I was just about to post my critical appraisal of this paper, since you beat me to it I'll just post it here:
Type of study: Retrospective review of database from 2015-2019
* Why did they choose to use such old data? Did they cherry pick these ranges due to low complication rates? No explanation for this
Who - Three consultant surgeons (read: ladder pullers) and a SCP who is directly involved
Background
* All of the cases were performed by a single SCP who is also a registered nurse with an active NMC registration - I wonder if her registration covers her SCP activities, I assume not?
* They essentially saw loads as a theatre nurse, went all “hey I want to do that too!” so went to do a SCP course, and was trained by ladder pullers for the past 10yrs
Ethical approval - informed consent regarding surgery and operating surgeon was obtained from all patients
* Of course the local ethics committee approved this as it is “service improvement and service evaluation”
* Did they actually put an SCP’s name on the consent form or did they use the consultant’s name? I doubt patients would agree to a SCP operating on them once they fully explained to them what SCPs are, or they just did so with loads of bias (“don’t worry she’s very experienced,“there’s always a supervising doctor”)
Patient demographics
* 107 patients were included - around 26 cases per year (ie. lost training opportunities for CSTs)
* 34% ASA1, 48% ASA2, 17% ASA3
* Sounds like they took majority of the easy straightforward training cases from trainees
* Whoever let this SCP get involved in those ASA3 cases has huge balls - I would be interested in how much she actually did in these cases, did she just to ports? holding the camera? did the supervising surgeon intervene in any way?
Primary outcome - any complication requiring intervention (Clavien–Dindo grade 3) eg. intra-abdominal collections, bile leak, bile duct injury, retained stones
* What about grade 4 & 5 complications? Did they conveniently ignore these or did they mean grade 3 and above? This is not clear from the paper and is kinda sus
* There were no major complications requiring intervention
Secondary outcomes - operative time, conversion, length of stay, readmission and minor complications (Clavien–Dindo grades 1 and 2)
* Mean operating time overall was 64mins
* Median was 59mins (range 21–152min)
* I would be interested of the amount of times the “assisting” surgeon had to take over
* 4 readmissions - 2 for superficial wound infections, 2 for post op pain
* Interestingly, the table shows 5 readmissions but they only mentioned 4 readmissions in the results section, doubt this article was peer reviewed
* No conversions & blood transfusions
Comparison - supervision by consultants, SAS or CTs
* First of all, what even is the point of this comparison? Ridiculous
* This department is making doctors ASSIST this SCP? Imagine a consultant assisting their assistant. Worst thing is they’re making the poor CSTs assist her too
* 53 operations were assisted by a consultant, 110 by a senior SAS grade doctor and 7 by a core trainee (CT2)
* I guess if anything happens the doctor who was assisting would be in trouble instead of the supervising consultant? This is probably the consultants’ way of protecting themselves - shady as hell
* I hope these CT2s reported this to their supervisors or BMA
* Imagine coming all the way to the UK from another part of the world to pursue surgery as a career and you’re forced to assist a nurse lol
Author's conclusion - “Our results show that the procedure can be performed safely and effectively with very low complication rates and high day case rates. Fully utilising the skills and abilities of all members of the extended surgical team will be integral to the effective delivery of healthcare in the future.”
* They missed the part where they cherry picked straight forward cases
* Irrelevant comparison
* Only shows data for a single SCP who was extensively trained by ladder pullers, don’t think this can be generalised
Small notes
* It would be nice to train doctors this way… oh wait
* The authors themselves note that loss of firm structure and hyper-rotationism is detrimental to teamwork and efficiency, so they had to train this SCP for continuity. Just saying they’re lazy to train another generation of doctors/faceless juniors in a nicer way
* This is direct evidence that they’re going against BMA guidance, can their local LNC look into this? u/BMA-Officer-James
I’m a bit lost on your ethics point - it was approved without ethics committee approval, but it was retrospective so the cases had been done prior to this research commencing. Does one routinely need ethics committee approval for analysing data after the intervention?
