The introduction of reforms in higher surgical training in trauma and orthopaedics in the UK has highlighted the problems in assessing trainees with regards to quality and quantity of training.

The logbook has been the traditional record of operative skills training. We have reviewed such training records from trauma and orthopaedic trainees in the pre- Calman training era. A postal questionnaire was sent to twenty trauma and orthopaedic consultants in 1997 who had recently finished pre- Calman orthopaedic higher surgical training.


 

The questionnaire required information on estimated total number of trauma and elective operations, plus standard representative operations performed over the total training period.

In addition, an estimate of the percentage of supervision was recorded. A total of 28,008 operations were included in this study. Twelve questionnaires (60% return rate) were returned, two were incomplete and not included in the study. Each consultant had performed a mean number of 2334 operations in their higher surgical training. The training posts were scattered throughout the United Kingdom with a mean length of 5.3 years. The number of representative operations showed wide variations in numbers and standard deviation (table 1). The estimated percentage of trauma and elective surgery supervision was 13.4% and 24.1% respectively.

Table 1. Operation Mean (SD)

Total elective procedures 1197 (479)
Total trauma procedures 1137 (831)
Joint arthroscopy 255 (142)
Total hip replacement 143 (63)
Dynamic hip screws 107 (48)
Total knee replacement 83 (27)
Hip hemiarthroplasty 80 (30)
Intramedullary nailing 54 (40)
Ankle fixation 54 (34)
Carpal tunnel decompression 44 (31)

It is accepted that the number of operations is not an ideal index of "adequate" training. Current logbooks provide minimal information on operative skills acquired and little indication of the grade of trainer, if present. Although the sample size is small these results indicate a great variation in the number of operations performed by higher surgical trainees in the pre-Calman era. The estimated level of supervision was low, especially with regards to trauma surgery.

This study also highlighted the difficulties trainees had in assimilating their operative training and supervision due to poor records. A better measure of training would perhaps be to perform a competence assessment of surgical skill or a portfolio presentation of evidence based surgical cases. We recommned an alternative competence based or case-portfolio type logbook should be developed to ensure that both the trainee and trainer are better able to assess competence and progress safely through higher surgical training. A comparative review of logbooks of Calman trainees at completion of their training against this data will be useful. However, for new training to be properly assessed the current logbook must be improved and be more accurately certified.

Chris Oliver
Edinburgh Orthopaedic Trauma Unit
Royal Infirmary of Edinburgh
EH3 9YW
 

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