By Mr Henry G Smith MBBS MRCS PhD, specialist registrar at The Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen
The number of hours in training that it takes for a surgical trainee to achieve both clinical and technical competence is a seemingly endless topic of debate. The significant global
variation in a surgical trainee’s average hourly week begs the question as to why such variation exists and to what extent all training programmes are created equal (1). Given the increasing recognition of burnout amongst medical professionals, and its association with excessive workloads, it is reasonable to think a shorter working week may benefit the surgical trainee’s wellbeing (2). However, any potential benefits much be weighed against the risk of reducing training opportunities and clinical exposure. Having personal experience of both British, with its nominal 48-hour working week, and Danish general surgical training, where surgeons work a 37-hour week, it is clear that whilst these countries have very similar healthcare systems, they differ markedly in their approach to training. Whilst neither training programme is without its limitations, their differences highlight potential ways in which the efficiency of surgical training may be improved.
The most striking difference between the British and Danish programmes is the absence of the ‘firm’ structure in Denmark. Trainees belong to the department rather than to subspeciality specific teams. The same is true of acutely admitted patients, who whilst broadly divided into those with upper and lower gastrointestinal conditions are not ‘owned’ by the consultant who was on call at the time of admission. As a consequence, there are no ward rounds, post-take or otherwise. Instead, the acute and elective inpatients are divided more or less equally between consultants and trainees alike, with a typical ratio of 2-3 patients to be seen by a single doctor each day. The lack of a rigid structure dictated by a team-based ward round leads to much greater flexibility in all other aspects of the working day. These days are thematic, with trainees having 4 major functions: elective operations, endoscopy, outpatient clinics and on-calls. When a trainee is not assigned to one of these functions, they have zero hours to be used as they see fit.
The flexibility of the Danish system brings two major advantages. The first is that the structure leaves the trainee with the feeling that the majority of time spent at work is spent training. That feeling is emphasised by the organisation of the operating days in particular.
Whilst the trainee spends undoubtedly fewer days in an elective theatre than in the British system, these days are almost exclusively spent attending training lists. Attended by a single trainee and a consultant, comprising repeated exposure to the same operation and booked on the presumption that the trainee will be the primary surgeon, these lists maximise training opportunities. The same is more or less true in endoscopy, where the trainee has their own full day list, with a supervisor on hand if needed. The second advantage is that the planning of absence from work for annual leave, courses or conferences is far less complicated. The minimum number of trainees required at work is determined at a departmental level, avoiding the need to organise cross cover between firms. As such, denied requests to attend conferences are very much the exception rather than the rule and it is almost unheard of that a trainee would be unable to take all of their allocated leave during a rotation.
These structural differences are accompanied by an in-house culture that not only prioritises training but is also ferocious in its defence of working conditions. There is a greater expectation for trainees to be actively involved, at least in part, in the majority of operations, and independent operating is encouraged at a much earlier stage. Senior house officers are expected to be capable of independently performing common acute operations, such as appendicectomies, and whilst consultants are often present for laparotomies, their presence is not compulsory. ‘Service provision’ is rarely mentioned, perhaps a reflection of a healthcare system that is better resourced to match the demands of its population. With regard to the working environment, trainees hold a structured monthly meeting for both positive and negative feedback on issues ranging from training opportunities and supervision to the frequency of on-call duties and conditions of the on-call rooms. The vocal complaints in a recent meeting of the comfiness of the on-call beds are not only a far cry from trying to catch some rest on an old sofa in a British hospital mess but also give an insight into how seriously the Danes take their working conditions.