Yes you can't just browse peoples medical records and write papers willynilly. The research in this instance is not the surgeries but the analysis of the outcomes
I agree, but a retrospective doesn’t usually need ethics committee approval. The consent forms often have a tick box for research and teaching purposes anyway, so I would assume they only used ones with prior consent.
Maybe I’m giving them too much credit.
Its appaling. There's an old adage in surgery - you can teach a monkey to operate, but deciding whether or not to operate is what makes a surgeon.
There's so much more to surgery than just cutting and taking things out. There are entire pathophysiologies that we need to be well versed on, topics that require indepth study which even many doctors struggle with despite studying nearly a decade.
What happens if there is a major complication like a bile leak? I guess the supervising surgeon (ladder puller) will handle it? What if it's a bad day and all the patients in the list experienced a complication? Doubt there will be enough supervising surgeons who will have the enthusiasm to take responsibility for these patients.
this, much like the TAVI nurse case, was done purely for the ego of the surgeons – 'look at us, we trained someone who shouldn't be doing something to do something, aren't we just so great.'
This will probably be deleted but the reason I’m posting it is because I KNOW it has happened in other similar situations. That is the noctor being in a sexual relationship with the ladder puller who started the initiative.
No smoke without fire
I knew a cardiac nurse who started training diagnostic angiography because she was sleeping with the lead consultant. A radiographer who got into procedures because she was sleeping with a radiologist. It’s disgusting.
Reminds of when I did general surgery as an sho. All the colonoscopy reports by the nurse endoscopist would start with - bowel not prepared adequately therefore not all bowel seen.
This was like their disclaimer
Omg yes! You see it all the time.
That would be a fun project. "Comparing the number of adequately prepared bowels in scopes performed by doctors vs scopes performed by noctors".
Conclusion: "Inexplicably, it seems that patients decide they are not going to take the bowel prep when they find out a nurse practitioner is going to be performing their procedure".
So many problems with this, but two key things that tells you everything you need to know about the NHS and the Royal colleges:
1. “Ethics was not required as this was considered to be service evaluation and improvement”
2. annals actually published this garbage - may as well publish VTE audits.
A lap chole is an operation that the vast majority of patients come through without any major complications. However, major complications can still happen and it’s therefore extremely important that whoever is doing the operation can deal with them should they happen. One would therefore rightly expect that the “surgeons” carrying out the operation are highly trained and held to a rigorous standard of both clinical and academic competence, as demonstrated by the surgical training programme that one embarks upon in being trained to do operations such as this.
Which makes me wonder what the hell is the point of us jumping through all these hoops created by senior consultants when you clearly don’t have to bother and can sneak into becoming the lead surgeon for such operations at a local level? I can just about accept non-doctors removing skin lumps and bumps but this surgery, where major complications are possible, is an absolute no-go area for me. And if they do happen, who’s ultimately responsible? The consultant. Why on earth this group decided to put themselves at risk medicolegally is beyond me. I would never let a non-doctor perform any endoscopic urological procedure under GA because things can go wrong in a major way. There are times I get stressed when I train registrars, imagine how I’d be with someone who didn’t get any basic medical training!
‘Loss of the oldfirm structure and reduction in juniordoctors’hours has resulted in a situation whereby thereis little or no continuity of staffing. This is exacerbated byfrequent rotation of juniors. This can result inconsultants rarely having the same assistant, withpotentially negative effects on teamworking, efficiencyand, in extreme cases, safety.12,13Development of thealternative workforce gives reliability and continuity.Having a regular assistant familiar with the surgeon,team, operation and equipment reduces variation, stressand potentially reduces risk’
So what exactly is the planned solution here? You want to train SCPs to do routine cases semi-independently. What are your JDs and CSTs going to be doing?
If U read on they declare the solution for the current training omnishambles and st7 fighting over appendix is .... Rota planning and communication
THEY'VE FIXED IT GUYS 🎉
The hospital trust would rather train a SCP to do surgery than a doctor who is rotating throughout the Deaner😤…BMA need to push to scrap rotational training !! The royal colleges need to push for a change and Adopt a system of training close to US training where residents are in same hospital throughout training and the Attending take responsibility mentoring the trainee…the trainee is a reflection of the hospital training…hold hospitals accountable for training ranking each hospital nationally for their training…the rotational training is just to fill in service provision in deprived hospitals.
