Alexandros Charalabopoulos, MD, MSc, PhD, MRCS, FRCS
Consultant Oesophagogastric and General Surgeon, Broomfield Hospital, Chelmsford, Essex, CM1 7ET, UK; E-mail: acharalabopoulos@yahoo.com
The advent of laparoscopic surgery with its many benefits for both patients and surgeons have meant that increasingly more operations are now performed laparoscopically. For junior doctors this rise means that a large proportion of the operations they see and the patients they care for post-operatively have had laparoscopic procedures.
One key aspect of the laparoscopic approach is that even relatively simple operations such as appendicectomy cannot be performed independently. There is always a need for an assistant to operate the camera and provide an optimal view of the operative site for the surgeon. In many hospitals, this responsibility is usually that of the junior members of the surgical team.1 Despite this role being vital for the operation, often the junior doctors drafted into providing this service have very little prior experience.2 The consequence of this is increased operating time and substandard views for the operating surgeon due to the junior doctors lack of familiarity with laparoscopic principles.3 During normal working hours there may be other more experienced trainees available to step in and assist but out of hours, in many hospitals, the only assistant available may be a first-year training doctor.3
Undergraduate exposure to laparoscopic surgery is limited to very few UK medical schools having dedicated teaching on the subject. Furthermore, in the current foundation year curriculum there is no specific requirement for trainees to attain surgical skills let alone laparoscopic skills.4
Modern computing and video game technology means that current trainees have a greater aptitude for the technical skills needed for laparoscopic surgery.5 It has been shown that the tuition of basic laparoscopic skills on commonly available simulators provides trainees with skills that are directly transferable to the operating theatre.6 This highlights the fact that there is a prime opportunity for enhancing trainee learning as studies have shown that technical performance during real-time surgery is improved when there is prior training on models.6 In turn, it has been shown that learning on these models prior to theatre confers to greater time efficiency when performing simple skills.2,6
Currently, the training pathway into surgery for UK graduates is relatively linear. After medical school, it is compulsory to complete 2 foundation training years rotating usually through 6 different specialities (4-monthly placements) which usually, but not always, includes the trainees desired future speciality. During the second foundation year, trainees apply for core surgical training, which is a 2-year training program themed to their chosen surgical speciality but also including allied surgical specialities. At the end of this, trainees will finally apply for higher surgical training into their chosen speciality, which typically lasts from 4 to 6 years.
Even though not all year one trainees passing through a general surgical rotation aspire to become surgeons this should not prevent them from gaining surgical experience. Laparoscopic surgery is widespread and most specialities especially general practice will deal with or refer patients on to general surgery. As such it is vital that all trainees appreciate the basic concepts of these procedures in order to understand the patient’s surgical experience.1 In surgery, the best way to do this is to assist and observe these procedures directly in order to understand how patients are treated and appreciate how certain post-operative complications arise.7,8
With the increasingly competitive entrance into surgical training, junior doctors are required to make career decisions far earlier than their more senior peers. Core surgical training applications are now submitted at the beginning of foundation year 2 thus junior doctors may only have their foundation year 1 to make their decision. Evidence shows that the vast majority (88% men and 79% women) of surgical trainees made their decision after the end of their first year.9 This limited timeframe highlights that career decisions can be made with very little experience, thus it is vital that junior doctors get adequate exposure in order to make an informed career choice.9
In this study, we aim to look at the exposure junior doctors, in particular, year one trainees, currently have in laparoscopic surgery. The main reason for including year 1 trainees, was that studies show that decision to pursue surgical training is shaped primarily in the first year of training.9 Hence, we wished to assess the quality of training received in the lead up to foundation year 1 and during the foundation year 1 year. Furthermore, applications to core surgical training are at the beginning of foundation year 2 (FY2) thus the training and experience that leads up to this decision are primarily in foundation year 1. With this study, we assess undergraduate training and identify potential areas of weakness in the current Foundation Year programme with respect to developing laparoscopic surgical skills.
