed by the Association of Surgeons of Great Britain and Ireland (ASGBI), and recorded the number of procedures performed by subspecialty and also the level of supervision. It was not mandatory for trainees to record whether or not a procedure was an emergency. In those recording their data electronically, procedures were documented according to Confidential Enquiry into Perioperative Deaths (CEPOD) status and it was therefore possible to assess emergency surgery experience from these data. Logbooks were included for those who completed training without any periods of repeat or targeted training. Those whose logbooks were incomplete or included

Ann R Coll Surg Engl (Suppl) 2013; 95: XXXX

Table 1 DISTRIBUTION OF SPECIAL INTERESTS Subspecialty Breast Colorectal Upper gastrointestinal Vascular Endocrine Transplant
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Number of trainees 10 (1 trainee also endocrine interest) 20 17 (1 trainee also transplant interest) 9 1 1

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periods of out-of-training fellowships were excluded. Results The logbook consolidation sheets of 58 trainees were reviewed. Their special interests were not described explicitly but were apparent from the content. The distribution of special interests is shown in Table 1. The average duration of training was 72 months (range: 5887 months). Throughout training, trainees were involved with a median of 28 procedures (first quartile: 23) each month. The total number of procedures in which trainees were involved (either assisting or performing) in general surgery and their own special interest is shown in Table 2. The largest absolute number of procedures was performed by colorectal trainees. This reflects partly the numbers of colonoscopies performed in addition to other procedures. The numbers for endocrine and transplantation surgery are expressed as a mean only because of the small number of trainees. The overall experience in general surgery of childhood was limited. The number of cases in which trainees were involved that were not in their area of special interest but part of their training in general surgery was also estimated. The median number for breast surgery was low at 53 (range: 0399). Not unexpectedly, the larger numbers were in upper gastrointestinal (GI) (196 [range: 43643]) and colorectal surgery (280 [range: 88662]). Non-vascular trainees were involved in a median of 126 vascular procedures (range: 11377), principally varicose veins and access surgery. In view of the median number of procedures performed monthly, this experience could be achieved in a six-month attachment to a vascular unit. General Surgery The index procedures that should be undertaken by all are identified in the general surgery curriculum as inguinal hernia repair, laparotomy for trauma, laparotomy for acute abdomen and Hartmanns operation. Laparotomy for acute abdomen is not defined specifically in the ASGBI logbook. For

Table 2 PROCEDURES in which trainees were involved (assisting or performing) Mean General surgery Breast surgery Colorectal surgery Upper gastrointestinal surgery Hepatopancreatobiliary Oesophagogastric Vascular surgery Endocrine surgery* Transplant surgery** General surgery in childhood 607 902 1,023 788 357 435 864 398 250 35 13 0228 3 Number of procedures Median Range First quartile 601 962 870 818 324 444 949 2271,384 4741,272 3321,905 2251,506 184604 40940 4091,041 460 670 730 591 235 200 750

* Endocrine 2 trainees; 1 endocrine, 1 breast and endocrine ** Transplant 2 trainees 1 renal and liver

Table 3 General surgery index procedures performed by trainees Number of procedures Mean Inguinal hernia surgery 90 Median 86 4 68 10 Range 19214 020 18227 243 First quartile 60 2 42 5

Laparotomy for 5 trauma* Laparatomy for 83 acute abdomen** Hartmanns operation 13

* includes splenectomy ** includes division of adhesions, palliative bypass, staging/diagnosis, postoperative complications and small bowel resection; excludes appendicectomy

Table 4 emergency procedures performed by trainees (cepod classification)* Number of procedures Mean All trainees (n=14) Gastrointestinal trainees (n=11) 158 179 Median 164 182 Range 42249 70249 First quartile 120 143

* includes any procedure recorded as performed on a CEPOD list (eg laparotomy for acute abdomen and for trauma, segmental colectomy, Hartmanns operation, surgery for acute peptic ulceration, cholecystectomy and surgery for acute abdominal vascular pathology)

