title: Involvement of surgical trainees in surgery for colorectal cancer and their effect on outcome.
abstract: OBJECTIVE
  Surgical training in the UK is undergoing substantial changes. This study assessed: 1) the training opportunities available to trainees in operations for colorectal cancer, 2) the effect of colorectal specialization on training, and 3) the effect of consultant supervision on anastomotic complications, postoperative stay, operative mortality and 5-year survival.
  
  
  METHODS
  Unadjusted and adjusted comparisons of outcomes were made for unsupervised trainees, supervised trainees and consultants as the primary surgeon in 7411 operated patients included in the Northern Region Colorectal Cancer Audit between 1998 and 2002.
  
  
  RESULTS
  Surgery was performed in 656 (8.8%) patients by unsupervised trainees and in 1578 (21.3%) patients by supervised trainees. Unsupervised operations reduced from 182 (12.4%) in 1998 to 82 (6.1%) in 2002 (P < 0.001). Consultants with a colorectal specialist interest were more likely than nonspecialists to be present at surgical resections (OR 1.35, 1.12-1.63, P = 0.001) and to provide supervised training (OR 1.34, 1.17-1.53, P < 0.001). Patients operated on by unsupervised trainees were more often high-risk patients, however, consultant presence was not significantly associated with operative mortality (OR 0.83, 0.63-1.09, P = 0.186) or survival (HR 1.02, 0.92-1.13, P = 0.735) in risk-adjusted analysis. Supervised trainees had a case-mix similar to consultants, with shorter length of hospital stay (11.4 vs 12.4 days, P < 0.001), but similar mortality (OR 0.90, 0.71-1.16, 0.418) and survival (HR 0.96, 0.89-1.05, P = 0.378).
  
  
  CONCLUSIONS
  One third of patients were operated on by trainees, who were more likely to perform supervised resections in colorectal teams. There was no difference in anastomotic leaks rates, operative mortality or survival between unsupervised trainees, supervised trainees and consultants when case-mix adjustment was applied. This study would suggest that there is considerable underused training capacity available.
authors.affiliation: Department of Surgery, North Tyneside General Hospital, Rake Lane, North Shields, Tyne & Wear, UK.
authors.forename: D W
authors.initials: DW
authors.lastname: Borowski
authors.forename: A A
authors.initials: AA
authors.lastname: Ratcliffe
authors.forename: B
authors.initials: B
authors.lastname: Bharathan
authors.forename: A
authors.initials: A
authors.lastname: Gunn
authors.forename: D M
authors.initials: DM
authors.lastname: Bradburn
authors.forename: S J
authors.initials: SJ
authors.lastname: Mills
authors.forename: R G
authors.initials: RG
authors.lastname: Wilson
authors.forename: S B
authors.initials: SB
authors.lastname: Kelly
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence; D015331:Cohort Studies; D015179:Colorectal Neoplasms / Q000401:mortality* / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000193:education* / Q000401:mortality; D004503:Education, Medical, Graduate / Q000379:methods*; D017558:Elective Surgical Procedures; D004638:Emergency Treatment; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007396:Internship and Residency; D007431:Intraoperative Complications / Q000453:epidemiology; D008297:Male; D008485:Medical Audit; D008505:Medical Staff, Hospital; D008875:Middle Aged; D016017:Odds Ratio; D011183:Postoperative Complications / Q000453:epidemiology; D011336:Probability; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome; D006113:United Kingdom