We created a questionnaire using Google Survey comprising of a total of 16 questions (Appendix 1). This was sent to Year 1 training doctors in East of England, London and Midlands’s area. The survey was designed by the authors in order to assess foundation year past and present training and also confidence in operative skills. Dissemination of questionnaires was made via Foundation Training doctor coordinators at trusts across England. Further numbers were elicited by asking trainee doctors to complete surveys during mandatory teaching and training sessions. All trainees were invited to complete the email-sent questionnaire, but was not compulsory for them to complete it. Regular email reminders were sent over a 2-month period, after which data collection ended and returned questionnaires were analysed. A total number of 302 questionnaires were sent to 13 different hospitals. All questionnaires were made anonymous after submission and no personal or identifiable data was recorded. A total of n=64 completed responses were received from trainees. For the sample year, there were n=7638 Foundation Year 1 Trainees across the United Kingdom, with n=572 of them being in the relevant deaneries. A margin of error was then calculated for sample size using standard margin of error statistical calculation with 99% confidence level. The margin of error of results in regards to total number of trainees in deanery sampled (n=572) was 16%, while the margin of error of results in regards to total number of FY1’s in sample year (n=7638) was 17%.
A total of n=64 out of 302 questionnaires were fully completed and returned (response rate 21.3%). Fifty-three percent of respondents were female and 47% male. All respondents had undergraduate training in the UK and represented 12 different medical schools from across the country. Sixty-three percent of respondents had General Surgical placements in their foundation year one with 52% having surgical on-call night shifts during their placement.
Those questioned had varying interest in surgery as a future career with a greater majority (51%) not wishing to pursue a surgical career (Figure 1).
Figure 1. Interest in Surgery as Future Career
Of the respondents that had general surgery placements most felt they had adequate opportunities to assist and gain experience in theatre with 77% of respondents either strongly agreeing or agreeing with the above statement (Figure 2). Eighty percent of those surveyed with general surgery placements were able to go to theatre 1-2 or 2-3 times per week, with 17% of respondents being unable to go to the theatre at all during the week. A contributing factor to this was the intensity of work on the ward with 40% of respondents agreeing or strongly agreeing that ward work prevented them from going to the theatre (Figure 2).
Figure 2. Opportunity for Theatre Experience
To assess confidence in basic laparoscopic principles and skills we asked respondents 5 questions that covered the tasks early years training doctors are commonly asked to assist in during theatre. There was a wide range of confidence levels in these skills (Figure 3). When it came to understanding laparoscopic cameras only 37% of respondents felt they knew the different types available and additionally only 33% the differences in the images they produced.
Figure 3. Confidence with Basic Laparoscopic Skills
In regards to gaining laparoscopic access and the principle of insufflation, an understanding was better, with 50% strongly agreeing or agreeing that they understood the underpinning principles. When it came to port placement this was not the case, with only 33% strongly agreeing or agreeing that they were confident with how this was done. Finally, only 25% of respondents felt confident in using basic laparoscopic tools when asked to assist in theatre (Figure 3).
Majority of respondents (67%) felt they were able to develop the basic skills outlined in previous questions in the questionnaire during their general surgery placement (Figure 4). This especially correlated with those respondents who were able to attend theatre more often during the week.
Figure 4. Development of Basic Laparoscopic Skills during First Year of Training
The final part of the questionnaire focussed on the standard of teaching, foundation year doctors received both as under-graduates and post-graduates. When it came to undergraduate training only 25% of all respondents strongly agreed or agreed that they had received adequate teaching on laparoscopic skills during medical school. Furthermore, only 29% of all respondents had training on basic skills using laparoscopic trainers/models at any stage of their training. Most undergraduate teachings were via one-off sessions in medical schools that had available simulation suites or by self-organised sessions with box trainers (Figure 5).
Figure 5. Undergraduate and Post-graduate Teaching Exposure
Post-graduate training was mainly compromised of on-the-job training and to lesser extent self-funded courses. Only 8% of all respondents stated they had any formal laparoscopic skills teaching during their Foundation year. Most teaching came from assisting in theatre and getting informal teachings from seniors. Thirteen percent of respondents attended courses with nearly all of them attending the Royal College of Surgeons “Basic Surgical Skills” course (Figure 5).
