Jonathan Glass: Irrational numbers in surgical training

jonathan glassI enjoy numbers. I enjoy the accuracy they provide; the guidance they give in the practise of clinical medicine; and, though very far from being a mathematician, I like reading of their discovery throughout history, their quirkiness, and I like being shown their logic even though I know I won’t be able to remember or explain all I hear.

Just as I enjoy numbers, I get distressed when numbers are used to distort facts. It distresses me when they are misinterpreted to imply one football manager is better than another, when they are used erroneously to suggest one country’s healthcare outcomes are better than another’s, or when they are used by politicians to lie to the population.

In medicine we should not be allowing numbers to be arbitrarily bandied about, yet this still happens.

If you were applying for a certificate of completion of training (CCT) in urology last year, the surgical advisory committee recommended, and increasingly imposed, that you had to have seen or assisted in at least 20 radical prostatectomies before being signed off as competent. This year, for no apparent reason, it appears 10 will do.

Changes to the required numbers of various procedures to which a trainee needs to be exposed are often made year on year, and yet failure to achieve these “indicative numbers” when a trainee applies for a CCT is increasingly a reason for the application to be referred back to the candidate. Indicative numbers are found in other surgical specialties, including general surgery, orthopaedics, and maxillofacial surgery.

Yet I have a problem with urology’s indicative numbers. Firstly, as shown by the arbitrariness of changes to the numbers year on year, the actual numbers seem to be plucked out of the air. On what basis do we suggest that watching 10 cystectomies (it was 15 in 2014) makes you a trained urologist in a way watching seven wouldn’t have done? How do we know that observing 10 is enough? Why were 20 radical prostatectomies necessary if you applied for a CCT last year, but now 10 is sufficient? Who’s to say that five won’t be sufficient in 2019?

Trying to achieve these arbitrary numbers also has a big impact on training. The final year of training should be spent becoming very good in the subspecialty area in which you will be marketing yourself when applying for a consultant post and at the surgical procedures you will be performing on patients in that subspecialty. Instead, the final year of training is being spent watching—and I emphasise that, watching, not doing—all the procedures the trainee won’t ever do as a consultant, but that need to be watched just to achieve her or his CCT.

A broad knowledge of urology is essential prior to being awarded a CCT. That’s why we make our registrars pass the intercollegiate examination in urology—an excellent test of urological knowledge—before becoming consultants.

Surgical experience used to be acquired by trainee surgeons making themselves available—exposing themselves to as many procedures as possible to become good at their art. Open the abdomen this time and, who knows, you may get to do part of the bowel anastomosis next time.

Standing in a theatre unscrubbed so you can tick off that you’ve seen a procedure was never previously part of surgical training, nor should it be now. It has no value. It’s no better than sitting in front of a computer watching a video on YouTube. Just watching a procedure will never make you a better surgeon unless you are very good at the procedure already, and you are learning nuanced surgical techniques from a master surgeon; it has no value for a junior trainee. Trainees should spend their training doing the things that they’ll be spending their lives doing, not watching procedures they will never do again.

We have lost our way in much of what is important in medicine. I fear that in the future we will look back on the evolution of medical training in our era and ask ourselves how did we let it go so wrong? Why did we decide competence was sufficient—why did we no longer aim for excellence? Why did we decide the postgraduate year should be out of hospital and not hospital based? Why did we think medicine should be a profession that asks its practitioners to clock in and clock out, rather than to focus on the patient? Why did we decide that watching 10, 20, or 30 procedures was more important than actually doing one procedure?

Numbers are important as a trainee. Trainees should know the numbers of any procedures they have done, they should know how many grams of prostate they resected, how many complications they have had after performing hydrocele repairs or ureteroscopies. They should know the percentage chance of becoming incontinent after radical prostate surgery, and the creatinine of the patient they are looking after on the ward after a cystectomy.

It’s time that we focused on what really makes a surgeon better and stopped pursuing pointless processes, which surround training in superficial administrable number crunching and do nothing to improve the quality of the trainee. Let’s abandon indicative numbers and put trainees into the theatres they want to be in, where the training is hands on, they know the patient in their theatre, and follow them post-operatively.

I wish I understood the beauty of numbers better, but I do know when they are being used irrationally.

 Jonathan Glass is a consultant urologist and lead clinician for urology at Guy’s & St Thomas’ Foundation Trust.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.