BJUIB J U I N T E R N A T I O N A L

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1 2 9 6 B J U I N T E R N A T I O N A L © 2 0 11 B J U I N T E R N A T I O N A L | 1 0 9 , 1 2 9 6 – 1 3 0 2 | doi:10.1111/j.1464-410X.2011.10579,10601.x

What ’ s known on the subject? and What does the study add? One of the main components of surgical training is the development of operative skills which, in part, is related to the extent of the practical operative experience. The operative experience of urological trainees in the UK has not being previously published.

We examine trainees ’ current operative experience and analyse the changes over recent years. With a notable decrease in experience of certain procedures, we highlight the possible reasons and discuss the implications for future training.

We have examined the operative experience of urological trainees in the UK over a 6-year period. Between 2004 and 2009, urological trainees submitting their operative logbooks to the Specialist Advisory Committee for the award of Certifi cate of Completion of Training were analysed. We recorded trainees ’ experience in eight operative procedures; transurethral resection of the prostate (TURP, including bipolar TURP), transurethral resection of bladder tumour (TURBT), radical nephrectomy (RN, open and laparoscopic), radical cystectomy (RC), radical prostatectomy (RP), percutaneous nephrolithotomy (PCNL) and ureteroscopy (fl exible and rigid). In all, 251 logbooks were identifi ed over the 6-year period. In 2008/2009, the mean (range) number of cases ‘ performed ’ and ‘ supervised ’ were as follows; TURP 189 (41 – 516), TURBT 190

(50 – 432), open RN 21 (2 – 78), RC 10 (0 – 70), RP 13 (0 – 80), PCNL 19 (0 – 125), ureteroscopy 131 (14 – 465), laparoscopic RN 11 (0 – 97). Latterly there has been a signifi cant reduction in the numbers of TURP, open RNs and RCs. There has been an increase in the use of trainees as assistants for RC, RP and open RN. There was a large variation in numbers of procedures performed between trainees.

In summary there has been a recent decline in the numbers of TURP, open RNs and RCs performed. For all procedures, signifi cant variability exists between trainees.

KEYWORDS

European Working Time Regulations (EWTR) , urological training , operative logbook , TURP , nephrectomy

Operative experience of urological trainees in the UK Jonathan D. Gill , Lianne F. Stewart * , Nicholas J.R. George † and Ian Eardley Pyrah Department of Urology, St. James ’ s University Hospital, Leeds , * Joint Committee on Surgical Training, Royal College of Surgeons of England, London , and † Department of Urology, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK

INTRODUCTION

Until 2007, trainees wishing to pursue a career in urology in the UK, after leaving medical school, underwent a pre-registration year, followed by a 2 – 3 year period in basic surgical training during which they acquired basic, broad-based surgical competencies while sampling the various different surgical specialties. Most then undertook a period of time in research, typically acquiring a higher degree within a 2 – 3 year period. They then entered specialty training in urology, which took place over 5 – 6 years before being certifi ed as competent to practice independently.

When a trainee commences surgical and urological training, his or her operative experience is usually minimal. During the course of the training period he or she

acquires a range of knowledge, clinical skills, technical skills and behaviours such that by the end of training he or she is certifi ed as competent to practice independently. For a surgeon, among the chief competences that he or she needs to acquire are the technical skills required to undertake surgery. These were traditionally acquired using an apprenticeship model whereby the trainee observed a surgeon at work, then would be assisted through one or more procedures before being allowed to undertake the procedure themselves. Assessment of competence to operate independently was undertaken informally and was implicit. Although it has been recognised for some time that feedback is helpful in developing technical competencies, in the apprenticeship model feedback is irregular, informal and the emphasis is on the development of competence by repetition.

In recent years, a number of pressures have resulted in the re-evaluation of the apprenticeship model. These have included the interests of patient welfare and the reduction in training hours imposed by the progressive application of the European Working Time Regulations (EWTR). Historically, junior doctors in the UK spent on average 30 000 h in training but with the full introduction of EWTR this is now predicted to fall to 8000 h [ 1 ] .

Development of competence in a procedure occurs at different speeds in different individuals, such that the number of procedures required to achieve competence depends upon the innate ability of the trainee, the degree to which he or she is actually ‘ trained ’ and the duration over which that training takes place. ‘ Able ’ trainees master technical skills faster than

Accepted for publication 10 June 2011

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less ‘ able ’ trainees, while the provision of close supervision and regular feedback improves the speed of acquisition of competence. Finally, irregular infrequent exposure to an operation results in a longer learning curve. While absolute numbers are alone not measure of competence, they are a surrogate, and for many training systems they remain the only measure of the operative competence of a trainee.

