Early career choices and successful career progression in surgery in the UK: prospective cohort studies

Background: Changes to the structure of medical training worldwide require doctors to decide on their career specialty at an increasingly early stage after graduation. We studied trends in career choices for surgery, and the eventual career destinations, of UK graduates who declared an early preference for surgery. Methods: Postal questionnaires were sent, at regular time intervals after qualification, to all medical qualifiers from all UK medical schools in selected qualification years between 1974 and 2005. They were sent in the first year after qualification, at year three and five years after qualification, and at longer time intervals thereafter. Results: Responses were received from 27 749 of 38 280 doctors (73%) at year one, 23 468 of 33151 (71%) at year three, and 17 689 of 24 870 (71%) at year five. Early career preferences showed that surgery has become more popular over the past two decades. Looking forward from early career choice, 60% of respondents (64% of men, 48% of women) with a first preference for a surgical specialty at year one eventually worked in surgery (p < 0.001 for the male-female comparison). Looking backward from eventual career destinations, 90% of responders working in surgery had originally specified a first choice for a surgical specialty at year one. 'Match' rates between eventual destinations and early choices were much higher for surgery than for other specialties. Considering factors that influenced early specialty choice 'a great deal', comparing aspiring surgeons and aspiring general practitioners (GPs), a significantly higher percentage who chose surgery than general practice specified enthusiasm for the specialty (73% vs. 53%), a particular teacher or department (34% vs. 12%), inclinations before medical school (20% vs. 11%), and future financial prospects (24% vs. 13%); and a lower percentage specified that hours and working conditions had influenced their choice (21% vs. 71%). Women choosing surgery were influenced less than men by their inclinations before medical school or by their future financial prospects. Conclusions: Surgery is a popular specialty choice in the UK. The great majority of doctors who progressed in a surgical career made an early and definitive decision to do so

Examining the impact of audience response systems on student performance in anatomy education: a randomized controlled trial

Background and Aims: Electronic audience response systems (ARSs) offer the potential to enhance learning and improve performance. However, objective research investigating the use of ARSs in undergraduate education has so far produced mixed, inconclusive results. We investigated the impact of ARSs on short- and long-term test performance, as well as student perceptions of the educational experience, when integrated into undergraduate anatomy teaching. Methods and Results: A cohort of 70 undergraduate medical students were randomly allocated to one of two groups. Both groups received the same anatomy lecture, but one group experienced the addition of ARSs. Multiple-choice tests were conducted before, immediately after the lecture and again 10 weeks later. Self-perceived post-lecture subject knowledge, confidence and enjoyment ratings did not differ between groups. Test performance immediately following the lecture improved when compared against baseline and was modestly but significantly superior in the group taught with ARSs (mean test score of 17.3/20 versus 15.6/20 in the control group, p = 0.01). Tests conducted 10 weeks after the lecture showed no difference between groups (p = 0.61) although overall a small improvement from the baseline test was maintained (p = 0.02). Conclusions: Whilst ARSs offer opportunities to deliver novel education experiences to students, an initial superiority over standard methods does not necessarily translate into longer-term gains in student performance when employed in the context of anatomy education. Key words: medical education; education methodology; education technology; audience response systems; anatomy

Hospital volume and patient outcomes after cholecystectomy in Scotland:retrospective, national population based study

To define associations between hospital volume and outcomes following cholecystectomy, after adjustment for case mix using a national database

Global evaluation and outcomes of cholecystectomy:protocol for a multicentre, international, prospective cohort study (GlobalSurg 4)