However, not all the differences are positive. The greater flexibility in the Danish system
places greater demands on the discipline of its trainees. Although there are still dedicated
rotations in trauma and tertiary centres, the lack of other subspecialty specific rotations
means that the trainee must take more responsibility for ensuring that they meet the specific requirements of the training programme. Whilst focused trainees may turn this to their advantage, allowing them to focus on their preferred subspecialty at an earlier stage of training, those who are as of yet undecided may be at risk of drifting in a less structured system. In a similar vein, for a trainee raised in the British system, the absence of the firm structure is accompanied by a sense of a lack of belonging, at least at the beginning of a new placement, although this is somewhat lessened by the daily morning conferences, attended by the whole department. A further concern is the consequences a more flexible system has on the quality and continuity of care. It is not uncommon for acutely admitted patients to be seen by a different doctor each day, a situation commonly thought to increase the risk of delays in discharge or investigations. However, this does not appear to have an adverse effect on patient outcomes, with a 30-day mortality following high-risk laparotomies of approximately 20% in Denmark, mirroring the reports from the National Emergency Laparotomy Audit (NELA) in Britain (3-5). Finally, one must remember that achieving competence as a surgeon is not only about developing technical skills. As the old saying goes “good surgeons know how to operate, better surgeons know when to operate, and the best surgeons know when not to operate”. Although the Danes may have a more efficient approach to the technical aspects of training, it is undeniable that the clinical exposure of British trainees is far greater. The cumulative clinical experience of following both elective and acute patients from admission to discharge is difficult to replicate and whilst any differences in decision-making seem to have disappeared by the end of training, these skills appear to develop more rapidly in the British systems. Disruptions to the continuity of care present another barrier for clinical exposure in the Danish system, with the following up of the patients seen on-call or in the operating theatre left to the trainee’s own initiative.
The hourly week occupies much of the debate on surgical training and, in doing so,
prioritises quantity over quality of training. With a focus on maximising the efficacy of
training opportunities, the Danish surgical training system demonstrates how surgeons can be effectively trained on a shorter working week. Whilst this system has its own limitations, the organisation of a trainee’s operative commitments in particular provides an example for other systems to follow. Surgical training faces major challenges ahead, with a global pandemic that has not only limited training opportunities but also taken an inevitable toll on workforce morale (6). Furthermore, the backlog of operations cancelled since the beginning of the pandemic is likely to place a huge emphasis on efficiency in operating theatres, which may have further negative effects on training opportunities (7-8). However, the return of some degree of normality will also offer the opportunity to reconsider the structure of training and perhaps in doing so, the best aspects of these respective training systems could be combined, shifting the focus away from the number of hours spent at work to the amount of time spent training.
- Jackson GP, Tarpley J. How long does it take to train a surgeon? British Medical
Journal. 2009, 5;339:b4260.
- Galaiya R, Kinross J, Arulampalam T. Factors associated with burnout syndromes in
surgeons: a systematic review. Annals of the Royal College of Surgeons of England.
- Cihoric M, Tengberg LT, Foss NB, et al. Functional performance and 30-day post-
operative mortality after emergency laparotomy – a retrospective, multicenter,
observational cohort study of 1084 patients. Perioperative Medicine. 2020, 9(13).
- Peacock O , Bassett M G, Kuryba A, et al., National Emergency Laparotomy Audit (NELA) Project Team. Thirty-day mortality in patients undergoing laparotomy for small bowel obstruction. Br J Sur. 2018 Jul;105(8):1006-1013. doi: 10.1002/bjs.10812. Epub 2018 Mar 30
- Boyd-Carson H, Doleman B, Herrod P J J, et al., on behalf of the NELA Collaboration, Association between surgeon special interest and mortality after emergency laparotomy, British Journal of Surgery, Volume 106, Issue 7, June 2019, Pages 940–948, https://doi.org/10.1002/bjs.11146
- COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020;107(11):1440-1449. doi:10.1002/bjs.11746
- Rai O, Fernandes R. COVID-19 and the reintroduction of surgical training. British Journal of Surgery, Volume 108, Issue 1, January 2021, Page e6, https://doi.org/10.1093/bjs/znaa003
- Hennessy O, Fowler A L, Hennessy C, et al. Covid 19 and Surgical training: Carpe Diem. British Journal of Surgery, Volume 107, Issue 12, November 2020, Page e591, https://doi.org/10.1002/bjs.12032