The objective of the present study was to measure the operative experience of trainees within the UK during higher surgical training in urology. Furthermore, we looked at changes over the period of the study both in terms of the degree of supervision and in terms of the actual numbers of procedures undertaken. While the structure of training in the UK changed in 2007 to a more streamlined shorter pathway, the trainees ‘ studied ’ in the present paper all entered urological training before or during 2004. The body that manages urological training in the UK and Ireland is the Specialty Advisory Committee (SAC) in

Urology, which ‘ signs off ’ trainees at the end of their training based on a submission by the trainee, which includes, amongst other things a logbook of their operative experience during specialty training.

MATERIALS AND METHODS

Over a 6-year period, from 2004 to 2009, operative logbooks (paper and electronic) submitted to the SAC for the Certifi cate of Completion of Training (CCT) were analysed. There were no logbooks from Article 14 trainees. For the years 2004 – 2005, data was collected retrospectively by analysing logbooks kept in fi le. For the years 2006 – 2009, data collection was prospective. We recorded trainees ’ experience in eight operative procedures; TURP (including bipolar TURP), transurethral resection of bladder tumour (TURBT), radical nephrectomy (RN, open and laparoscopic), radical cystectomy (RC), radical prostatectomy (RP), percutaneous nephrolithotomy (PCNL) and ureteroscopy (fl exible and rigid). In each case the

individual ’ s level of input was recorded; ‘ performed ’ (performed independently), ‘ supervised ’ (performed under supervision), and ‘ assisted ’ .

The review was undertaken initially as a means of quality assuring the certifi cation process, so less common procedures such as laser prostatectomy, nephroureterectomy (laparoscopic and open), open simple nephrectomy, laparoscopic and robotic RP and total pelvic exenteration were not included.

Statistical analysis was carried out using the Student ’ s t -test.

RESULTS

In all, 251 logbooks were identifi ed over the 6-year period. In 2008/2009, the mean (range) number of cases ‘ performed ’ and ‘ supervised ’ were as follows; TURP 189 (41 – 516), TURBT 190 (50 – 432), open RN 21 (2 – 78), RC 10 (0 – 70), RP 13 (0 – 80), PCNL 19 (0 – 125), ureteroscopy 131 (14 – 465), and laparoscopic RN 11 (0 – 97).

Data for all years is shown in Table 1 . Latterly there has been a signifi cant reduction in the numbers of TURP, open RN and RC ( Table 2 ). For the percentage of procedures carried out as an assistant, there has been a signifi cant increase in RC, RP and open RN ( Table 3 ). Trends specifi cally for open RN (historically a core procedure for all urologists) are highlighted in Fig. 1 . The ratio of cases ‘ performed ’ to ‘ supervised ’ remained the same for all procedures throughout the study period.

For the years 2004 – 2006 the logbooks did not routinely record data for ureteroscopy and laparoscopic RN, and so comparisons were not possible.

Finally, a large variation in numbers of procedures performed between trainees was noted ( Figs 2 – 9 ).

DISCUSSION

The present data shows for the fi rst time, the operative experience of urological trainees in the UK. It also provides a benchmark against which trainee experience

TABLE 1 The mean numbers of procedures performed in all years (P + S and A)

Procedure, n

2004 2005 2006 2007 2008 2009 n = 21 n = 47 n = 25 n = 49 n = 52 n = 57P + S A P + S A P + S A P + S A P + S A P + S A

TURP 228 6 221 3 216 12 202 4 189 3 190 4TURBT 184 3 187 3 171 5 182 3 179 2 204 3Open RN 32 16 36 15 27 22 24 17 20 17 24 18RC 12 11 16 12 12 15 11 15 10 16 10 17RP 11 16 17 19 14 29 12 27 13 30 14 30PCNL 13 7 15 7 13 11 15 7 14 7 23 10Ureteroscopy N/A N/A N/A N/A N/A N/A 119 6 109 5 151 7Laparoscopic RN N/A N/A N/A N/A N/A N/A 7 11 6 9 16 19

P (performed independently), S (performed under supervision), and A (assisted).

Procedure, n 2004/2005 2008/2009

P n = 68 n = 109TURP 223 189 < 0.001TURBT 186 190 NSOpen RN 35 21 < 0.001RC 15 10 0.005RP 15 13 NSPCNL 14 19 NSUreteroscopy N/A 131 N/ALaparoscopic RN N/A 11 N/A

TABLE 2 Changes in mean numbers of procedures performed over time (P + S)

NS, not statistically signifi cant; N/A, not available.

