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Abstract
Introduction Older patients undergoing cancer surgery are at increased risk of post-operative complications, prolonged hospital stay, and mortality. Identification of frailty can help predict patients at high risk of peri-operative complications and allow a collaborative, multidisciplinary team approach to their care. A survey was conducted to assess the confidence and knowledge of trainees in obstetrics and gynecology regarding identification and management of peri-operative issues encountered in frail gynecological oncology patients.
Methods A web-based survey was distributed via the Audit and Research in Gynaecological Oncology (ARGO) collaborative and UK Audit and Research Collaborative in Obstetrics and Gynaecology (UKARCOG) . The survey on the management of frail peri-operative patients was disseminated to doctors-in-training (trainees) working in obstetrics and gynecology in the United Kingdom (UK) and Ireland. Specialty (ST1–7), subspecialty, and general practice trainees, non-training grade doctors, and foundation year doctors currently working in obstetrics and gynecology were eligible. Consultants were excluded. Study data were collected using REDCAP software hosted at the University of Manchester. Responses were collected over a 6-week period between January and February 2020.
Results Of the 666 trainees who participated, 67% (425/666) reported inadequate training in peri-operative management of frail patients. Validated frailty assessment tools were used by only 9% (59/638) of trainees and less than 1% (4/613) were able to correctly identify all the diagnostic features of frailty. Common misconceptions included the use of chronological age and gender in frailty assessments. The majority of trainees (76.5%, 448/586) correctly answered a series of questions relating to mental capacity; however, only 6% (36/606) were able to correctly identify all three diagnostic features of delirium. A total of 87% (495/571) of trainees supported closer collaboration with geriatricians and a multidisciplinary approach.
Conclusions Obstetrics and gynecology trainees reported inadequate training in the peri-operative care of frail gynecological oncology patients, and overwhelmingly favored input from geriatricians. Routine use of validated frailty assessment tools may aid diagnosis of frailty in the peri-operative setting. There is an unmet need for formal education in the management of frail surgical patients within the UK and Irish obstetrics and gynecology curriculum.
- postoperative care
- surgical oncology
- gynecology
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HIGHLIGHTS
Two-thirds of trainees reported inadequate training in peri-operative management of frail patients.
Misconceptions regarding the diagnostic features of frailty and delirium are common.
Trainees overwhelmingly feel that introducing specialist services for frail patients would improve peri-operative outcomes.
Introduction
The global population is aging with a corresponding increase in the incidence of cancer.1 While cancer outcomes have improved globally, the rate of progress has been slower in older patients, especially women with gynecological cancers.2 Frailty is an age-related, multisystem syndrome characterized by diminished physiological reserve. This results in reduced tolerance of stressors and increased vulnerability to adverse outcomes including falls, disability, hospitalization, and death.3 It is related to, but distinct from, co-morbidity and disability.4 Frailty is characterized by sarcopenia, poor nutrition, functional, sensory and cognitive decline, and lethargy.5 Frailty occurs in 25% of women aged ≥65 years and increases to 45% in those aged 85 years and older.6 More than 50% of older patients with cancer have frailty, or pre-frailty,5 and both the disease process and treatments can challenge physiological reserve. A recent meta-analysis revealed that frailty is an independent risk factor for post-operative complications, prolonged hospitalization, mortality, and non-home discharge.7 Only a few studies have evaluated frailty in gynecological cancers, but the same trends regarding adverse post-operative outcomes have been observed.8–12 However, early recognition of frailty, followed by ‘prehabilitation’, with the aim of modifying the degree of frailty before surgery, may improve surgical outcomes.5
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report on elective and emergency surgery in the elderly identified major shortfalls in the peri-operative care, resulting in excess morbidity and mortality.13 The main deficiencies included poor documentation of disabilities and nutritional assessments, lack of formal frailty assessments, and inadequate post-operative care. Indeed, a recent study demonstrated that close involvement of multidisciplinary team in daily care is beneficial.14 In recognition of the importance of integrated services for older adults, the British Geriatrics Society have produced the ‘Fit for Frailty’ guideline on the recognition and management of frailty in community and outpatient settings;15 however, this has yet to be widely implemented in gynecological oncology.
Routine post-operative care is provided by trainees ranging from foundation doctors to subspecialty trainees and fellows in gynecological oncology. Previous studies have identified that surgical, hematological, medical,and radiation oncology trainees lack confidence, competence, and specific training in the management of older adults with cancer.16–19 The aim of this survey was to assess confidence and knowledge regarding common peri-operative problems encountered in frail gynecological oncology patients in trainees working in obstetrics and gynecology.