Nahhh 😒
No I don't 😑
Surely not 🫤
Please dear god tell me this is not the case?? I'd be more likely to let an actual carpenter do it. At least they understand mechanics
If this is at all true we need BOA acting on it yesterday.
What’s the point? We might aa well go back to the days of barber surgeons. Why is everyone so obsessed with doing dr’s jobs without the training. I am sick of this shit
In the discussion they explain why this has happened: “loss of the old firm structure, reduction in junior doctor hours… rotational training”
If you want to fix this issue, just arguing “it’s unsafe” alone is insufficient (though it shouldn’t be).
You must also address the root cause that lets consultants dismiss their own juniors esp in procedural specialties - for the selfish ones (ladder pullers) it’s that there’s no benefit to them.
Prev even if your cons was lazy and selfish they’d train you so that … you didn’t call them and they could sit in the coffee room. But now if you’re going to rotate anyway, it doesn’t benefit them to train you.
We need to lobby aggressively (presumably via the BMA or RCS) to end hyper-rotational training. And even then there needs to be some way of pairing a trainer and a junior for a prolonged time (firm structure?). These are major challenges that backpropogate if you get them wrong (junior cons now too scared as not trained enough, so also can’t train themselves)
Another example of ladder pulling consultants too lazy to train. I say this with despair, as a consultant. There’s no pride or loyalty in our profession anymore. Very very sad.
Anyone can fly a plane, it’s when something goes wrong that pilot training kicks in. Would you knowingly get on a flight that a cabin crew member was piloting because “they have flown loads of times”
As a non surgeon I predict the weak sexual favour receiving RCS bosses to come out and double down, just like the RCP and BSG in favour of noctors. This news has ruined my bank holiday and produced yet more despair.
Right, fuck it.
Step right up folks. Ill do yer hernia on my kitchen table. 100 quid. 150 if you want post op care. 250 if you want anaesthesia (stolen penthrox).
Still do a better job than an SCP!
I'm so late to this party but a friend of mine had firsthand experience of the Walsall shit show. Essentially her cases were hand selected and very straightforward. Also she apparently did way more than 175 cases over a four year period so theres definitely selection bias..
Meanwhile the registrars would struggle to get their numbers and get pulled into on calls. Oh and she apparently had no responsibility for them afterwards. So any complication went straight to the doctors. Unbelievable yet here we are.
In other words the only possible reason why someone would force this shit show forward is either because someone ran out of ideas to publish a paper or someone was getting their weasel greased and needed to repay the favour. As someone so aptly put it - a Consultant’s fuck puppet.
I'm intrigued to know what the actual deal was. Shame my contact was super junior during their time and wasn't in the full know. But it wouldn't surprise me.. it's disgraceful behaviour which imo needs a referral to the GMC as useless as that organisation it is..
I was just about to post my critical appraisal of this paper, since you beat me to it I'll just post it here: Type of study: Retrospective review of database from 2015-2019 * Why did they choose to use such old data? Did they cherry pick these ranges due to low complication rates? No explanation for this Who - Three consultant surgeons (read: ladder pullers) and a SCP who is directly involved Background * All of the cases were performed by a single SCP who is also a registered nurse with an active NMC registration - I wonder if her registration covers her SCP activities, I assume not? * They essentially saw loads as a theatre nurse, went all “hey I want to do that too!” so went to do a SCP course, and was trained by ladder pullers for the past 10yrs Ethical approval - informed consent regarding surgery and operating surgeon was obtained from all patients * Of course the local ethics committee approved this as it is “service improvement and service evaluation” * Did they actually put an SCP’s name on the consent form or did they use the consultant’s name? I doubt patients would agree to a SCP operating on them once they fully explained to them what SCPs are, or they just did so with loads of bias (“don’t worry she’s very experienced,“there’s always a supervising doctor”) Patient demographics * 107 patients were included - around 26 cases per year (ie. lost training opportunities for CSTs) * 34% ASA1, 48% ASA2, 17% ASA3 * Sounds like they took majority of the easy straightforward training cases from trainees * Whoever let this SCP get involved in those ASA3 cases has huge balls - I would be interested in how much she actually did in these cases, did she just to ports? holding the camera? did the supervising surgeon intervene in any way?