INTRODUCTION: Cholecystectomy is one of the most common operations performed worldwide. Although laparoscopic surgery has been the 'gold-standard' approach for this operation, there is a paucity of global evidence around the variations of safe provision of cholecystectomy, including low-income and middle-income countries. This international collaborative study will allow contemporaneous data collection on the quality of cholecystectomies using measures covering infrastructure, care processes and outcomes, with the primary aim define the global variation in compliance with preoperative, intraoperative and postoperative audit standards.METHODS AND ANALYSIS: Global Evaluation of Cholecystectomy Knowledge and Outcomes is a prospective, international, multicentre, observational cohort study delivered by the GlobalSurg Collaborative. Consecutive patients undergoing cholecystectomy between 31 July 2023 and 19 November 2023 will be recruited, with follow-up at 30 days and 1-year postoperatively. The study will be undertaken at any hospital providing emergency or elective surgical services for biliary disease. The primary endpoint of this study is compliance with preoperative, intraoperative and postoperative audit standards. Secondary outcomes include rates of 30-day complications, achievement of critical view of safety and rates of gallbladder cancer.ETHICS AND DISSEMINATION: This project will not affect clinical practice and has been classified as clinical audit following research ethics review at University Hospital Birmingham NHS Trust. The protocol will be disseminated through the international GlobalSurg and CovidSurg network.TRIAL REGISTRATION NUMBER: NCT06223061.</p

Risk stratification of patients with covid-19 in the community

Back when covid-19 was emerging and little was known about the disease, there was a monumental effort to understand the evolving data and develop prediction tools that patients, healthcare workers, and policy makers could use to optimise care. The unfortunate result was a tidal wave of poorly conceptualised prediction models, often using small convenience samples, incorporating little or no validation, and including no substantive plan for implementation.(1) As a result, most developed prediction tools were never meaningfully applied in clinical care.Examples of good practice existed, including two collaborative projects we were fortunate to be involved in – QCOVID (estimating risk of being hospitalised or dying due to catching covid-19) (2) and the ISARIC 4C models (estimating risk of dying or deteriorating after hospital admission with covid-19).(3,4) However, an obvious gap existed in the assessment of symptomatic patients in the community. As the disease profile has changed and the focus of care shifts to supporting diagnosis, treatment, and monitoring outside hospitals, this has become increasingly important.In the Lancet Digital Health, we welcome the study by Espinosa-Gonzalez and colleagues on the derivation and validation of two much-needed risk stratification tools for use in a community setting.(5) These pragmatic decision aids support the assessment of patients with covid-19 symptoms, seeking to identify those who will likely require further monitoring (RECAP-GP) and those in whom treatment escalation is warranted (RECAP-O2). They were developed according to a pre-published protocol and utilise linked primary and hospital healthcare records, together with data from the WhatsApp-based patient monitoring platform, Doctaly Assist.(6)What do these data tell us and how well do the models work? First, it is interesting to reflect on what the models actually capture. These were patients with symptoms of covid-19, but who did not necessarily have covid-19. This is pragmatic and appropriate, as a covid-19 diagnostic test may not be available at the time of assessment. But as covid-19 prevalence drops in the community, how patients are selected to use this tool will impact significantly on its performance.A second point of reflection goes by the unhelpful term, “incorporation bias”. The researchers here are testing to see if symptoms predict admission, but the same symptoms have likely been used to determine the need for the actual hospital admission. The prediction tool can therefore become a self-fulfilling prophecy, and this circularity can artificially increase sensitivity and specificity. The authors mitigate against this by requiring an admission to be at least one night (and by implication require clinical management rather than simply assessment), but the effects of this bias may persist. The RECAP-GP model performs well in the first external cohort (NWL), but the discrimination is poorer in the second (CCAS; AUROC 0.66) and similarly for RECAP-O2 (Doctaly-2; AUROC 0.68). These cohorts were from later in the pandemic and differences in population (younger and less comorbid), virus variants, and vaccination status may partly explain this.(7) Calibration (the performance of the model across the range of risk) is important (8) and while good to see included for the development dataset, it would have been useful for the external validation as well. Similarly, while good to see model performance presented by age and sex, it is important to ensure that it performs as well across different ethnic groups.As presented the models may confuse users. The risk of hospital readmission for those breathless on moderate exertion is lower than for those with mild exertion (RECAP-GP; similar finding in RECAP-O2). For instance, a 45 year-old male with hypertension and a fever complaining of moderate breathlessness will be flagged amber (8.1% risk) while the same patient describing only mild breathlessness will be flagged red (11.5% risk). This is likely explained by the incorporation of non-significant factor levels, but the resulting biological implausibility may reduce face validity.Applicability in low- and middle-income countries (LMICs) must also be considered. Continued reduced access to vaccination, varied public health policy implementation and higher death rates (9,10) suggest research should be relevant and generalisable to such settings. The widespread absence of peripheral oxygen monitors means the RECAP-O2 model is currently unlikely have relevance beyond a select few countries. However, RECAP-GP has the potential for global clinical utility and validation in resource-limited settings is an urgent priority.We declare no competing interests.<br/