Methods
Setting, Participants, and Recruitment
An online survey was distributed via the Audit and Research in Gynaecological Oncology (ARGO) collaborative and UK Audit and Research Collaborative in Obstetrics and Gynaecology (UKARCOG) to United Kingdom (UK) and Irish trainees working in obstetrics and gynecology. Specialty (ST1–7), subspecialty, and general practice trainees, non-training grade doctors, and foundation year doctors currently working in obstetrics and gynecology were eligible. Consultants were excluded. Study data were collected using REDCAP software hosted at the University of Manchester, Manchester, UK. The survey was disseminated via ARGO and UKARCOG representatives, advertised during the national and regional study days, and publicized on the ARGO social media feed. Responses were collected over a 6-week period between January and February 2020.
Ethical Approval
The National Health Service (NHS) Health Research Authority decision tool was implemented. This study was assessed as service evaluation with the aim to define the current clinical care and adequacy of training in the management of frailty through the implementation of clinician-completed questionnaires. No patient data were included in this study. Thus, no NHS research ethics committee review was sought.
Questionnaire Design
The authors reviewed the literature on the peri-operative management of frail surgical patients and of trainees’ knowledge in the management of frailty. Relevant issues were identified and used to inform questionnaire design. Trainees and consultants in gynecological oncology and geriatrics identified three key domains: (1) trainee demographics and prior training in geriatric medicine; (2) current clinical practice and attitudes regarding the assessment and management of frail patients; and (3) multidisciplinary care in the management of frail patients. The questionnaire consisted of 19 questions (Online supplemental material); questions addressing confidence and clinical experience used a five-point Likert scale while those addressing clinical knowledge used multiple choice or true/false formats. Delirium and mental capacity were chosen for trainees’ competency assessment as these have been identified as areas of particular importance in peri-operative care in the NCEPOD report.13 The questionnaire was pre-tested in 10 trainees and changes were made to improve readability and non-ambiguity.
Supplemental material
Supplemental material
Statistical Analysis
For categorical data, responses were analyzed in frequencies and percentages. The Chi-square test was used to compare responses between junior and senior trainees. Junior trainees were defined as ST1–2, general practice, and foundation year trainees (interns) and junior non-training grade doctors, whereas ST3–7, subspecialty trainees, and senior non-training grade doctors were considered senior trainees. Respondents who did not specify their training grade were excluded from this analysis (n=49, 7.4%). Data from partially completed surveys were included in the analysis, but only if the respondent answered all questions in the relevant section, for example, all questions relating to mental capacity. SPSS v26.0 statistical software package (SPSS, Inc., Chicago, IL, USA) was used for data analysis. A p value <0.05 was considered statistically significant.
Results
Participants and Demographics
A total of 666 trainees participated in the survey. Of these, 91.1% (607/666) of respondents were enrolled in obstetrics and gynecology specialty training, giving an approximate response rate of 30% of all UK and Irish trainees. Junior and senior trainees represented 32.1% and 55% of respondents, respectively. The remaining 12.9% were in non-training grades or academic posts. Overall, 67.8% (451/666) of participants were based in a tertiary gynecological oncology center at the time of survey completion. Incomplete questionnaires were returned by 14.3% (95/666). For transparency, participant drop out is summarized in the Online supplemental data. Of note, there were no overt differences in the characteristics of trainees who submitted incomplete data and those who completed the full survey. It is possible that the participants who submitted incomplete responses did not feel appropriately qualified to complete the survey or may have found the length of the survey unacceptable.
Training in the Care of Older Adults
In total, 8.9% (59/666) of the respondents reported never having received any training in the care of older adults. More than half received formal undergraduate (62.1%, 413/666) and/or postgraduate (50.2%, 334/666) training, such as a post in elderly medicine. Only 24.8% (165/666) of respondents reported having received training relevant to the care of older adults during their hospital induction. Overall, two-thirds of trainees (66.6%, 425/638) did not feel that their postgraduate training adequately prepared them for the peri-operative management of frail patients. Perceived adequacy of postgraduate training was strongly associated with greater confidence in managing frail patients in the peri-operative period (p<0.01).
Frailty
A total of 36.7% (234/638) of trainees felt confident in their ability to assess and manage a frail patient pre-operatively. No differences were seen between trainees who had received formal training in the care of older adults and those who had not (p=0.14). Use of a validated frailty assessment tool in pre-operative evaluation of patients was uncommon, with only 9.2% (59/638) of respondents regularly using these. Trainees were asked to identify key characteristics of a frailty assessment tool. The majority of trainees correctly identified that level of independence with activities of daily living (91.4%, 560/613), medical co-morbidities (89.7%, 550/613), social support (76.3%, 468/613), number of regular medications (71.6%, 439/613), and weight loss (67.9%, 416/613) were components of frailty assessment tools (Figure 1). Interestingly, 40.8% (250/613) of respondents thought gender was considered during a frailty assessment, and only 10.9% (67/613) identified that chronological age is not routinely considered. There were no significant differences in the responses from junior and senior trainees. Crucially, only 0.65% of trainees (4/613) correctly identified all diagnostic features commonly included in frailty assessment tools.
Trainees’ responses to factors taken into account in frailty assessment tools.
