Asian Cardiovasc Thorac Ann 2007;15:307-309
© 2007 Asia Publishing EXchange Ltd
Blood, Sweat, Toil, and Tears of Surgical Training. Part I: Blood
Andrew J Drain, FRCS,
Jonathon I Ferguson, FRCS,
Sharon Wilkinson, BSc,
Samer AM Nashef, FRCS
Department of Surgery, Papworth Hospital, Cambridge, United Kingdom
For reprint information contact: Andrew J Drain, MRCS Tel: 44 1480 364 299 Fax: 44 1480 364 744 Email: andrewdrain{at}doctors.org.uk, Papworth Hospital, Cambridge CB3 8RE, United Kingdom.
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ABSTRACT
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There may be conflict between the requirements of surgical training and those of the clinical service if training has an impact on clinical outcomes. One area of potential impact is perioperative blood loss. We compared total and 12-hour blood loss after 2,079 consecutive cardiac operations performed over 2 years by trainees and consultants. One- and two-way analyses of variance with EuroSCORE and surgeon status as factors were carried out to evaluate the impact of surgeon status on blood loss. There was no difference in blood loss between consultants and trainees. We also compared the rates between consultants and trainees of patients returning to the operating room due to bleeding. This showed a significant difference, with trainees having a higher rate of investigation for bleeding. Cardiac surgical training can be achieved without an adverse effect on blood loss, but it may be associated with a higher rate of re-intervention for bleeding.
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INTRODUCTION
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Surgical trainees need experience in observing, assisting, and performing operations under supervision.1 It is important to ensure that fulfilling training requirements does not adversely affect the outcomes of the clinical service. There is evidence that cardiac surgery can be performed by supervised trainees without adversely affecting survival.2 This study investigates the effect of training on two important aspects of operative morbidity, namely blood loss and the rate of take-back to the operating room for investigation of bleeding.
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METHODS
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Data on total and 12-hour blood loss were collected prospectively for 2,079 consecutive cardiac operations performed between 2000 and 2002, including all redo and emergency operations. Operative details including the operating surgeon were obtained from computerized records made at the time of surgery.
The operating surgeon, defined as the surgeon performing the coronary anastomoses or heart valve procedure, was classified as consultant, junior trainee (specialist registrar year 1–3), or senior trainee (year 4–6). All patients were prospectively risk-stratified using EuroSCORE-predicted mortality: low risk (0%–2%), medium risk (3%–5%), high risk (> 6%).3 Blood loss is reported as median and interquartile range. As blood loss has a skewed distribution, the data were log-transformed prior to analysis. One-way analysis of variance (ANOVA) was carried out to evaluate the impact of surgeon status on blood loss and to adjust for risk profile. A two-way ANOVA with EuroSCORE and surgeon status as factors was also completed. The rate of return to the operating room (take-back) in the same group of patients was also analyzed using a normal chi-squared test, on the basis of surgeon status.
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RESULTS
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Table 1
shows the range of operations and the distribution of cases between consultants and trainees. The blood loss distribution is shown in Table 2. Statistical analysis indicated that surgeon status was not significantly associated with blood loss in both one-way ANOVA and the 2-factor ANOVA (adjusted for EuroSCORE) at 12-hour (p = 0.35, p = 0.33 respectively), as well as for total blood loss (p = 0.54, p = 0.48 respectively). The total number of take-backs was 161/2,079 (7.7%). The relative rates of take-back are shown in Table 2. The difference in these rates between the consultants and trainees was significant (p = 0.03).
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DISCUSSION
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While several factors have been shown to affect perioperative bleeding, the impact of surgical training on this complication has never been studied.4,5 Postoperative blood loss has a skewed distribution, and it is important to remember that while total blood loss is recorded (Table 2
), the amount of blood lost in the worst 5% of cases is considerably more.
At Papworth Hospital, surgical trainees begin by assisting and observing, but rapidly (within their first 3 months) progress to performing parts of the procedure under direct supervision, assisted by consultants. As the trainees achieve mastery of straightforward components of the operation (incision and closure), direct supervision is withdrawn for these components but remains in place for the cardiac part of the procedure, until completion of specialist training. Which case is actually given to the trainee varies from consultant to consultant, and cannot be fully standardized. Factors involved include the complexity of the case, the grade of trainee, observed operative skill (not always the same), and any time constraints or other issues arising during the procedure.
This study investigated operations where the cardiac part was carried out by trainees under direct supervision. However, because all operations at Papworth are to a variable extent ‘training cases’, it is important to recognize that regardless of who performs the surgery, the trainee is often responsible for opening and closing the chest. A limitation of the study is that attribution is not on an intention-to-treat basis: if problems are encountered, the consultant may elect to do more of the operation, which could confound the variables. Despite this, the paper addresses reality with reality.
In keeping with the training culture of this institution, supervised operating is an essential part of surgical training.6 The increasing national, local, and individual scrutiny of surgical results may lead to reluctance among trainers to train and, ultimately, fewer procedures being performed by trainees. We feel it is important for surgical training to objectively assess any disparity between trainee and consultant outcomes to ensure quality care for the patient and to address training-service conflicts. Surgical training with appropriate supervision can be safely performed.6,7 While we have shown no impact of training on perioperative blood loss in cardiac surgery, we observed a small but significant difference in the take-back rate between consultant and trainee cases. The results demonstrate that what has previously been considered as a straightforward part of the procedure, i.e., chest closure, can lead to differences in take-back rate. Whether this was due to a skewed bleeding pattern (more massive bleeders and less minor bleeders in trainee patients), or to different criteria for take-back (i.e., lower threshold for take-back of the trainee’s patients) is the subject of further study. It is unclear from these results whether additional consultant supervision for more than just the cardiac part of the procedure would alter the take-back rate. Many other effects of training have yet to be assessed. These findings suggest no conflict between service and training with regards to blood loss in cardiac surgery, but there is conflict with regards to patients being returned to the operating room for bleeding. Further study is needed to determine the impact of training on sweat, toil, and tears.
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Footnotes
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Note: we have entitled this paper according to the prevalent misquotation of Sir Winston Churchill’s famous speech to the House of Commons. The authors are aware that what he actually said was: "I have nothing to offer but blood, toil, tears and sweat".
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REFERENCES
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- Anderson JR, Parker DJ, Unsworth-White MJ, Treasure T, Valencia O. Training surgeons and safeguarding patients. Ann R Coll Surg Engl 1996;78(3 Suppl):116–8.[Medline]
- Goodwin AT, Birdi I, Ramesh TP, Taylor GJ, Nashef SA, Dunning JJ, et al. Effect of surgical training on outcome and hospital costs in coronary surgery. Heart 2001;85:454–7.[Abstract/Free Full Text]
- Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999;16:9–13.[Medline]
- Nuttall GA, Oliver WC, Santrach PJ, Bryant S, Dearani JA, Schaff HV, et al. Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology 2001;94:773–81; discussion 5A–6A.[Medline]
- Liu B, Belboul A, Larsson S, Roberts D. Factors influencing haemostasis and blood transfusion in cardiac surgery. Perfusion 1996;11:131–43.[Medline]
- Hargreaves DH. A training culture in surgery. BMJ 1996;313:1635–9.[Free Full Text]
- Collins C. Surgical training, supervision, and service. BMJ 1999;318:682–3.[Free Full Text]
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