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can be measured in the future. We have also shown that over a 6-year period that there has been a reduction in the numbers of TURPs, open RNs and RCs performed by UK trainees. Finally, we have seen an increase in the role of the trainee as an assistant, rather than the operator, in the more major open cases.

In terms of the descriptive data, several things were obvious. Firstly, there is an enormous variation in the operative experience of urological trainees in the UK. Some trainees gain signifi cantly more experience than others. For instance, for TURP, the most experienced trainee undertook more than fi ve-times more TURPs than the least experienced trainee, although both these trainees were ‘ signed off ’ as being technically competent at the time of certifi cation. While some of this will refl ect the varying aptitudes of trainees, it also refl ects the different exposure to the varying procedures in different hospitals and training units. These differences were even seen between trainees in the same training rotation, while as yet we have been unable to identify signifi cant differences between rotations.

This disparity was even more marked in some subspecialty areas. For pelvic resections (RC and RP), PCNL and laparoscopic RN, a proportion of trainees undertook very few procedures, either as an assistant, under supervision or as the primary surgeon. This suggests that those trainees had chosen not to pursue that particular subspecialty area, and that this was understood by the trainer. In short, the trainee had begun to develop an area of specialty interest whilst still in training. With

such a wide variety of experience amongst CCT holders, employers must be sure that potential employees are suitably matched to their job plans.

During the study period, the ‘ Improving Outcomes Guidance ’ with centralisation of services has been implemented [ 2 ] . As a result, some procedures (e.g. RC, RP) are

Procedure, %2004/2005 2008/2009

Signifi cance increase?

n = 68 n = 101 P TURP 2 2 NoTURBT 1 1 NoOpen RN 30 45 < 0.001RC 45 64 < 0.001RP 54 73 < 0.001PCNL 39 40 NoUreteroscopy N/A 5 N/ALaparoscopic RN N/A 69 N/A

TABLE 3 Percentage of procedures performed as an assistant (A/ [ A + P + S ] )

N/A, not available.

5045403530

Mea

n N

umbe

rs/%

2520151050

2004 2005

P+SA%

2006 2007Year of CCT

2008 2009

FIG. 1. The mean numbers of open RNs (P + S), with % performed as assistant (A).

Num

bers

Per

form

ed

100

200

300

400

500

600

01 26 51 76 101

Trainees

TURP

AssistedSupervisedPerformed

FIG. 2. Variation in numbers of TURPs (2008/2009). Each bar representing an individual trainee ’ s logbook.

Num

bers

Per

form

ed

100

200

300

400

500

01 26 51 76 101

Trainees

TURBT

AssistedSupervisedPerformed

FIG. 3. Variation in numbers of TURBTs (2008/2009). Each bar representing an individual trainee ’ s logbook.

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now only performed at larger centres with a higher turnover, aiming to improve outcomes. This does not appear to have yet made a difference in the range of trainees ’ overall operative experience; the interquartile range for all procedures has not changed signifi cantly over the study period. This is perhaps explained by the fact that trainees rotate around different hospitals in the deanery during their training, and so whilst the variety of procedures differs from hospital to hospital, exposure at a regional level has remained constant.

The decline in the exposure to TURP probably has a number of explanations. First, there has been a gradual reduction the total number of TURPs performed worldwide as a consequence of the increased use of medication to treat LUTS due to BPH [ 3 ] . Second, we have seen the gradual introduction of new technologies; particularly laser prostatectomy as a means of treating LUTS secondary to BPH [ 4 ] . One might speculate that as a new technology is introduced, there is a tendency for the senior surgeon to ‘ learn ’ the procedure fi rst, before training the trainee. TURBTs are procedures that have been relatively unaffected by recent advances in surgical techniques and so make for a more robust comparison, in that regard there has not been a signifi cant reduction in recent years.

The decline in the number of open RNs undoubtedly refl ects, in part, the advent of laparoscopy as the primary means of undertaking RN [ 5 ] . What is perhaps surprising is that the number of laparoscopic RNs did not increase in a compensatory way until 2009. This probably refl ects the collective learning curve of the trainers, who were busy consolidating their own skills at the expense of the trainee. However, what is clear again is the proportion of trainees who gain minimal experience in open RN, and it is for that reason that in the most recent UK urological curriculum, open RN to competency level 4 (i.e. able to undertake the surgery independently and to deal with any relevant perioperative complications) is not a mandatory requirement for all trainees [ 6 ] . The trends we have noted in open and laparoscopic RN might perhaps increase the likelihood of a surgeon being unable to convert a laparoscopic case to an open

Num

bers

Per

form

ed

40

20

60

80

100

120

01 26 51 76 101

Trainees

Open Radical Nephrectomy

AssistedSupervisedPerformed

FIG. 4. Variation in numbers of open RNs (2008/2009). Each bar representing an individual trainee ’ s logbook.