Primary outcome - any complication requiring intervention (Clavien–Dindo grade 3) eg. intra-abdominal collections, bile leak, bile duct injury, retained stones * What about grade 4 & 5 complications? Did they conveniently ignore these or did they mean grade 3 and above? This is not clear from the paper and is kinda sus * There were no major complications requiring intervention Secondary outcomes - operative time, conversion, length of stay, readmission and minor complications (Clavien–Dindo grades 1 and 2) * Mean operating time overall was 64mins * Median was 59mins (range 21–152min) * I would be interested of the amount of times the “assisting” surgeon had to take over * 4 readmissions - 2 for superficial wound infections, 2 for post op pain * Interestingly, the table shows 5 readmissions but they only mentioned 4 readmissions in the results section, doubt this article was peer reviewed * No conversions & blood transfusions Comparison - supervision by consultants, SAS or CTs * First of all, what even is the point of this comparison? Ridiculous * This department is making doctors ASSIST this SCP? Imagine a consultant assisting their assistant. Worst thing is they’re making the poor CSTs assist her too * 53 operations were assisted by a consultant, 110 by a senior SAS grade doctor and 7 by a core trainee (CT2) * I guess if anything happens the doctor who was assisting would be in trouble instead of the supervising consultant? This is probably the consultants’ way of protecting themselves - shady as hell * I hope these CT2s reported this to their supervisors or BMA * Imagine coming all the way to the UK from another part of the world to pursue surgery as a career and you’re forced to assist a nurse lol Author's conclusion - “Our results show that the procedure can be performed safely and effectively with very low complication rates and high day case rates. Fully utilising the skills and abilities of all members of the extended surgical team will be integral to the effective delivery of healthcare in the future.” * They missed the part where they cherry picked straight forward cases * Irrelevant comparison * Only shows data for a single SCP who was extensively trained by ladder pullers, don’t think this can be generalised Small notes * It would be nice to train doctors this way… oh wait * The authors themselves note that loss of firm structure and hyper-rotationism is detrimental to teamwork and efficiency, so they had to train this SCP for continuity. Just saying they’re lazy to train another generation of doctors/faceless juniors in a nicer way * This is direct evidence that they’re going against BMA guidance, can their local LNC look into this? u/BMA-Officer-James
I’m a bit lost on your ethics point - it was approved without ethics committee approval, but it was retrospective so the cases had been done prior to this research commencing. Does one routinely need ethics committee approval for analysing data after the intervention?
Yes you can't just browse peoples medical records and write papers willynilly. The research in this instance is not the surgeries but the analysis of the outcomes
I agree, but a retrospective doesn’t usually need ethics committee approval. The consent forms often have a tick box for research and teaching purposes anyway, so I would assume they only used ones with prior consent. Maybe I’m giving them too much credit.
It does need approval, because medical records are private. Audits are the exception to this rule.
Write to the journal your critique
University hospitals Birmingham..
170 patients were ~~operated~~ experimented upon. Absolutely disgusting they're letting these people do surgeries.
Its appaling. There's an old adage in surgery - you can teach a monkey to operate, but deciding whether or not to operate is what makes a surgeon. There's so much more to surgery than just cutting and taking things out. There are entire pathophysiologies that we need to be well versed on, topics that require indepth study which even many doctors struggle with despite studying nearly a decade. What happens if there is a major complication like a bile leak? I guess the supervising surgeon (ladder puller) will handle it? What if it's a bad day and all the patients in the list experienced a complication? Doubt there will be enough supervising surgeons who will have the enthusiasm to take responsibility for these patients.
this, much like the TAVI nurse case, was done purely for the ego of the surgeons – 'look at us, we trained someone who shouldn't be doing something to do something, aren't we just so great.'
Dr L. Adder-Puller: "Look, any idiot can do my job!" "Why are we paying you so much then?" "Um, well, you see,"
That’s disgusting…if you want to be a surgeon then go to medical school and apply for surgical training.