A multi-country analysis of COVID-19 hospitalizations by vaccination status

BACKGROUND: Individuals vaccinated against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), when infected, can still develop disease that requires hospitalization. It remains unclear whether these patients differ from hospitalized unvaccinated patients with regard to presentation, coexisting comorbidities, and outcomes.METHODS: Here, we use data from an international consortium to study this question and assess whether differences between these groups are context specific. Data from 83,163 hospitalized COVID-19 patients (34,843 vaccinated, 48,320 unvaccinated) from 38 countries were analyzed.FINDINGS: While typical symptoms were more often reported in unvaccinated patients, comorbidities, including some associated with worse prognosis in previous studies, were more common in vaccinated patients. Considerable between-country variation in both in-hospital fatality risk and vaccinated-versus-unvaccinated difference in this outcome was observed.CONCLUSIONS: These findings will inform allocation of healthcare resources in future surges as well as design of longer-term international studies to characterize changes in clinical profile of hospitalized COVID-19 patients related to vaccination history.FUNDING: This work was made possible by the UK Foreign, Commonwealth and Development Office and Wellcome (215091/Z/18/Z, 222410/Z/21/Z, 225288/Z/22/Z, and 220757/Z/20/Z); the Bill &amp; Melinda Gates Foundation (OPP1209135); and the philanthropic support of the donors to the University of Oxford's COVID-19 Research Response Fund (0009109). Additional funders are listed in the "acknowledgments" section.</p

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries:a prospective, international, multicentre cohort study

BACKGROUND: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.METHODS: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.FINDINGS: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p&lt;0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p&lt;0·001).INTERPRETATION: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.FUNDING: DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.</p

Post-Hospitalisation COVID-19 Rehabilitation (PHOSP-R):A randomised controlled trial of exercise-based rehabilitation

OBJECTIVE: Post-COVID syndrome involves prolonged symptoms with multi-system and functional impairment lasting at least 12 weeks after acute COVID-19. We aimed to determine the efficacy of exercise-based rehabilitation interventions, either face-to-face or remote, compared to usual care in individuals experiencing Post-COVID syndrome following a hospitalisation of acute COVID-19.DESIGN: This single-blind randomised controlled trial compared two COVID exercise-based rehabilitation interventions (face-to-face or remote) to usual care in participants with Post-COVID syndrome following a hospitalisation. The interventions were either a face-to-face or remote eight-week program of individually prescribed exercise and education. The primary outcome was the change in Incremental Shuttle Walking Test (ISWT) following eight weeks of intervention (either face-to-face or remote) compared to usual care. Other secondary outcomes were measured including health related quality of life (HRQoL), and exploratory outcomes included lymphocyte immunotyping.RESULTS: 181 participants (55% male, mean [sd] age 59 [12] years, length of hospital stay 12 [19] days) were randomised. There was an improvement in the ISWT distance following face-to-face rehabilitation (mean 52 [95% CI 19 to 85]m, p=0·002) and remote rehabilitation (mean 34 [95% CI 1 to 66]m, p=0·047) compared to usual care alone. There were no differences between groups for HRQoL of self-reported symptoms. Analysis of immune markers revealed significant increases in naïve and memory CD8+ T cells following face-to-face rehabilitation versus usual care alone (p&lt;0·001, n=31).CONCLUSION: Exercise-based rehabilitation improved short-term exercise capacity in Post-COVID syndrome following an acute hospitalisation and showed potential for beneficial immunomodulatory effects.</p