Recruitment to higher specialty training in anaesthesia – we must do better

Any department will be familiar with the difficulties faced when appointing consultants or other senior doctors. We simply need more trained anaesthetists. Yet, the current trainee cohort have experienced major issues around all aspects of training, and this new survey elicits the associated consequences. It is, I believe, a landmark paper for several reasons. First, surveys are notoriously difficult to get right, especially as a full paper for publication in Anaesthesia. It serves as an excellent reminder of their utility, as well as how to do it. Second, this is a survey of trainees, by trainees, for trainees. The authors have responded to their own difficulties by producing a fine piece of academic work that will undoubtedly change things for others. Third, anyone involved with trainees and training should study the contents of the paper carefully, as we all have a duty to do better. Carey et al. discuss the recent curriculum and COVID-19 on training. It seems clear that more collaboration is needed between Royal Colleges, regulators and those who plan and run national recruitment processes. Clyburn et al. ask whether we have now created another lost tribe and make several recommendations as to how this cohort may one day be ‘found’.

Figure 1 Responses to questions about future plans (n = 437).

Are we all clear on how SARS-CoV-2 infection influences the timing of elective surgery, given that we now have vaccines and new variants? No? Look no further than this timely update from the Association of Anaesthetists, Centre for Perioperative Care, Federation of Surgical Specialty Associations, Royal College of Anaesthetists and Royal College of Surgeons of England. The main news is that previous recommendations that, where possible, patients should avoid elective surgery within 7 weeks of SARS-CoV-2 infection remain, unless the benefits of doing so exceed the risk of waiting. This is the key point though, as it is less about absolute rules and more about bespoke risk assessment and shared decision making. The paper contains a useful risk assessment template as well as a nicely written reminder about the importance of understanding relative vs. absolute risk.

Although we work in a low-risk specialty for litigation against doctors, it is important that we learn from claims to better understand clinical risk regarding trends, procedures and specialist areas of practice. This new analysis of claims made during 2008-2018 updates our understanding, which was based previously on work that is now a decade old. There are around 200 claims related to anaesthesia costing £14.5 million each year. Although this sounds like a lot, it is the equivalent of £4.39 per case. One of the surprises here is our reliance on researchers to do this work, as there are no formal processes to bring these data together. There must be a better way and the authors provide some excellent suggestions. Crosby argues that It’s time to eliminate tort from the management of medical mishaps in the NHS. Perhaps modifying the operation of NHS Resolution may allow it to do so meaningfully and eliminate the need for a new agency? D’Sa and Griffiths ask whether we can learn from our mistakes by looking in depth at medicolegal claims? They remind us that medicolegal risk is not the same as clinical risk, and we should reflect on which type of risk should drive changes in our practice. 

Figure 2 Proportion of claims by category in each of two time periods, 1995–2007 (blue) and 2008–2018 (grey).

Litigation arising from pain during caesarean section under neuraxial anaesthesia has replaced accidental awareness under general anaesthesia as the most common successful medicolegal claim against obstetric anaesthetists. These new recommendations are the only ones available in this area and benefit from the experience of a patient, who is also an author. The importance of effective communication is a strong theme running throughout as is the need to support clinicians and promote standardisation of practice in this area. The guidelines are accompanied by a systematic review from Patel et al. which find that approximately 1 in 1750 women require conversion to general anaesthesia due to inadequate neuraxial anaesthesia, and 15% require supplemental analgesia or anaesthesia ranging from nitrous oxide to general anaesthesia. In the associated editorial, Stanford (the patient author of on the authorship group) reminds us that the ends (a well baby) do not always justify the means, and inadequate neuraxial anaesthesia is associated with long-term psychological consequences. Afterall, physical safety is the bare minimum of what should be expected during caesarean sections.  

Elsewhere we have: an e-Delphi process with training facilitators of Priorities for content for a short-course on postoperative care relevant for low- and middle-income countriesa retrospective study of the effect of iron deficiency without anaemia on days alive and out of hospital in patients undergoing valvular heart surgery; anda prospective study of functional recovery after discharge in enhanced recovery video-assisted thoracoscopic lobectomy.

Finally, this prospective randomised trial from Hestin et al. aimed to elucidate whether general or regional anaesthesia is better for surgical evacuation of chonic subdural haematoma. In terms of time to become medically fit for discharge or postoperative complications, there was no difference and both techniques were comparable. In the associated editorial, Dinsmore and Wiles argue that patients should receive the anaesthetic that is best for them, and no large RCT will ever prove one technique to be superior than the other. Perhaps we now need to treat surgery for chronic subdural haematoma like that for hip fracture. This would require standardised care packages for the whole patient journey, rather than just the peri-operative period.  

Booking is now open for Annual Congress in September later this year, which be a face-to-face meeting! We hope to see you there! Our journal session will focus on emergencies relevant to those working in anaesthesia, critical care and pain.

Mike Charlesworth and Andrew Klein