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Eur J Cardiothorac Surg 2004;25:1131
© 2004 Elsevier Science NL

Letter to the Editor

Surgical assistants and working time directives

J. Rafael Sadabaa*, Grayson H. Wheatleyb

a Department of Cardio-thoracic Surgery,Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA 6009, Australia
b University of Texas Southwestern Medical Center,Dallas, TX, USA

Received 3 March 2004; accepted 10 March 2004.

* Corresponding author
e-mail: rafael.sadaba{at}health.wa.gov.au

Key Words: Surgical nurse assistant • Working time directive • Training

We commend Alex and co-workers for raising the important, and sometimes overlooked, issue of the impact of working time directives on training cardio-thoracic surgeons [1].

The authors have carried out a retrospective review of two non-randomised groups of patients. Their aim was to ascertain whether the harvest of saphenous vein graft by a qualified and fully trained surgical assistant had a negative impact on outcomes when compared with a junior surgical trainee performing similar tasks. They conclude that although surgical nurse assistants can be used effectively in low-risk cases without compromising postoperative results, they can compromise the training needs of junior surgical trainees.

We agree with the first statement, but disagree with the second. In their conclusion they also implicitly affirm that junior surgical trainees are as effective, if not more so, in harvesting venous conduits for CABG, than surgical assistants. They base this conclusion on the analysis of outcomes which are largely irrelevant on how or who harvested the venous conduits. Quality of harvesting venous conduits affect at least two important outcomes which have not been analysed in their study, namely shaphenectomy site infection, and mid and long-term patency of venous grafts.

It is practice in some teaching departments to let the junior-most trainee to harvest the long saphenous vein, whilst more senior surgeons harvest the arterial conduits and prepare the patient for cardio-pulmonary bypass. It is therefore conceivable that the quality of the harvested conduits and wound closure technique would not compare favourably to someone who has received formal teaching and has broad experience in completing the task.

Junior trainees benefit from having surgical assistants available in the operating theatre. They can learn from these assistants who have the time and knowledge to teach. In addition, once the trainee has become competent in the procedure, he or she can dedicate their educational time to learn other advanced techniques. Needlessly performing simple, repetitive tasks, such as vein harvesting, compromises the overall learning continuum and advancement of junior trainees. Allowing proficient surgical assistants to complete straightforward tasks in the operating room facilitates the learning process of junior and senior trainees.

In their paper the authors also state that cardio-thoracic surgery training is based on a form of apprenticeship. This concept needs to be changed.

Never before have cardio-thoracic surgeons been as accountable as they currently are, and never before have there been so many expectations placed on them. And yet, cardio-thoracic trainees are asked to limit the time they spend at their teaching hospitals in order to comply with working time directives.

The cardio-thoracic surgeons of the XXI century will have to be trained in a ‘48 h week’ setting. Novel and innovative training strategies will have to be introduced in the teaching of the specialty. The time residents spend at their teaching units will have to be optimised for learning. We have to evolve from the concept of trainees as apprentices to the concept of trainees as learners. Surgical assistants can play an important role in this process.

References

  1. Alex J., Rao V.P., Cale A.R., Griffin S.C., Cowen M.E., Guvendik L. Surgical nurse assistants in cardiac surgery: a UK trainee's perspective. Eur J Cardiothorac Surg 2004;25:111-115.[Abstract/Free Full Text]




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