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Eur J Cardiothorac Surg 2006;30:574-577
© 2006 Elsevier Science NL

Impact of the European Working Time Directive on exposure to operative cardiac surgical training

Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge CB3 8RE, UK

Received 19 December 2005; received in revised form 10 April 2006; accepted 19 April 2006.

^_* Corresponding author. Tel.: +44 1480 830 541; fax: +44 1480 830 336. (Email: eric.lim{at}cvsnet.org).

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
Objective: To evaluate the impact of the reduced working hours, an anticipated decline in case load and increasing patient risk profile, we performed a cohort study to determine the factors that influenced operative surgical training. Methods: A historic cohort study design was utilised, and data were acquired from a prospective operative surgical database a year before, and a year after the introduction of the European Working Time Directive (EWTD) compliant rota (1st August 2004). Logistic regression was used to determine the predictors of operative surgical training, and individual variables were ranked by likelihood ratio. Results: In total, 3312 cardiac surgical operations were performed over a 2-year period between 3rd August 2003 and 31st July 2005. The proportion of cases performed by trainees was 39% (626/1587) in the year before and 40% (695/1725) in the year after the introduction of WTD compliant rota. There were no differences in operative risk (logistic EuroSCORE of 8, P = 0.853). Independent predictors for surgery performed by a trainee (in descending order of influence) were the consultant in charge ( 273.1; P < 0.001), procedure performed ( 163.5; P < 0.001), increasing seniority of trainee ( 142.3; P < 0.001), revision surgery ( 45.9; P < 0.001), lower EuroSCORE ( 17.6; P < 0.001), and better ventricular function ( 7.8; P = 0.020). The odds ratio of an operation performed by a trainee increased after the introduction of the EWTD compliant rota to 1.19 (95% CI 1.00–1.41; P = 0.045). Conclusions: With a successful institution-specific training module and a commitment to training, exposure to operative surgical training can be sustained despite shortening of working hours.

Key Words: Cardiac surgery • Training • Working time directive

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
Considerable disquiet amongst trainers and trainees in cardiothoracic surgery already exists with regard to the quality and quantity of training opportunity due to the expansion in the number of cardiothoracic trainees and influence of the publication of surgeon-specific results in the press [1], difficulties that are now compounded by restrictions to junior doctors working hours. The Working Time Directive (WTD) introduced in 1993 originally excluded doctors, but revisions by the European Commission in 2000 required doctors-in-training employed by the National Health Service of the United Kingdom to comply with a 58 h working week by 2004, a 56 h week by 2007 and a 48 h week by 2009 [2]. In response to the WTD, a full-shift pattern was introduced by the hospital administration (Table 1 ) for the seven registrar posts at our institution on the 1st of August 2004.

To determine the factors that influenced operative surgical training, and to evaluate the impact of the full shift working pattern, case volume and operative risk, we reviewed data from our prospective registry of surgical operations.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
A historic cohort study design was utilised to assess the impact of the EWTD on operative surgical training. Data were acquired from our prospective operative surgical database spanning 1 year before, and 1 year after the introduction of the EWTD compliant rota. During this time, the number of working hours changed from a working pattern that consisted of a 1 in 6 partial shift rota, where registrars undertook a 24 h on call (1 day every 6 days) with a day off the day after, averaging 62.1 h over the rota cycle to a full-shift system consisting of a week of nights every 7 weeks, and a week of intensive care cover every 7 weeks during the day, averaging 53.4 h over the rota cycle. The average number of days a trainee was allocated to theatre was approximately 16 days per month before and 11 days per month after the introduction of the working time directive (without taking into account, and assuming no differences in the commitments to outpatient clinics, annual and study leave).

Risk stratification was undertaken using logistic EuroSCORE [4]. In this study, we defined a procedure as a training case, when the trainee was documented as the first surgeon for the procedure with the consultant assisting. The number of MEDLINE indexed publications resulting from research at our institution (‘Papworth Hospital’ had to be stated as the institution of affiliation on MEDLINE) by trainees was compared between the two time frames (allowing for a 6-month time lag to the time of print).

Continuous variables were summarised as mean with standard deviations (SD) or as median with interquartile range (IQR) and compared using t-test or Mann–Whitney test as appropriate to the distribution of the data. Count data were expressed as frequency (percentage) and compared using the ²-test. Logistic regression analysis was used to determine the predictors of surgical training and as multivariable analysis to evaluate the impact of the EWTD on operative surgical training after correcting for confounding factors. Robust standard errors were used throughout to adjust the precision of the estimates of non-normally distributed variables. Likelihood ratio tests were used to evaluate the contribution of the individual nested terms in final regression model. The influence of clustering (grouping) of data by trainee and consultants were taken into account by re-estimating the results with binomial Generalised Estimating Equations using a logit link and exchangeable correlation structures. Statistical analyses were performed using Stata 9.1 (StataCorp, College Station, TX, USA).

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
Between 3rd August 2003 and 31st July 2005, a total of 3312 cardiac surgical operations were performed at our institution. The mean age of the patients was 68 (11) years and 2366 (71%) were male. The mean logistic EuroSCORE was 8.2 (11.5). Overall, a total of 1321 (40%) operations were performed by training surgeons, 39% (626/1587) in the year before and 40% (695/1725) in the year after the introduction of the WTD compliant rota. The baseline characteristics are summarised by year in Table 2 .