From the study, it is quite clear that first year junior doctor’s experience in laparoscopic surgery is low. Most respondents had very little teaching or hands-on experience in laparoscopic skills as undergraduates. In the first year of training, weekly theatre time was also limited to an average 1-2 times per week. In conjunction, this leaves very little time to develop and practice basic skills.10
Studies show that when ‘laparoscopic naive’ trainees receive systematic training using laparoscopic simulators they develop basic skills that are directly transferable to the operating theatre.2,11,12 Students who received prior simulation sessions gained proficiency more quickly, were more comfortable assisting in theatre and were more time efficient.2,7,13 Systematic review shows strong evidence supporting the fact that simulation training shows general increase in proficiency at all grades of training and shortens the learning curve for real laparoscopic procedures.7,8,14 However over the long-term this effect has not been shown to persist over numerous subsequent procedures.8,14 This shouldn’t be considered a disadvantage in this case as most foundation doctors spend 4 months rotating through a surgical speciality. Hence the short-term benefits that could potentially be gained from simulation training would be invaluable.
The most common role for foundation doctors within the surgical team is that of the assistant, which in laparoscopic surgery is mainly comprised of manipulating the camera and the use of simple tools to assist the surgeon.15 Though these are skills that can be taught with relative ease, tuition intra-operatively isn’t the most effective introduction to them.15 Prior simulation sessions would confer to greater proficiency and confidence from the very first case a junior doctor assists in.16 This would be an asset for the entire surgical team, as less time would have to be dedicated to teaching the basics during precious theatre time. Only a small proportion of our respondents were confident with the basic skills needed. Nevertheless, they mostly agreed that they could build on these skills during their rotation with 67% stating so, despite regular theatre time being scarce. Concurring with the published literature, it is evident that the amount of time junior doctors spendduring their first year in theatre is low with most time being spent on the ward.17 Thus it is imperative that they are able to maximize the time that they do spend there. When trainees have an understanding of the basic skills prior to the theatre they are able to spend time developing more complex skills.18
Simulation training is a safe and cost-effective method of training basic laparoscopic skills.19 Students are much more comfortable training in the safe confines of a simulation suite. Learning to manipulate and to provide a view with a camera under the stresses of a real-time operation is not conducive to learning. Basic skills teaching can be delivered effectively and with little cost.20 Using local education center resources and local faculty basic skills can be taught with relative ease.
There is clearly a lack of exposure to hands-on surgical skills development in medical school as evidenced by the fact that only 25% of our respondents from 12 different UK medical schools felt they received adequate teaching. This is similar to findings in other studies that found a lack of formal practical skills teaching at the undergraduate level.18,20 A lot of the experience respondents acquired was through self-directed learning, extra-circularly, for example, student-led simulation sessions or as part of a research project. At the post-graduate level the current foundation programme curriculum makes very little provision for the development of surgical skills and in particular laparoscopic skills.4 From our respondents, from 13 different hospitals, only 8% received any form of formal teaching on laparoscopic skills despite the fact that 63% of respondents had a general surgical rotation. This highlights the fact that there is a very real gap in surgical teaching at a junior level.
Thirty-three percent of our respondents were interested in a surgical career with 16% being unsure. Trainees who show an interest early, during the first year of training, are the most likely to succeed.9,21 With the accelerated surgical training application at the beginning of the second year of training, trainees have very little time to gain adequate exposure in order to make an informed decision. Studies reveal that juniors who received surgical skills teaching were shown to have a greater interest in pursuing a surgical career afterwards; therefore, providing more formal hands-on experience early will allow the best and most motivated trainees to apply to higher surgical training.20,22
The study’s main limitation is the low response rate to the circulated questionnaire (21%). This is difficult to interpret; one possible explanation may be a career choice away from surgery or lack of engagement/enthusiasm amongst early year trainees towards surgery that is currently noticed in the UK.23 This is also supported by our study where 51% of respondents did not wish to pursue a surgical career. Nevertheless, the received responses provided a good cross-section of the trainees and hospitals available within the region. The surveyed trainees were all from the southern half of the country and as such this study does not take into account more broad regional variances in training across the UK. On the other hand, all trainees presented from medical schools from all across the UK.