Num

bers

Per

form

ed

40

30

20

10

60

50

70

80

90

01 26 51 76 101

Trainees

Radical Cystectomy

AssistedSupervisedPerformed

FIG. 5. Variation in numbers of RCs (2008/2009). Each bar representing an individual trainee ’ s logbook.

Num

bers

Per

form

ed

60

40

20

100

80

120

140

160

01 26 51 76 101

Trainees

Radical Prostatectomy

AssistedSupervisedPerformed

FIG. 6. Variation in numbers of RPs (2008/2009). Each bar representing an individual trainee ’ s logbook.

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procedure, having had a lack of training in performing an open RN. Ensuring support staff are on standby may therefore be an increasing requirement.

Whilst there is no substitute for operative experience, other methods of skills development such as simulation may play an increasing role in the future, although at present the validity of such training models remains unproven [ 7 ] . Fellowships will perhaps be an increasingly important means of skills acquisition, along with subsequent mentorship for newly appointed consultants [ 8,9 ] . If there is a lack of availability of mentors, mutual mentoring is an alternative particularly when setting up a new service, whereby post-fellowship consultants jointly perform cases, sharing their experiences, knowledge and skills [ 10 ] .

To what extent the implementation of EWTR has affected these fi gures is unclear. Evidence from some centres has already highlighted the detrimental effects on training. Bates et al. [ 11 ] reported a 14 – 15% reduction in total procedures performed by general surgical trainees after the initial implementation of a 58-h EWTR-compliant rota. With regard to the implementation of a 48-h EWTR-compliant rota, Heath et al. [ 12 ] reported a 59% reduction in elective procedures performed by general surgical trainees.

In recent years, the role of the trainee has changed, particularly for major procedures. This probably refl ects the recent expansion of urological consultant numbers, with the appointment of large numbers of younger consultants, who were likely to be consolidating their own experience before concentrating upon training the next generation of trainees.

There are defects in the methodology of the present study. All logbooks were completed by the trainees themselves and would be subject to the normal omissions and inaccuracies. The difference between whether a procedure was ‘ performed ’ or ‘ supervised ’ is very subjective, and there is clearly a huge difference in trainees ’ interpretation of these terms. A case that is ‘ performed ’ implies that the trainer was not present and took no part in the procedure. A case that is ‘ supervised ’ implies that the trainer was in theatre directly supervising and advising as necessary, and so training

Num

bers

Per

form

ed

60

40

20

100

80

120

140

01 26 51 76 101

Trainees

Laparoscopic Nephrectomy

AssistedSupervisedPerformed

FIG. 7. Variation in numbers of laparoscopic RN (2008/2009). Each bar representing an individual trainee ’ s logbook.

Num

bers

Per

form

ed

200

100

300

400

500

01 26 51 76 101

Trainees

Ureteroscopy

AssistedSupervisedPerformed

FIG. 8. Variation in numbers of ureteroscopy (2008/9). Each bar representing an individual trainee ’ s logbook.

Num

bers

Per

form

ed

80

60

40

20

100

120

140

01 26 51 76 101

Trainees

PCNL

AssistedSupervisedPerformed

FIG. 9. Variation in numbers of PCNL (2008/2009). Each bar representing an individual trainee ’ s logbook.

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is assumed to be taking place. There follows a grey area when the trainer is in the coffee room or the offi ce, and may pop in and out of the theatre room. Does this constitute supervision? This appears to have been interpreted differently by different trainees.

In conclusion, the present data provides a ‘ snapshot ’ of the current surgical exposure of urological trainees in the UK. There is signifi cant variability between trainees, and a recent decline in numbers of TURPs, open RNs and RCs. Currently, trainees are usually the assistants for major open procedures, and there has been a signifi cant increase in their role as an assistant over the 6-year period. Now that the fi nal step of implementation of the EWTR is upon us, our data provides a benchmark for future comparisons.

ACKNOWLEDGEMENTS

We acknowledge all the urological trainees who initiated, maintained, updated and submitted their logbooks during the period of the study.

CONFLICT OF INTEREST

None declared.