The number of MEDLINE indexed publications achieved by trainees in the two time frames was similar, 10 in the year before and 13 in the year after the introduction of the EWTD compliant rota.

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
The Royal College of Surgeons of England commented that the WTD ‘will undoubtedly shake the foundations of surgery in the United Kingdom’ [5]. A vast proportion of trainees and consultants in Wales have opposed the introduction of the WTD, believing that it will have (amongst other listed reasons) a detrimental effect on training [6], and a decline in overall number of cases preformed has already been reported in a study amongst orthopaedic surgical trainees [7].

Every cloud has a sliver lining; never has a more focused approach to surgical training and assessment been accomplished. Training committees have put considerable time and effort into developing structured training schemes, there has been an introduction of exit examinations, and a focus on continual assessment based on competencies [8].

Many surgical training programmes are now developing set competencies that trainees are expected to achieve at the appropriate stage. For operative surgery, this entails fragmenting a procedure into individual small components with individual assessment. Critics of this approach regard this as a move away from proficiency in the pursuit for ‘competency’ [9] and there are concerns that this compromise may be used as justification for poor surgical training in centres where trainees rarely perform entire operations.

The two training philosophies are not dichotomous. In coronary artery surgery, where an operation has many components, achieving competency in each component prior to performing an entire operation is a sensible approach. However, the time required to achieve the individual competencies are short. The results of our study suggest that at the end of the second year, trainees are performing 10% of the cases from skin to skin after the introduction of the WTD compliant rota. An important limitation of competency (component)-based training and assessment is the assumption of no transition between each step of the operation. After initial competencies have been achieved, we believe that supervised exposure to the appropriate volume of cases is the succeeding component of surgical training.

Currently the surgical training programme in the United Kingdom is undergoing radical changes, but the pathway of surgical training in the time frame of this study starts at the House Officer year (immediately after qualifying from medical school) followed by a basic surgical training programme (Senior House Officer) of surgery in general for a minimum of 2 years, followed by higher surgical training programme (Specialist Registrar) in speciality training such as cardiothoracic surgery for 6 years. The responsibilities of the surgical registrar at our institution is to lead the ward rounds, manage the patients on the wards and intensive care unit in liaison with the consultant in charge, to contribute to theatres, outpatient clinics and receive phone calls from external referrers (hospital or general practitioners and patients).

As shift work becomes inevitable, the time spent with a single consultant trainer becomes fragmented; therefore, a team approach to surgical training has been advocated [5]. This is the model adopted at our institution, where trainees are allocated to operating theatres either with their respective trainers or according to case mix appropriate to their stage of training. Each trainee is guided in a step-by-step process through the various sections of the operation. All trainees are carefully supervised throughout the entire course of their training. When it is appropriate for trainees to develop ability for independent operating, consultants will help plan the operation, be present in theatre to supervise (unscrubbed) when necessary and are available to scrub at any time if difficulties arise. A team approach to surgical training is ideal for single institutions with the same team of trainers, and may not be as suitable for rotations that involve a large number of different hospitals.

We believe that the improvements in the volume of operations performed by training surgeons after the introduction of WTD compliant rota result from a training model that is suitable for our institution, stemming from a well-established culture [10] and a firm commitment to surgical training. The main effect was an increase in the proportion of training cases allocated to trainees at a more junior stage of training (Table 5 ).

	5. Conclusions

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
With a successful institution specific training module and a commitment to training, sustained exposure to operative surgical training can be achieved despite shortening working hours. Close surveillance and further audit is essential to determine if the improvements to surgical training can be sustained with the anticipated decline in the workload for coronary surgery.

	Appendix A

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
List of contributors

Registrars: Ayyaz Ali, Lognathan Balacumaraswami, Roger Baskett, Stephen Billing, William Davies, Ravi De Silva, Andrew Drain, Mariano Feccia, Jonathan Ferguson, Reza Hosseinpour, Gundas Katlaps, Eric Lim, Shafi Mussa, Choo-yen Ng, Tom Routledge, Rana Sayeed, Ivor Skalsky, Serban Stoica, and Catherine Sudarshan.

Consultants: John Dunning, David Jenkins, Stephen Large, Sam Nashef, Andrew Ritchie, Bruce Rosengard, Steven Tsui, John Wallwork, and Francis Wells.

Locum Consultants: Kumud Dhital, Andrew Goodwin, and Paul Jansz.

	Acknowledgments

 
The authors gratefully acknowledge the assistance of Mr Jago Kitcat (Clinical Audit Department, Papworth Hospital) for data retrieval, and to Lyn Edmonds and Julie Aikens (Library and Knowledge Services, Papworth Hospital) for their assistance in searching the literature for publications by the registrars listed in this manuscript.

	Footnotes

 
Presented at the joint 20th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 14th Annual Meeting of the European Society of Thoracic Surgeons, Stockholm, Sweden, September 10–13, 2006.

¹ See Appendix A for list of contributors.

	References

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Eric Lim Steven Tsui Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lim, E. Search for Related Content PubMed PubMed Citation Articles by Lim, E. Related Collections Education Professional affairs