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Table 5 Special interest experience in breast surgery Number of procedures Mean Image guided surgery (diagnostic/ wide local excision) Mastectomy Duct and nipple surgery Sentinel node biopsy Axillary clearance Implant-based reconstruction Reduction mammoplasty 69 Median 57 Range 17134 First quartile 37

Non-special interest experience Training naturally exposes trainees to common procedures outside their own area of special interest. These include cholecystectomy, segmental colectomy and Hartmanns operation (Table 11). Although not formally documented, the majority of cholecystectomies were laparoscopic. Endoscopy Experience in endoscopy for surgical trainees has been variable for some time. Trainees have had the facility to record their endoscopy experience in the ASGBI logbook. However, this was at the same time as the Joint Advisory Group on GI Endoscopy (JAG) ePortfolio was being introduced. This may have created some limitations on the accuracy of the data on endoscopy. For those with an upper GI interest, the median number of oesophagogastroduodenoscopies performed was 58 (range: 0477). For those with a declared oesophagogastric interest, the median number was 211 (range: 0477). Colorectal trainees performed a median number of 203 colonoscopies (range: 0707). In addition, upper GI trainees performed a median of 37 colonoscopies (range: 0105) and colorectal trainees performed a median of 83 oesophagogastroduodenoscopies (range: 0420). Trainee supervision Trainee supervision was estimated from the total number of procedures recorded as undertaken with the supervisor scrubbed, or present but unscrubbed. Overall, approximately 66% of all procedures were performed by trainees. The extent of supervision was variable, with an average of 65% of procedures being performed under supervision. For emergency procedures, 80% were performed by trainees, with 50% under supervision. The rates of supervision varied from 46% for laparotomies for acute abdomen to 67% for laparotomies for trauma. Supervision of complex procedures was naturally high. Approximately 50% of all breast reconstructions were undertaken by trainees, with 84% under supervision. In contrast, 59% of axillary clearance operations were performed by trainees, with 68% under supervision. Colorectal trainees performed 61% of anterior resections, with 95% under supervision.

66 13 95 64

12 68 90 58 18 18 3

3192 127 16169 42112 835 048 023

51 8 70 45 12 3 1

Myocutaneous flap 19 19 8

Table 6 Special interest experience in colorectal surgery Number of procedures Mean Anterior resection Colonoscopy Fistula surgery* Segmental colectomy** Haemorrhoidectomy Prolapse surgery 40 238 34 80 31 8 Median 38 203 35 81 29 6 Range 1496 0707 667 33139 571 218 First quartile 28 90 18 52 15 4

* includes advancement flap, drainage seton or other treatment (high fistula-in-ano) and lay-open technique (low fistula-in-ano) ** includes right, left, transverse and sigmoid colectomy

this analysis, laparotomy for acute abdomen included surgery for intestinal obstruction, peritonitis, palliative bypass and postoperative complications as well as other unspecified procedures. The general surgery index procedure experience is shown in Table 3. It is likely that some of the procedures were performed electively. Emergency experience (ie procedures recorded as performed according to the CEPOD classification of emergency or urgent) is shown in Table 4. These data are from the electronic logbooks of a group of trainees in the main cohort.
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Special interest experience The total number of index procedures performed (supervisor scrubbed, supervisor unscrubbed, performed or training a junior colleague) according to the special interest of each trainee is shown in Tables 510. The data for upper GI surgery are presented separately for those with a general upper GI interest and an oesophagogastric (OG) or hepatopancreatobiliary (HPB) interest. Since there were only two trainees expressing interests in endocrine surgery or transplantation, their numbers are simply presented without analysis (Tables 9 and 10).

