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Letters and emails |
We read the paper by Qureshi et al.1 with great interest. It makes several important points about the training of junior doctors in the laparoscopic management of tubal ectopic pregnancy. We were particularly interested in the paper because of our own work on the surgical training of specialist registrars (SpRs) in obstetrics and gynaecology in the Wales Deanery and our subsequent research specifically focused on the training of juniors in the laparoscopic management of ectopic pregnancy.2
In addition to questions around other issues of surgical training, our survey in 2000 asked trainees about their competence to manage tubal ectopic pregnancy laparoscopically. We then developed and, in 2002, administered a postal questionnaire focused on this specific issue. A follow-up study using the same methodology was completed in 2004. The questionnaire included questions around eight of the 11 areas that Qureshi et al. report were covered in their survey. Thus the work of Qureshi et al. is very similar to ours in content, methodology and purpose, and the results of all these studies must be of direct relevance to each other. The results of our 2000 survey and more detailed findings of the 2002 study have been published.3 The results of all three surveys were reported to the British Congress of Obstetrics and Gynaecology in 20044 and, following a request, this synopsis was sent to Dr Qureshi.5 We think it would have added value to their interesting paper if they had considered our findings.
Qureshi et al. report that ‘fewer than 20% of year 4/5 trainees in the Welsh deanery are able to perform [laparoscopic surgery for tubal pregnancy] without supervision’. We know that in 2000, 2002 and 2004, the proportion of independently competent year 4/5 trainees was 63%, 44% and 48%, respectively. The figures for SpRs, regardless of training year, were 38%, 21% and 33%. It seems that there has been further deterioration as part of a continuing trend. Attendance by trainees on laparoscopic skills courses where the procedure is taught has also declined. In 2002 and 2004, most trainees (92% and 88%) were aware of such courses and 69% and 63% had attended a course. In the current paper, the figure for attendance was only 30%.
We asked trainees about factors that they believed were preventing them from becoming competent in the laparoscopic management of tubal pregnancy. Several factors were identified but when asked to identify the most important, lack of senior supervision (41%) and a lack of practical experience (41%) were easily the most significant in 2004, as they had been in 2002 – well ahead of inadequate/unavailable equipment (3%). These are similar problems to those reported in the recent paper. Additionally, some trainees (8% in 2004) added comments, reporting that they simply managed too few ectopic pregnancies to attain competence. The lack of sufficient hands-on experience to master the technique is, presumably, exacerbated by the fact that 69% of trainees do, on average, fewer than one complex MAS procedure a week.2
Qureshi et al. hope that ways can be found to improve training in the laparoscopic management of tubal pregnancy. Certainly, action is necessary to try to ensure universal availability of this ‘gold standard’ procedure. It must be true that some trainees are completing their training and taking up consultant posts without acquiring this skill. Only a minority of current consultants can be competent to teach or perform this operation. These issues will further complicate the provision of training.
Enhancement of training must be important and, given that laboratory skills training seems to be underutilised, this area should be given a high priority. However, skills training cannot replace actual clinical experience. The authors hope that changes to the RCOG training logbooks will eventually have a positive effect on the rates of laparoscopic management of ectopic pregnancy in the UK. Until that happens, they urge trainees to do more laboratory skills work and to work hard at recording their current MAS activity. We strongly support these latter two proposals but are unsure that the necessary improvement can be achieved by these methods alone. Taken together with our work, the current paper points to a chronic and worsening problem that is likely to be replicated in other deaneries. We are planning a further survey to confirm this theory.
Given universal constraints on hours of work and variable provision of training, it may simply not be possible to train all trainees in this technique. As a specialty we accept that some common procedures are no longer done by every specialist. Unless the identified deficits in training can be resolved quickly, it may be better to aim to train some trainees well in this procedure than to fail even to train most trainees badly.
Nicholas Myerson, MRCOG, Consultant Obstetrician and Gynaecologist/Lead for Undergraduate Education Bradford Royal1 and David Pugh, FRCOG, Consultant2
1. Infirmary, West Yorkshire, UK Nicholas.Myerson{at}bradfordhospitals.nhs.uk
2. Royal Glamorgan Hospital, Glamorgan, Wales, UK
Acknowledgment
Note: We are grateful to the Editor-in-Chief for bringing to our attention Qureshi et al.'s comment that the results of their literature search did not show any references to our own papers, which we refer to in our letter above. We recognise that this would, inevitably, have limited their knowledge of these papers and in retrospect it is unfortunate that they did not ask for any references when they contacted us to discuss our work. We still feel that the omission somewhat limits the completeness of their own analysis. Additionally, we ourselves found important papers in Gynaecological Endoscopy and other non-PubMed journals during our literature searches simply by close inspection of references in other papers.
References
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