the 16 bulletin
Independent operating Stephen Large, Papworth Hospital
I
ndependent operating is what the trained consultant cardiac surgeon does. The patient, the surgeon and the team are in the operating theatre following an agreement to proceed between the patient and the surgeon. Should a problem arise it is the surgeon who bears the responsibility. Indisputably, the surgeon is in charge of the operation and Independent operating is, of course, the aspiration of every cardio-thoracic surgical trainee. It is, I guess, an assumed indication of completeness of training. Is this true? And is it true to say that the more independent operating done, the better the trainee? My interest in this area has been re-kindled following reports from my senior trainee after his sniffing about for a consultant’s position. In his search for a possible career placement, my fine trainee was advised that his 30 independently performed procedures of 465 logged operations was less impressive than another applicant’s 100 independent operations in a portfolio of 200. Let’s take a look at what was being judged here. Firstly, we have to ask how many operations are needed before a trainee is safely awarded a certificate of completion of specialist training (CCST)? This issue is both a current and a recurring debate and one that also dogged me in my training, so many years ago. As a result, I fell into a reflective mood. I’d notched up 887 operations in my seven years of registrar training. It was a time when 1 in 1 and 1 in two on calls were the norm and these numbers of performed cases, common-place.
A better trainee with this experience, you’d be tempted to say, than someone with only 200 or even 465 cases under his or her belt? However, this number is probably not a marker of excellence of training as so many of my cases were performed independently with senior guidance available at the end of a ‘phone. Surely CCST indicates a competence with the skilful and appropriate use of cardio-pulmonary bypass. What is carried out, once safely on bypass, varies according to the needs of the patient. The absolute number of training operations (that is where the trainee is mentored through the operation and not where one trainee performs a median sternotomy, another a top end and an additional one a bottom end or two each claiming the operation for their record) should be tailored to the trainee’s needs, ensuring that this core competence has been achieved. In this way, the numbers of training operations needed by the trainee, varies and is probably, I’ll guess, between 150 – 300 cases and less about numbers and more about the quality of guidance and mentoring during the training episode. Secondly, what of independent operating, our main concern? Here the training consultant is not in the room. We must ask what is the lesson to be learned? Not the demonstration by our trainee whom I’ll frivolously call Mr Al O’Nmeown, that he can re-enact, faultlessly, the sequence of steps in the operation from beginning to end; certainly not the stumbling progress of a
“Indisputably, the surgeon is in charge of the operation and Independent operating is, of course, the aspiration of every cardio-thoracic surgical trainee.”
lonely trainee discovering how to perform the operation by trial and error, nor the acquisition of the award of “Independent Operating” as a portfolio medal; not independence thrust on the trainee because the trainer was required elsewhere but some essential lesson to help win surgical excellence which will lead to that longed for senior position. My retrospect reminded me of the pain of my early consultant time. I discovered that despite my huge operative experience these had been performed on my consultants’ accounts. In this way I was spared the pain of answering for patients’ morbidity and loss. It was accountability that I had had little exposure to. How long did it take me to settle into accepting the weighty burden of the responsibility for recruitment, consent, admission, operation and post-operative care of my patients? I’d say many months, probably 12. Maybe times have changed and Mr Al O’Nmeown is now very much Mr Alt O’Gether with regular M&Ms and MDTs where the enormity of accountability can be shared? Or perhaps nothing has changed as accounting for the patient is lost in these committees? So, what to do? My proposal is that the experienced registrar leading the operating team independently by proxy in operating room, loses out in senior guidance and in the very tough lesson of accountability. These shortcomings must be resolved, if only to satisfy the demands of consent from the patient for such surgery. I propose that the final year of SpR training in cardio-thoracic surgery should be as a named junior consultant colleague receiving and operating upon patients on their own account. This would be undertaken in a fixed-term, final year contract surrounded by his or her familiar and supportive mentors. This finishing school would better ensure a well-rounded, well trained, Mr or Ms Alt O’Gether-Perfect; a well-rounded colleague, well equipped for future practice and a joy to share practice with. n
