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\begin{document}

\title{On the left or on the right\ldots{}side of the table. Where do you
stand?}



\author[1]{Arnaldo Dimagli}%
\author[2]{Gianni Angelini}%
\affil[1]{Bristol Heart Institute}%
\affil[2]{Bristol University}%


\vspace{-1em}



  
  \date{June 09, 2024}


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\selectlanguage{english}
\begin{abstract}
Being able to perform surgery first-hand represents the backbone of
every training program and the key to successful development of the new
generation of skilful surgeons. In this issue of the Journal, Comanici
et al. presented a thorough systematic summary of the current evidence
on the outcomes of cardiothoracic operations performed by trainees.1
Taking for granted the importance of training young surgeons, it is
paramount to identify and tackle any potential obstacles hindering the
surgical growth of a trainee.%
\end{abstract}%



\sloppy


\textbf{On the left or on the right\ldots{}side of the table. Where do
you stand?}

Arnaldo Dimagli MD\textsuperscript{1,2}, Gianni D Angelini
MD\textsuperscript{1}

\textsuperscript{1} Bristol Heart Institute, University of Bristol,
Bristol, United Kingdom

\textsuperscript{2} Department of Cardiothoracic Surgery, Weill Cornell
Medicine, New York, NY, USA

\textbf{Conflict of interests:} none

\textbf{Acknowledgments} : This work was supported by the British Heart
Foundation and the NIHR Biomedical Research Center at University
Hospitals Bristol and Weston NHS Foundation Trust and the University of
Bristol.

\textbf{Word count:} 781

\textbf{Keywords:} surgical education; surgical training; medical
education

\textbf{Corresponding Author:}

Gianni D. Angelini MD,

BHF Professor of Cardiac Surgery.

Level 7, Bristol Royal Infirmary,

Bristol, BS2 8HW.

Phone number: +441173423165

Email: G.D.Angelini@bristol.ac.uk

Being able to perform surgery first-hand represents the backbone of
every training program and the key to successful development of the new
generation of skilful surgeons. In this issue of the Journal, Comanici
et al. presented a thorough systematic summary of the current evidence
on the outcomes of cardiothoracic operations performed by
trainees.\textsuperscript{1}

Taking for granted the importance of training young surgeons, it is
paramount to identify and tackle any potential obstacles hindering the
surgical growth of a trainee.

Firstly, there is an ever-growing scrutiny on the performance of each
surgeon with publicly available reports on mortality and
morbidity.\textsuperscript{2} In the United Kingdom, public reporting
was systematically implemented by the Society for Cardio-Thoracic
Surgery in 2004 following the Bristol enquiry.\textsuperscript{3,4} The
benefits of public reporting are well-recognized and includes improved
transparency, higher accountability of healthcare providers and informed
patient's choice. However, downsides should also be acknowledged.
Trainees may be direct innocent victims of public reporting due to the
tendency of surgeons to safeguard their publicly scrutinized outcomes.
Under the erroneous assumption that trainee-led cases can lead to worse
outcomes, surgeons may be hesitant to allow trainees to perform the
operation as first operators. This does not only reduce the absolute
number of cases performed by trainees but also limits surgical exposure
to only selected less complex procedures. Reports such as the one of
Comanici et al. are pivotal to provide compelling evidence that trainee
cases are not likely to negatively impact surgeons' outcomes.

Secondly, the cohort of patients presenting for surgery is continuously
evolving and changing. Patients are now older, with a greater burden of
comorbidities and more advanced
disease.\textsuperscript{5}Traditionally, a trainee case is described as
a low-risk case in which there is ample space for education and
supervision, however, sticking to this paradigm would sharply reduce the
number of eligible patients for trainees given the increasing higher
risk surgical population. However, surgeons should not be discouraged to
let trainee operate first-hand also on high risk profile patients. There
are previous reports that focused on this issue and showed that
regardless of the increased risk of nowadays patients trainee cases have
similar favourable outcome than when performed by trainers and patients
welfare is still preserved and prioritized.\textsuperscript{1,6,7}
Extension of training to complex operations also facilitates the always
challenging transition from trainee to consultant position.