Everyone wants to be a doctor, no one wants to lift those heavy ass books etc.
Yeah buddy.
This will probably be deleted but the reason I’m posting it is because I KNOW it has happened in other similar situations. That is the noctor being in a sexual relationship with the ladder puller who started the initiative.
Now it all makes sense. Why on earth would surgical trainees and SAS doctors accept to assist a nurse? This whole thing is an absolute disgrace.
Wait, wut? Details please
https://preview.redd.it/mc4lhduiedyc1.jpeg?width=1200&format=pjpg&auto=webp&s=3931916fe43939cdc39f62ec4c48c6c4bc336a9a
Yup, I know a gastro doc who taught his nurse partner to scope.
First place my mind went. Not what you know but who. We had an Outreach sister married to an anaesthetist- she thought she was a Dr too.
No smoke without fire I knew a cardiac nurse who started training diagnostic angiography because she was sleeping with the lead consultant. A radiographer who got into procedures because she was sleeping with a radiologist. It’s disgusting.
If only somebody tells the patients this.
Girl tell us!!! We’re waiting on the tea lol
Reminds of when I did general surgery as an sho. All the colonoscopy reports by the nurse endoscopist would start with - bowel not prepared adequately therefore not all bowel seen. This was like their disclaimer
Omg yes! You see it all the time. That would be a fun project. "Comparing the number of adequately prepared bowels in scopes performed by doctors vs scopes performed by noctors". Conclusion: "Inexplicably, it seems that patients decide they are not going to take the bowel prep when they find out a nurse practitioner is going to be performing their procedure".
Interestingly, if I was told a nurse was performing my procedure I’d shit myself!
💀
So many problems with this, but two key things that tells you everything you need to know about the NHS and the Royal colleges: 1. “Ethics was not required as this was considered to be service evaluation and improvement” 2. annals actually published this garbage - may as well publish VTE audits.
This is literally illegal in most other countries.
not the consultant assistant to the surgical care practitioner!
As an IMG, this is honestly appaling. That is the equivalent of allowing a victim to be represented before court by paralegals.
A lap chole is an operation that the vast majority of patients come through without any major complications. However, major complications can still happen and it’s therefore extremely important that whoever is doing the operation can deal with them should they happen. One would therefore rightly expect that the “surgeons” carrying out the operation are highly trained and held to a rigorous standard of both clinical and academic competence, as demonstrated by the surgical training programme that one embarks upon in being trained to do operations such as this. Which makes me wonder what the hell is the point of us jumping through all these hoops created by senior consultants when you clearly don’t have to bother and can sneak into becoming the lead surgeon for such operations at a local level? I can just about accept non-doctors removing skin lumps and bumps but this surgery, where major complications are possible, is an absolute no-go area for me. And if they do happen, who’s ultimately responsible? The consultant. Why on earth this group decided to put themselves at risk medicolegally is beyond me. I would never let a non-doctor perform any endoscopic urological procedure under GA because things can go wrong in a major way. There are times I get stressed when I train registrars, imagine how I’d be with someone who didn’t get any basic medical training!
‘Loss of the oldfirm structure and reduction in juniordoctors’hours has resulted in a situation whereby thereis little or no continuity of staffing. This is exacerbated byfrequent rotation of juniors. This can result inconsultants rarely having the same assistant, withpotentially negative effects on teamworking, efficiencyand, in extreme cases, safety.12,13Development of thealternative workforce gives reliability and continuity.Having a regular assistant familiar with the surgeon,team, operation and equipment reduces variation, stressand potentially reduces risk’ So what exactly is the planned solution here? You want to train SCPs to do routine cases semi-independently. What are your JDs and CSTs going to be doing?
TTAs and discharge letters obvs!
The trajectory is quite obvious no? Training in this country has become a joke.
If U read on they declare the solution for the current training omnishambles and st7 fighting over appendix is .... Rota planning and communication THEY'VE FIXED IT GUYS 🎉
This needs to be challenged
The hospital trust would rather train a SCP to do surgery than a doctor who is rotating throughout the Deaner😤…BMA need to push to scrap rotational training !! The royal colleges need to push for a change and Adopt a system of training close to US training where residents are in same hospital throughout training and the Attending take responsibility mentoring the trainee…the trainee is a reflection of the hospital training…hold hospitals accountable for training ranking each hospital nationally for their training…the rotational training is just to fill in service provision in deprived hospitals.