Though there has been some work towards developing alternatives to the surgical assistant in laparoscopic surgery, with one example being the robotic camera assistant, there is currently no substitute for the status quo.24 Therefore it makes perfect sense that the junior doctors who fill this vital role, are well trained and equipped for the job. It is clear that the current training is not the best that can or should be delivered and changes must be made to the training programme to better prepare junior doctors.
The authors would like to thank the trainee doctors who have responded to the questionnaires.
The authors declare that they have no conflicts of interest.
1. Bennett A, Birch DW, Menzes C, Vizhul A, Karmali S. Assessment of medical student laparoscopic camera skills and the impact of formal camera training. Am J Surg. 2011; 201(5): 655-659. doi: 10.1016/j.amjsurg.2011.01.007
2. Hyltander A, Liljegren E, Rhodin PH, Lönroth H. The transfer of basic skills learned in a laparoscopic simulator to the operating room. Surg Endosc. 2002; 16(9): 1324-1328. doi: 10.1007/s00464-001-9184-5
3. Leff DR, Aggarwal R, Rana M, et al. Laparoscopic skills suffer on the first shift of sequential night shifts: Program directors beware and residents prepare. Ann Surg. 2008; 247(3): 530-539. doi: 10.1097/SLA.0b013e3181661a99
4. The Foundation Programme Curriculum 2016. Web site. Foundationprogramme.nhs.uk. Accessed February 26, 2018.
5. Paschold M, Schröder M, Kauff DW, et al. Virtual reality laparoscopy: Which potential trainee starts with a higher proficiency level? Int J Comput Assist Radiol Surg. 2011; 6(5): 653-662. doi: 10.1007/s11548-010-0542-4
6. Aggarwal R, Ward J, Balasundaram I, Sains P, Athanasiou T, Darzi A. Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery. Ann Surg. 2007; 246(5): 771-779. doi: 10.1097/sla.0b013e3180f61b09
7. Zendejas B, Brydges R, Hamstra SJ, Cook DA. State of the evidence on simulation-based training for laparoscopic surgery. Ann Surg. 2013; 257(4): 586-593. doi: 10.1097/SLA.0b013e318288c40b
8. Dawe SR, Pena GN, Windsor JA, et al. Systematic review of skills transfer after surgical simulation-based training. Br J Surg. 2014; 101(9): 1063-1076. doi: 10.1002/bjs.9482
9. Goldacre MJ, Laxton L, Harrison EM, Richards JM, Lambert TW, Parks RW. Early career choices and successful career progression in surgery in the UK: Prospective cohort studies. BMC Surgery 2010; 2(10): 32. doi: 10.1186/1471-2482-10-32
10. Packer T, Yan S, Lort S, King G, Patel K, Smart C. Surgical operative experience amongst foundation year one doctors (Fy1ds): A deanery wide perspective. Int J Surg. 2013; 11(8): 701. doi: 10.1016/j.ijsu.2013.06.611
11. Abbott EF, Thompson W, Pandian TK, Zendejas B, Farley DR, Cook DA. Personalized video feedback and repeated task practice improve laparoscopic knot-tying skills: Two controlled trials. Acad Med. 2017; 92(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 56th Annual Research in Medical Education Sessions): S26-S32. doi: 10.1097/ACM.0000000000001924
12. Buescher JF, Mehdorn AS, Neumann PA, et al. Effect of continuous motion parameter feedback on laparoscopic simulation training: A prospective randomized controlled trial on skill acquisition and retention. J Surg Educ. 2018; 75(2): 516-526. doi: 10.1016/j.jsurg.2017.08.015
13. Larsen CR, Oestergaard J, Ottesen BS, Soerensen JL. The efficacy of virtual reality simulation training in laparoscopy: A systematic review of randomized trials. Acta Obstet Gynecol Scand. 2012; 91(9): 1015-1028. doi: 10.1111/j.1600-0412.2012.01482.x
14. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance. Ann Surg. 2002; 236(4): 458-464. doi: 10.1097%2F00000658-200210000-00008
15. Abbas P, Holder-Haynes J, Taylor DJ, Scott BG, Brandt ML, Naik-Mathuria B. More than a camera holder: Teaching surgical skills to medical students. J Surg Res. 2015; 195(2): 385-389. doi: 10.1016/j.jss.2015.01.035
16. Glassman D, Yiasemidou M, Venkateswaran B, Sivakumar R, Majumder S, Biyani CS. A multi-specialty surgical course for residents transitioning from early to intermediate training. Int J Med Educ. 2016; 7: 130-131. doi: 10.5116/ijme.5708.e9ea