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Table 7 Special interest experience in upper gastrointestinal surGERY Number of procedures Mean Oesophagogastroduodenoscopy Oesphagogastric interest Anti-reflux surgery Oesophagogastric interest Gastrectomy* Oesophagogastric interest Oesophagogastrectomy Oesophagogastric interest Obesity surgery Oesophagogastric interest Acute peptic ulcer Cholecystectomy** Exploration of common bile duct Liver resection Hepatopancreatobiliary interest (2) Pancreatic necrosectomy Hepatopancreatobiliary interest (2) Pancreatic resection Hepatopancreatobiliary interest (2) 129 189 17 26 11 16 17 25 27 30 11 166 5 5 40 2 9 4 33 Median 58 211 8 30 10 16 14 20 15 22 10 132 2 0 0 0 Range 0477 0477 060 560 032 332 050 450 0124 080 128 60373 027 047 3347 015 215 049 1749 First quartile 0 21 3 10 3 11 1 16 0 13 6 110 0

* includes D2 subtotal and total gastrectomy as well as distal, subtotal and total gastrectomy ** predominantly laparoscopic cholecystectomy

Similarly, 49% of oesophagectomies were performed by trainees, with 97% under supervision. In vascular surgery, 66% of abdominal aortic aneurysm repairs were undertaken by trainees, with 85% and 76% of procedures supervised for bifurcated and tube grafts respectively. In endocrine surgery, only 34% of adrenalectomies were performed by trainees, with 95% under supervision. Finally, 68% of liver transplant implantation procedures were undertaken by trainees, all under supervision. Discussion This review of the logbooks of general surgical trainees completing training in 20102011 has defined the volume of experience achieved during the six years of higher surgical training. The nature of the process and analysis was highly dependent on the accuracy of the documentation by each trainee. The figures for overall activity, general elective and emergency experience, and special interest experience allow a benchmark to be set. It is proposed that this benchmark should be, as a minimum, the first quartile and this should be the indicative number for a specific procedure.

The determination of such a benchmark has several applications. First, it establishes the level of experience a trainee should reach by the end of training. Second, it allows a longitudinal assessment by training programme directors to determine the progress being made by an individual trainee, highlighting where experience is appropriate and, more importantly, where it is limited so that this can be addressed in future trainee posts. Third, it demonstrates to trainees what is expected of them as they progress through training. Finally, the benchmark can be used to set the expected level for those applying for entry on to the General Medical Council specialist register through the route of Certificate of Equivalence of Specialist Registration. This analysis represents a snapshot of the experience of one cohort of trainees. A limitation has been identifying the amount of emergency experience. This was particularly apparent for emergency laparotomies as it was not mandatory to record the urgency of a procedure in the ASGBI logbook. The data from the consolidation sheets show lower rates of emergency procedures than

in the electronic logbooks. It is likely that emergency procedures will have been recorded as specific operations in logbooks, hence the discrepancy. From these combined data, it is therefore recommended that trainees should complete a minimum of 100 emergency laparotomies by the end of training. The transfer from the ASGBI logbook to the Faculty of Health Informatics electronic logbook in 2011 has enhanced recording of operative experience and this will allow more contemporaneous analysis of activity in the future. Trainees must be careful in filling in their logbooks to ensure key metrics such as the level of urgency of a procedure are recorded. This is essential for the assessment of both trainee and training unit with regard to the level of emergency exposure. Failure to complete logbooks accurately will, ultimately, lead to erroneous benchmarks. The review has identified a number of areas that need further consideration. In the development of the curriculum, each subspecialty association education committee recommended a series of
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Table 8 Special interest experience in vascular surgery Number of procedures Mean Abdominal aortic aneurusm bifurcated graft Abdominal aortic aneurysm tube graft Carotid endarterectomy Infrainguinal bypass* Re-do vascular surgery Varicose vein surgery Vascular access 11 35 55 90 9 85 20 Median 12 21 44 94 4 82 15 Range 523 1190 26119 48154 029 41170 049 First quartile 5 13 33 61 2 59 1

