High-risk training: the courage to teach.

We read with interest John Pepper and Aman Coonar’s article that outlined the effect that publically available statistics based upon 30-day mortality is having on surgical practice. We agree that we must all strive to reduce poor outcomes from surgical procedures and that mortality statistics are important, albeit crude metrics, to inform practice review. Indeed, in the Oxford Vascular Unit we have a monthly review of all mortalities in a constructive environment in order to allow non-judgemental, open analysis of cases and lessons learnt: patient outcomes are of the highest priority. However, we are concerned about the impact of having surgeons held personally accountable for their statistics affecting surgical training. It is widely acknowledged that trainees need ever-increasing autonomy in order to allow them to develop their clinical and surgical skills. There is already substantial concern that current trainees may not receive enough experience during specialist training due to the European Working Time Directive and implementation of the Calman Report recommendations. If surgeons are primarily concerned with improving their statistics, they may be disincentivised to encourage or even allow trainees to be primary operators or be involved in decision-making outside of theatre. These opportunities are critical for surgical training and are likely to lead to a deterioration in future patient care. Therefore, we propose that the level of trainee involvement in cases as well as outcome is reported: whether that be 30-day mortality or a more diverse set of statistics. It is imperative that we continue to improve the standard of training for future surgeons, irrespective of how we try to regulate current surgical practice.