17. Minor S, Poenaru D. The in-house education of clinical clerks in surgery and the role of housestaff. Am J Surg. 2002; 184(5): 471-475. doi: 10.1016/S0002-9610(02)01001-2
18. Solanki K, Pisesky A, Frecker P. Basic surgical skills training in united kingdom foundation year doctors: Can we do more? Int J Surg. 2013; 11(7): 529-534. doi: 10.1016/j.ijsu.2013.05.002
19. IJgos19se WM, van Goor H, Luursema JM. Saving robots improves laparoscopic performance: Transfer of skills from a serious game to a virtual reality simulator. Surg Endosc. 2018. doi: 10.1007/s00464-018-6036-0
20. Eddama MM, Shah P, McCullough J, et al. A model of basic surgical skills course to supplement the training of foundation-year doctors by efficient use of local resources. J Surg Educ. 2016; 73(4): 567-574. doi: 10.1016/j.jsurg.2016.01.006
21. Du J, Sathanathan J, Naden G, Child S. A surgical career for New Zealand junior doctors? Factors influencing this choice. N Z Med J. 2009; 122(1300): 29-37.
22. Reznick RK, MacRae H. Teaching surgical skills – changes in the wind. N Engl J Med. 2006; 355(25): 2664-2669. doi: 10.1056/NEJMra054785
23. Lambert TW, Smith F, Goldacre MJ. Career specialty choices of UK medical graduates of 2015 compared with earlier cohorts: Questionnaire surveys. Postgrad Med J. 2018; 94(1110): 191-197. doi: 10.1136/postgradmedj-2017-135309
24. Aiono S, Gilbert JM, Soin B, Finlay PA, Gordan A. Controlled trial of the introduction of a robotic camera assistant (endoassist) for laparoscopic cholecystectomy. Surg Endosc. 2002; 16(9): 1267-1270. doi: 10.1007/s00464-001-9174-7
FY1 LAPAROSCOPIC SKILLS QUESTIONNAIRE
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Name *
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1. I am interested in a career in Surgery *
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2.I have had a General Surgery Placement during my FY1 year *
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3.During my surgical placement I did night shifts *
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4. I get enough opportunities to assist in laparoscopic surgery *
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5. How many times/week, during your Surgical Placement, did you assist in laparoscopic surgery? *
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23
34
>4
Not Applicable
6. I am too busy with ward work to go to theatre *
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7. As part of my FY1 placement I have had formal teaching on laparoscopic skills *
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Please provide details of any sessions
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8. I am aware of the different available types of laparoscopic cameras *
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9. I am confident in the differences in image from 0 degree to 30 degree cameras when assisting *
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10. I understand the principles of gaining laparoscopic access and insufflation *
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11. I am aware of different methods of port insertion and placement *
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12. I am confident in using basic laparoscopic tools when assisting in theatre *
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13. I have had the opportunity to develop the skills outlined in Q8 12 during my FY1 year *
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14. I have had simulation training using laparoscopic trainers/models (e.g box trainer, virtual reality, etc) *
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Please provide details of any models/trainers used
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15. I have attended courses/seminars to develop my laparoscopic skills (e.g Basic Surgical Skills Course) *
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Please state which courses/seminars attended
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16. I had teaching on the principles of laparoscopy during medical school *
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Please provide details of any teaching
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