Surgical skill decay in the contingency era

Abstract

Civilian evidence suggests larger operating volumes are linked to better surgical performance and that this contributes to improved patient outcomes. 2 The progressive and notably good survival rates seen in Camp Bastion, Afghanistan Role 3 Hospital trauma patients have been attributed to an array of factors, with high surgical case load noted as adding ample opportunity to refine technical skills and drive systematic improvements. Major UK Armed Forces deployments since then—to Sierra Leone (Operation GRITROCK 2014–2015), or to South Sudan (Operation TRENTON 2017– 2018)—have differed markedly from the 2003 to 2014 Iraq and Afghanistan era in terms of surgical operating, with very few procedures undertaken. Such ‘lowtempo’ circumstances, characterised by lack of opportunity to practise hardwon craft skills, are now a frequent hallmark of contemporary surgical deployment, particularly so for surgeons who deploy with a small Role 2 Forward Surgical Team. Skill decay—the partial or full loss of trained or acquired skills and knowledge following periods of nonuse—is a largely unacknowledged but real risk on such deployments. Interest in this phenomenon by UK Defence Medical Services (DMS) clinicians and US military surgeons 10 is increasing, but an organisational, systematic response is needed to consistently manage and prevent the likelihood of patient harm caused by skill decay. Time away from regular surgical practice is a key factor in skill decay. For a 3month deployment, and taking into account predeployment training (PDT) and postoperational tour leave, a UK DMS surgeon will probably spend around 4–6 months away from their NHS base hospital. Protracted military PDT— where surgeons have to undergo several months of nonclinical training to ensure their military skills are adequate before deploying to a particular theatre—may mean that skill fade has begun to affect technical performance before they even leave the UK. Once in theatre, such skill fade will be exacerbated if few or no cases are undertaken. Finally, once back in the UK, DMS surgeons’ fitness to resume civilian surgical duties—conducting highly specialised, elective surgery such as laparoscopic tumour resection or complex joint replacement—may have been compromised by their time away. As such, the problem is an important, multidomain one, with potential impact on military and NHS patients alike. Unfortunately, the realworld impact of military surgical skill decay is exceptionally difficult to measure, especially in the deployed setting—the paradox being that fewer cases passing through deployed surgical facilities means that there are fewer surgical events from which to analyse or draw meaningful conclusions. Furthermore, the kind of technical failures that might be ascribed to skill decay, such as incorrect application of a clamp, iatrogenic tissue damage and haemorrhage, or misjudged intraoperative decisionmaking—is nuanced and difficult to attribute to lack of practice. Any of these phenomena might occur during a difficult trauma case in a testing, farforward location, even in the most skilful of surgeon’s hands, and the role of skill fade never properly attributed. The comparative lack of understanding around, and attention paid to the issue of military surgical skill decay on deployment contrasts with the efforts to prepare military surgeons prior to leaving the UK. The ‘startstate’ for DMS surgeons’ skill sets is well described. 12 Organisational support is not only available but mandated for surgeons and the wider team to acquire or refresh technical skills on their pathway to deployment, including the Military Operational Surgical Team Training (MOSTT) course: a weeklong course that uses fresh human cadavers to review anatomy and rehearse damage control trauma surgery. Surgical teams are also exposed to Army Medical Services Training Centre exercises, which enable wholehospital simulation and the rehearsal of response to major incidents and difficult ethical scenarios. Once surgical teams have passed through such training, though, there is little grasp of how technical skills—such as common femoral artery exposure for management of vascular injury—remain fresh, and how skill decay curves differ for different training audiences. For instance, skill decay is probably buffered by cumulative surgical experience and practitioner seniority but detailed understanding is lacking. If it is correct to assume that skill decay is affected by the total time away from regular surgical practice, then length of deployment and the extent to which deployment length should be adjusted to limit the problem is germane. Conventionally, DMS surgical deployments—the time spent overseas—are not greater than 3 months—a time threshold which the Academy of Medical Royal Colleges acknowledges as ‘more likely to significantly affect [the] skills and knowledge’ of clinicians. It is accepted that this threshold is a tradeoff: shorter roulements burden the logistics and training chain (preparation and movement of surgeons in to, and out of, the operational theatre). They increase the frequency of deployment for any one individual (with more disturbance to professional and domestic life) and affect team continuity, with other team members having to familiarise themselves with new personalities every few weeks. Paradoxically, there are times when shorter surgical deployments are necessary because operational workloads are very intense—as was seen during the peak of operations in Afghanistan and Iraq—and the risk of team and individual burnout is high. Indeed, while many, if not most deployments are accompanied by risk of skill fade, it would be wrong to depict this as a universal threat of contemporary military deployment. A recent US military surgical team performed damage control surgery on 182 patients, including children, within a 3month period, transfusing an average of 100 units of blood product per week. Equally, such experience is very infrequent for the majority of UK teams deploying to support operations on the land or sea. The next question to answer is that, if it is agreed that skill fade should be taken into account as a factor important in determining surgical outcomes, where does the accountability lie in mitigating it? Individual surgeons ‘are responsible for keeping themselves up to date and maintaining competence in all areas of their practice’ but the responsibility for ensuring that they have the required training and preparation to do so rests across and between a large number of overseeing DMS authorities. Prior to deployment, and on behalf of the UK Surgeon General, the relevant senior surgeon (termed the Defence Consultant Vascular Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK Centre for Trauma Sciences, The Royal London Hospital, London, UK Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK