Written by,
Conor Boylan, medical student at the University of Birmingham hoping to pursue a career in orthopaedic or plastic surgery, while also staying involved with academic medicine (teaching and research). Conor loves global surgery and would like to spend some time working in lower income countries later in life.
Email: cxb584@student.bham.ac.uk
Smrithi Sriram, aspiring surgeon at St. George’s University of London
Surgical Case Volumes
In most parts of the world, general surgical accreditation requires the meeting of a myriad demonstrable operative competencies, clinical experiences and education and research commitments. To reach certification, trainees must decorate their portfolio with a logbook of surgical cases covering the expected breadth of their future responsibilities. In the United Kingdom this manifests as a baseline requirement of 1600 surgical cases covering fields such as breast, colorectal and vascular surgery.[1] In the United States, the requirement is a minimum 850 major cases during the 5 years of residency.[2] These case volume minimums are crucial to ensure surgical proficiency and have a palpable impact on health outcomes, with a large systematic review establishing the importance of experience in ensuring quality healthcare.[3]
Africa is no exception to this need for appropriate surgeon training; however, there is currently no established case volume requirement in use throughout the continent[4]. This can lead to a reduced capacity for surgical training and in regions such as sub-Saharan Africa, which has less than one percent the surgeons but three times the population of the United States,[5] the consequences can be drastic. To rectify this quandary was the goal of Dr Robert Parker and his colleagues across the United States and Africa.[4]
Figure 1: From Parker R, Topazian H, Parker A et al. Bar chart showing median case volumes taken from actual experience and the responses of various study participants.
Establishing a Minimum
They set out to establish minimum case volumes for use in Africa by examining the expectations and experiences of educators and graduates from the Pan-African Academy of Christian Surgeons (PAACS): a charitable organisation that trains surgeons across eight different African countries.[6] By ascertaining what members of PAACS expected of their general surgeons, Dr Parker et al were able to calculate the optimal minimum case volumes for trainee general surgeons in Africa both overall and relating to each of the specific sub-specialities. They determined at least 1000 major cases would be necessary, with a scope of experience covering abdominal, head and neck, urological and many other surgical fields.[4]
Following the development of the proposed case volume minimums, recent graduates were compared to the standard to deduce whether they would have met the new requirements. In regions such as orthopaedics, urology and plastic surgery trainees reached or came within touching distance of the new minimums, however in other fields such as thoracic surgery, upper endoscopy and laparoscopy only a minority of graduates would have achieved the required competencies. In complex laparoscopy, where a minimum of fifteen cases was decided on, no single graduate would have had enough experience.
Interview with Dr Parker
These results were fascinating and provided great insight into strategies to improve surgical training in Africa, but several questions were left unanswered. In a bid to amend this, I reached out to Dr Parker and was fortunate enough to be able to interview him about his recent paper and ask some questions regarding the findings:
Question: What factors are at play in the areas that did not on average reach the proposed minimum number of cases (for example abdomen, thoracic or laparoscopy)? Do you think introducing case volume minimums will help facilitate trainees getting more experience in these areas, or will they struggle to meet the higher requirements?
Answer: I do think that placing a goal minimum on case volumes will inspire trainees to try to meet those requirements and encourage training institutions to help facilitate such exposure. Due to lack of availability of surgical specialists or the burden of disease in a given region, there may be categories that remain challenging for trainees to meet minimums. Away rotations were one proposed solution but adapting case minimums to specific settings where the trainee will practice in the future is ideal. Our findings were important to demonstrate that there exists a discrepancy between what surgeons desired (very high case volumes) and what was the true experience. This would need to be accounted for any proposed minimums. Former trainees and trainers believed that prior graduates were well trained despite not having achieved the desired minimums that they also set. Having a target, potentially flexible based upon plans for practice setting, will allow future trainees the opportunity to aspire to achieve experience in a diverse case mix.
Question: You mentioned the regional differences and how different parts of Africa will require different minimum case volumes. Is this a flaw with your study design? How should future research go about establishing these regional minimums?
Answer: Good question. The region studied is incredibly diverse - both a strength and a weakness to the study design. This project should hopefully serve as an introduction to further investigation and implementation on a regional level. It may be that no minimum should be applied to the entire continent of Africa, however, Africa continues to have improved healthcare systems, and we have to start somewhere. Regional minimums will need to be dynamic as healthcare systems change. With increasing specialization in some areas, the general surgeon may need to become more focused. This shift is true for urban versus rural areas so that national minimums could be even more complicated. For example, urban areas between countries may be more similar than urban vs rural in the same country. There are many factors to consider. Going forward, I think that accrediting bodies should implement achievable minimums to ensure exposure, and then frequently assess the impact. One future avenue for investigation is to follow former trainees to see how their training case volumes match their practice case volumes to better understand the settings where they trained and currently practice.
Question: Apart from establishing a minimum case volume, are there any other changes to the current surgical training pathway you would consider implementing in order to ensure trainees are better standardised across the continent?
Answer: Definitely. Minimum case volumes are a small component of surgical education. As access to surgery gradually improves throughout the continent, quality surgical care should become standard. That starts in surgical training but continues throughout the surgeon's career. Successful efforts to improve quality in other settings should be examined for their applicability here. While it is necessary to have the exposure to cases during training, it is even more important for a surgeon to understand his or her abilities and limitations to best care for patients. To become a safe, competent surgeon, a trainee needs graduated levels of responsibility in all aspects of the care for the surgical patient. Improving autonomy, entrustment, and competence are all necessary components that are impacted by case volumes but must be guided by an educational experience that is focused on ensuring a surgeon has both clinical and technical expertise by the end of formal training.
Conclusions
In their paper, Dr Parker and his colleagues conclude that “there is a need to guarantee that surgical trainees have adequate exposure to different pathologies to properly care for the various cases they will encounter during practice”. This is evidently imperative to any surgical training pathway and is an issue that this paper at least begins to ameliorate. The team are optimistic about the future of surgical training in Africa, and with the right input from forward-thinking people they postulate “that this endeavour will drive forward a conversation on how to ensure quality in surgical training”.
Special thanks to Dr Robert Parker.
References
1. Joint Committee on Surgical Trainong. Certification guidelines for general surgery (PDF). July 2017. Accessed August 06, 2020. https://www.jcst.org/quality-assurance/certification-guidelines-and-checklists/
2. The American Board of Surgery. Booklet of Information – Surgery. American Board of Surgery; 2018
3. Maruthappu M, Gilbert B, El-Harasis M et al. The Influence of Volume and Experience on Individual Surgical Performance. Ann Surg. 2015;261(4):642-647.
4. Parker R, Topazian H, Parker A et al. Operative Case Volume Minimums Necessary for Surgical Training Throughout Rural Africa. World J Surg. 2020.
5. Bergstrom S, McPake B, Pereira C et al. Workforce innovation to expand the capacity for surgical services. In: Debas HT, Donkor P, Gawanda A et al, eds. Essential Surgery: Disease Control Priorities. 3rd ed. The International Bank for Reconstruction and Development/The World Bank; 2015
6. The G4 Alliance. Pan-African Academy of Christian Surgeons. Accessed August 06, 2020. http://www.theg4alliance.org/about-pan-african-academy-of-christian-surgeons