REFERENCES

1 Phillips H , Fleet Z , Bowman K . The European Working Time Directive – Interim Report and Guidance from the Royal College of Surgeons of England Working Party . London : Royal College of Surgeons , 2003

2 National Institute for Clinical Excellence . Guidance on Cancer Services – Improving Outcomes in Urological Cancers. The Manual . Available at: http://www.nice.org.uk:80/nicemedia/live/10889/28771/28771.pdf . Accessed August 2011

3 Wilson JR , Urwin GH , Stower MJ . The changing practice of transurethral prostatectomy: a comparison of cases performed in 1990 and 2000 . Ann R Coll Surg Engl 2004 ; 86 : 428 – 31

4 Aho TF , Gilling PJ , Kennett KM , Westenberg AM , Fraundorfer MR , Frampton CM . Holmium laser bladder neck incision versus holmium enucleation of the prostate as

outpatient procedures for prostates less than 40 grams: a randomized trial . J Urol 2005 ; 174 : 210 – 4

5 Bhayani SB , Clayman RV , Sundaram CP et al . Surgical treatment of renal neoplasia: evolving toward a laparoscopic standard of care . Urology 2003 ; 62 : 821 – 6

6 ISCP . ISCP – Urology Curriculum . Available at: http://www.gmc-uk.org/Urology_curriculum_2010.pdf_32485339.pdf . Accessed August 2011

7 Schout BM , Hendrikx AJ , Scherpbier AJ , Bemelmans BL . Update on training models in endourology: a qualitative systematic review of the literature between January 1980 and April 2008 . Eur Urol 2008 ; 54 : 1247 – 61

8 Bianco FJ , Cronin AM , Klein EA , Pontes JE , Scardino PT , Vickers AJ . Fellowship training as a modifi er of the surgical learning curve . Acad Med 2010 ; 85 : 863 – 8

9 Andrich DE , Mundy AR . A Fellowship programme in reconstructive urological surgery: what is it and what is it for? BJU Int 2010 ; 106 : 108 – 11

10 Jones A , Eden C , Sullivan ME . Mutual mentoring in laparoscopic urology – a natural progression from laparoscopic fellowship . Ann R Coll Surg Engl 2007 ; 89 : 422 – 5

11 Bates T , Cecil E , Greene I . The effect of the EWTD on training in general surgery: an analysis of electronic logbook records . Ann R Coll Surg Engl 2007 ; 89 ( Suppl .): 106 – 9

12 Heath RM , Gate TCS , Halloran CM , Callaghan M , Paraoan MT , Blair SD . The EWTD ‘ triple whammy ’ : hitting surgical trainees where it hurts . Ann R Coll Surg Engl 2007 ; 89 ( Suppl .): 26 – 8

Correspondence: Jonathan D. Gill, Pyrah Department of Urology, St. James ’ s University Hospital, Leeds LS9 7TF, UK. e-mail: jongill@hotmail.com

Abbreviations : EWTR , European Working Time Regulations ; SAC , Specialty Advisory Committee ; CCT , Certifi cate of Completion of Training ; TURBT , transurethral resection of bladder tumour ; RN , radical nephrectomy ; RC , radical cystectomy ; RP , radical prostatectomy ; PCNL , percutaneous nephrolithotomy .

EDITORIAL COMMENT

TRAIN HARD AND WELL BUT TRAIN INTELLIGENTLY: A COMMENT ON ‘ OPERATIVE EXPERIENCE OF UROLOGICAL TRAINEES IN THE UK ’

This paper provides a valuable contemporary insight into the current operative exposure of UK urological trainees in eight key procedures over a 6-year period [ 1 ] . It includes most of the urological registrars gaining a Certifi cate of Completion of Training within this period. It is particularly relevant to current urology trainees and their trainers for several reasons. One is the reassurance for individuals that their own logbooks conform with those of their peers nationally as they progress through specialist training. Other reasons are to allow realistic goals to be set, in terms of numbers of cases per year and range of exposure, by both the trainee and their trainers upon commencement of a placement.

The number of TURPs, open radical nephrectomies and open radical cystectomies performed has fallen in recent years. For TURP this may be due to reduced numbers of men requiring bladder outfl ow surgery compared with previously due to medical interventions, coupled with more urologists to do the job but could also be related to reduced access for trainees due to consultants learning new techniques (holmium laser enucleation of the prostate/Greenlight laser therapy) or increased sub-specialisation within urological teams. For prostatectomy and cystectomy, operative experience may have reduced due to the Improving Outcomes Guidance ruling regarding the centralisation of cancer services [ 2 ] . Trainees rotating into specialist services may have increased exposure to pelvic oncology cases but no exposure to TURPs for their entire training year. This might be a problem if adequate skills in core procedures such as TURP and TURBT are not reached; however, if the trainee wishes to become an endourologist then the numbers of radical pelvic surgical procedures logged is less relevant. In fact, spending considerable time gaining skills that will soon be forgotten forever upon consultant appointment is potentially a waste of time in the current times of increasing sub-specialisation and greatly reduced overall training hours. We cannot have it