Independent operating

Stephen Large, Papworth Hospital

Independent operating is what the A better trainee with this experience, you’d trained consultant cardiac surgeon be tempted to say, than someone with only does. The patient, the surgeon and 200 or even 465 cases under his or her the team are in the operating theatre belt? However, this number is probably following an agreement to proceed between not a marker of excellence of training the patient and the surgeon. Should as so many of my cases were performed a problem arise it is the surgeon who independently with senior guidance bears the responsibility. Indisputably, the available at the end of a ‘phone. surgeon is in charge of the operation and Surely CCST indicates a competence Independent operating is, of course, the with the skilful and appropriate use aspiration of every cardio-thoracic surgical of cardio-pulmonary bypass. What is trainee. It is, I guess, an assumed indication carried out, once safely on bypass, varies of completeness according to of training. Is this the needs of the true? And is it true to say that the “Indisputably, the patient. The absolute number more independent surgeon is in charge of training operating done, the better the trainee? of the operation and operations (that is where the trainee My interest in this area has been Independent operating is mentored through the operation and re-kindled following reports from my is, of course, the not where one trainee performs a median senior trainee after his sniffing about aspiration of every sternotomy, another a top end and an for a consultant’s cardio-thoracic additional one a position. In his search for a possible surgical trainee.” bottom end or two each claiming the career placement, operation for their my fine trainee record) should be was advised that his 30 independently tailored to the trainee’s needs, ensuring performed procedures of 465 logged that this core competence has been operations was less impressive than another achieved. In this way, the numbers of applicant’s 100 independent operations in training operations needed by the trainee, a portfolio of 200. Let’s take a look at what varies and is probably, I’ll guess, between was being judged here. 150 – 300 cases and less about numbers

Firstly, we have to ask how many and more about the quality of guidance operations are needed before a trainee is and mentoring during the training episode. safely awarded a certificate of completion Secondly, what of independent of specialist training (CCST)? This issue is operating, our main concern? Here the both a current and a recurring debate and training consultant is not in the room. one that also dogged me in my training, We must ask what is the lesson to be so many years ago. As a result, I fell into learned? Not the demonstration by our a reflective mood. I’d notched up 887 trainee whom I’ll frivolously call Mr operations in my seven years of registrar Al O’Nmeown, that he can re-enact, training. It was a time when 1 in 1 and 1 in faultlessly, the sequence of steps in two on calls were the norm and these numbers the operation from beginning to end; of performed cases, common-place. certainly not the stumbling progress of a 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