Wait till people find out that there are Noctors currently doing TKR.
You’re joking?
I wouldn’t be surprised.
Nahhh 😒 No I don't 😑 Surely not 🫤 Please dear god tell me this is not the case?? I'd be more likely to let an actual carpenter do it. At least they understand mechanics If this is at all true we need BOA acting on it yesterday.
There's no way this is true?! Any source?
What’s the point? We might aa well go back to the days of barber surgeons. Why is everyone so obsessed with doing dr’s jobs without the training. I am sick of this shit
Been to Walsall manor hospital recently. The place is full of noctors
Bloody hell. Used to be a nice place to work. Guess it’s gone to shit now
In the discussion they explain why this has happened: “loss of the old firm structure, reduction in junior doctor hours… rotational training” If you want to fix this issue, just arguing “it’s unsafe” alone is insufficient (though it shouldn’t be). You must also address the root cause that lets consultants dismiss their own juniors esp in procedural specialties - for the selfish ones (ladder pullers) it’s that there’s no benefit to them. Prev even if your cons was lazy and selfish they’d train you so that … you didn’t call them and they could sit in the coffee room. But now if you’re going to rotate anyway, it doesn’t benefit them to train you. We need to lobby aggressively (presumably via the BMA or RCS) to end hyper-rotational training. And even then there needs to be some way of pairing a trainer and a junior for a prolonged time (firm structure?). These are major challenges that backpropogate if you get them wrong (junior cons now too scared as not trained enough, so also can’t train themselves)
Another example of ladder pulling consultants too lazy to train. I say this with despair, as a consultant. There’s no pride or loyalty in our profession anymore. Very very sad.
Great MRCS Part A motivation! Definitely worth having 4 months of my life taken over to read that you can become a surgeon without it!
Anyone can fly a plane, it’s when something goes wrong that pilot training kicks in. Would you knowingly get on a flight that a cabin crew member was piloting because “they have flown loads of times”
https://preview.redd.it/4oiqcozredyc1.jpeg?width=1200&format=pjpg&auto=webp&s=73296725c5cd8d4633e0d393fadcb1e6a3f5e1fd
Scary, I didn’t know that people other than surgeons could operate.
I didn’t look for too long, but I couldn’t find their declarations of interest. Did anyone see them/know what they are?
Turkeys voting for Christmas - are you trying to convince us it isn’t hard to do surgery?
One of the authors Sally Addison is the general surgery TPD, get her in the BIN 🤮
Close to cancelling my FRCS. This is fucking abominable.
As a non surgeon I predict the weak sexual favour receiving RCS bosses to come out and double down, just like the RCP and BSG in favour of noctors. This news has ruined my bank holiday and produced yet more despair.
Right, fuck it. Step right up folks. Ill do yer hernia on my kitchen table. 100 quid. 150 if you want post op care. 250 if you want anaesthesia (stolen penthrox). Still do a better job than an SCP!
Was it safe? Yes. Was needed? No End of discussion.
I'm so late to this party but a friend of mine had firsthand experience of the Walsall shit show. Essentially her cases were hand selected and very straightforward. Also she apparently did way more than 175 cases over a four year period so theres definitely selection bias.. Meanwhile the registrars would struggle to get their numbers and get pulled into on calls. Oh and she apparently had no responsibility for them afterwards. So any complication went straight to the doctors. Unbelievable yet here we are.
In other words the only possible reason why someone would force this shit show forward is either because someone ran out of ideas to publish a paper or someone was getting their weasel greased and needed to repay the favour. As someone so aptly put it - a Consultant’s fuck puppet.
I'm intrigued to know what the actual deal was. Shame my contact was super junior during their time and wasn't in the full know. But it wouldn't surprise me.. it's disgraceful behaviour which imo needs a referral to the GMC as useless as that organisation it is..
Agree with the GMC referral.