*includes femoral-crural bypass, femoral-distal bypass, femoral endarterectomy, femoral-femoral crossover, femoral-popliteal bypass (above knee and below knee) and ilio-femoral bypass

index procedures, defined as standard operations that all trainees with that special interest should undertake. The figures for these show variation, with low numbers for certain specialist procedures. This raises the question of whether such numbers are acceptable experience for a trainee at the end of training and also whether the current index procedures are appropriate. The totality of experience shows a consistent range, with a median of 28 procedures a month. The current Joint Committee on Surgical Training quality indicators for training posts in general surgery recommend a minimum of three operating lists per week. Although the number of cases per list varies according to the complexity of the procedures, the current median total equates to 23 cases per list. Since two-thirds of cases are performed by trainees, it is crucial that these cases are used to the fullest extent for training. The introduction of simulation may help with operative experience in the sense that basic skills are mastered outside the operating theatre. Yet there is a strong argument to increase the proportion of cases performed by trainees, with at least part of every procedure being undertaken by a trainee. Experience in gastrointestinal endoscopy has been variable, reflecting the access of surgical trainees to endoscopy lists. This survey has shown a wide range of practice, confirming anecdotal reports of limited experience. Both upper GI surgery and coloproctology include endoscopy as
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index procedures in the curriculum. In order to increase experience, the SAC has recommended to training programme directors that trainees experience in endoscopy is carefully reviewed annually and targeted if necessary. There will shortly be a direct link between the ISCP and the JAG ePortfolio, which will enable trainees to record their data and thereby facilitate the annual review of competence progression. Progression through operative training is reflected in the level of supervision a trainee receives. In the early phases, the

presence of the trainer provides not only instruction but also the experience of a good assistant. With trainee progression, the ability to perform technical aspects improves and the ability to make decisions according to changes in circumstances develops with less involvement of the trainer. Eventually, the competent trainee is able to perform the procedure unsupervised. The level of supervision documented in the review reflects this progression, with 66% of procedures performed under supervision. In complex surgery,

Table 9 special interest experience in endocrine surgery (2 trainees) Number of procedures Mean Range Thyroidectomy Re-do thyroidectomy Parathyroidectomy Adrenalectomy 152 5 67 11 118186 56 5677 913

Table 10 special interest experience in transplantation surgery (2 trainees: 1 renal, 1 liver) Number of procedures Mean Range Kidney transplant Liver implantation Liver recipient hepatectomy 67 7 4 24111 013 08

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Table 11 experience in index procedures outside special interest Special interest Colorectal surgery Upper gastrointestinal surgery Breast surgery Procedure Mean Cholecystectomy Gastrectomy Segmental colectomy Hartmanns operation Cholecystectomy Segmental colectomy Hartmanns operation 96 2 33 11 56 26 3 Number of procedures Median 90 1 31 10 58 24 3 Range 24212 05 1652 237 2881 1263 210 First quartile 62 0 21 6 38 17 2

the majority of procedures are done under supervision and this is undoubtedly associated with the value of an experienced assistant. However, there is a potential negative aspect. If all procedures are carried out under supervision, the first procedure not supervised may be when the trainee undertakes his or her first list as a newly appointed consultant. There is an argument for competence assessment in complex surgery illustrating the level of complexity. This also prompts the question about the level of support and mentorship provided for newly appointed consultants.

Conclusions The ISCP has developed as a competencebased process. It has determined the skills and attributes required to practise as a consultant. Nevertheless, although the skills to perform an operation competently have been defined, the experience to manage all presentations requiring a particular procedure is more difficult to stipulate. This review has identified the median number of procedures undertaken by trainees. It also proposes an indicative minimum

number from the first quartile of numbers performed. The unknown measure is the number of procedures required to achieve competency as described in the PBA. Analysis of ISCP and eLogbook data should allow this to be determined. In addition, due allowance for complexity of a procedure and the associated clinical problem is planned to be built into the PBA, thereby resolving the tension between experience and competence.