Thirdly, there is a subjective variability within surgeons when it comes
down to teaching regardless of the complexity of the patients. Surgeons
can have a different level of comfort in letting a trainee perform the
surgery and this can clearly reduce the opportunities for trainees
working with less self-confident surgeons. Also, training is an
educative experience above all and as such it should be acknowledged
that some surgeons may be more willing to teach or better at it than
others. Identifying these educational skills and rewarding them in their
professional career could help improve the quality and quantity of
training.

Another source of heterogeneity is related to how much a surgeon feels
the trainee needs to perform during the operation. This is clearly
reflected in the diverging definitions of a ``trainee case'' in
published reports. It would appear logical that the ideal definition is
a skin-to-skin operation, however, this does not always match the
educational needs of a trainee. Training should be based on a
skill-oriented program which progressively exposes the trainee to the
surgical steps (e.g., sternotomy, proximal than distal anastomosis of
coronary grafts) of each procedure until all the pieces are dexterously
performed and can be put together to perform the whole procedure.
Therefore, this definition should be approached pragmatically
considering that a skin-to-skin procedure can be suitable for senior
trainees, whereas smaller surgical bits more appropriate for junior
trainees.

Finally, a new problem is providing exposure to technique like minimal
access and robotic cardiothoracic surgery. The limits here are even more
impeding. These techniques and particularly robotic platforms and
expertise are not readily available in every cardiac unit, and the
volume of procedures is much lesser than conventional surgery. These
factors create a ``training gap'' difficult to fill. Simulation
curricula can in part fill this gap by means of wet labs and virtual
reality simulators which have been shown to provide proficient expertise
level.\textsuperscript{8} Considering the potentiality of minimal access
and robotic surgery in the future, surgical programs should start to
consider the implementation of means to train the surgeons of tomorrow
in these ever-evolving technologies.

Concluding, there is a substantial body of evidence in the literature
and well-summarized by Comanici et al. that support the safety of
surgical training. This should eradicate any remaining reluctance
towards trainee-led cases. Today's well-trained doctors will be
tomorrow's good surgeons, trainers and guarantor of patient welfare.

\textbf{References}

1. Comanici M, Salmasi Y, Schulte KL, Raja S, Attia R. Are there
differences in cardiothoracic surgery performed by trainees vs fully
trained surgeons? \emph{J Card Surg} ; In-press.

2. Exworthy M, Gabe J, Rees Jones I, Smith G. Explaining health system
responses to public reporting of cardiac surgery mortality in England
and the USA. \emph{Health Econ Policy Law} 2021; 16: 183--200.

3. Keogh B, Spiegelhalter D, Bailey A, Roxburgh J, Magee P, Hilton C.
The legacy of Bristol: public disclosure of individual surgeons'
results. \emph{BMJ} 2004; 329: 450--454.

4. Bridgewater B. Cardiac registers: The adult cardiac surgery
register.\emph{Heart} 2010; 96: 1441--1443.

5. Grant SW, Kendall S, Goodwin AT, Cooper G, Trivedi U, Page R, et al.
Trends and outcomes for cardiac surgery in the United Kingdom from 2002
to 2016. \emph{JTCVS Open} . Epub ahead of print 2021. DOI:
https://doi.org/10.1016/j.xjon.2021.02.001.

6. Dimagli A, Sinha S, Benedetto U, Caputo M, Angelini GD. The impact of
surgical training on early and long-term outcomes after isolated aortic
valve surgery. \emph{Eur J Cardio-Thoracic Surg} . Epub ahead of print 6
August 2021. DOI: 10.1093/ejcts/ezab328.

7. Escorel Neto AC, S\selectlanguage{ngerman}á MP, Van den Eynde J, Rotbi H, Do-Nguyen CC, Olive
JK, et al. Outcomes of cardiac surgical procedures performed by trainees
versus consultants: A systematic review with meta-analysis. \emph{J
Thorac Cardiovasc Surg} . Epub ahead of print 23 August 2022. DOI:
10.1016/j.jtcvs.2021.12.029.

8. Valdis M, Chu MWA, Schlachta C, Kiaii B. Evaluation of robotic
cardiac surgery simulation training: A randomized controlled
trial.\emph{J Thorac Cardiovasc Surg} 2016; 151: 1498-1505.e2.

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