Perceived Confidence in Management of Older Patients
Trainees were asked to rate their confidence in managing common peri-operative issues including delirium, nutrition, and fluid management. The frequency of junior and senior trainees agreeing or strongly agreeing with each statement is shown in Table 1. Junior trainees reported significantly higher levels of confidence in managing post-operative delirium (p<0.01), identifying potential drug interactions and starting new medications (p<0.01), compared with senior trainees. Both senior and junior trainees reported low levels of confidence in their ability to assess the nutritional status of frail patients, and subsequently initiate treatment (Table 1). Conversely, two-thirds of trainees (68.3%, 402/589) felt confident in assessing fluid balance and prescribing fluids in older patients.
Trainees’ self-reported confidence in managing frail patients in the peri-operative period
Delirium
Only 37.4% (220/589) of trainees felt confident in managing post-operative delirium. Altered consciousness, sudden onset, and inattention were correctly identified as the three key diagnostic features of delirium by 59.4% (350/589), 60.6% (357/589), and 38.3% (226/589) of trainees (Table 2), respectively. Overall, only 5.9% (36/606) of all respondents were able to correctly identify all three key diagnostic criteria. Significantly more junior trainees correctly identified inattention and altered consciousness as key features, compared with senior trainees (p<0.01). It was a common misconception between junior and senior trainees that altered sleep–wake cycle and delusions were diagnostic features of delirium.
Trainees’ answers identifying the three clinical features most characteristic of delirium
Mental Capacity
A total of 31.7% (192/606) of trainees reported that they did not feel confident in assessing mental capacity or conducting a best interest meeting. Confidence was not associated with level of training (p=0.17) or formal training in care of older patients (p=0.06). Despite low confidence, the majority of trainees (76.5%, 448/586) correctly answered a series of true/false questions relating to mental capacity (Table 3).
Trainees’ responses to questions relating to consenting a patient for surgery
Multidisciplinary Care
A total of 89.7% (525/585) of trainees sought medical advice when managing frail surgical patients; typically from an anesthetist (82.9%, 483/583), physician (76.5%, 446/583), geriatrician (60.4%, 352/583), occupational therapist (63.1%, 368/583), or physiotherapist (67.6%, 394/583). Geriatric psychiatrists were least likely to be consulted. Trainees overwhelmingly felt that greater support from a specialist service for frail patients would improve pre-operative optimization (93%, 531/571) and post-operative rehabilitation (94.4%, 539/571) (Figure 2). Significantly more senior trainees agreed or strongly agreed that greater support from specialist services would improve their learning outcomes (p=0.042). Similarly, 86.7% (495/571) of trainees agreed or strongly agreed that frail patients would benefit from involvement of a geriatrician within the multidisciplinary team.
Trainees’ beliefs regarding areas likely to improve with a specialist service for frail gynecological oncology patients during the peri-operative period.
Discussion
To our knowledge, this is the first study to comprehensively assess the perception of training in the management of frailty among postgraduate trainees working in obstetrics and gynecology. This study captured the views of 30% of junior doctors training in obstetrics and gynecology in the UK and Ireland. The key finding is that a large proportion of junior doctors working in gynecological oncology have not received formal training in the care of elderly patients, either as part of their undergraduate (37.9%) or postgraduate (49.8%) training, and consequently lack confidence in managing frail patients.
Frailty is increasingly recognized as an important factor in post-operative recovery. In gynecological oncology, frailty indices have been shown to predict the incidence of post-operative complications, the need for critical care, non-home discharge, and 30-day mortality.8–12 Gynecological oncology patients are particularly vulnerable to the effects of frailty as they may be managed in stand-alone women’s hospitals with limited access to other specialties. To deliver optimal care to these patients requires doctors with adequate knowledge and training to recognize and manage frailty. Implementation of frailty screening tools during pre-operative assessment enables proactive optimization and management of high-risk patients, to facilitate improved outcomes and reduced length of stay.15
Only 9% of respondents reported regularly using frailty assessment tools and there were common misconceptions regarding the inclusion of chronological age and gender in these assessments. The Royal College of Anaesthetists recommend that older patients undergoing intermediate or high-risk surgery should be assessed for frailty using a validated tool.20 Screening tools such as the Edmonton Frailty Scale21 or Rockwood Clinical Frailty Scale22 may help non-specialist clinicians to identify frail patients who warrant specialist input. The Rockwood Clinical Frailty Scale measures frailty based on clinical judgment on a nine-point scale ranging from ‘very fit’ to ‘terminally ill’.22 The Edmonton Frailty Scale assesses nine domains, including general health, functional independence, functional performance, and cognition.21 Both scales can be undertaken by any appropriately trained healthcare professional and completed within 10 min. The Edmonton Frailty Scale is recommended by the British Geriatric Society for use in elective surgical settings, as it specifically identifies aspects of frailty amenable to pre-operative optimization.15 Only 0.65% of trainees correctly identified all diagnostic features commonly included in frailty assessment tools. This is likely to reflect lack of widespread use of these tools in gynecological oncology and a lack of formal training on frailty.
Post-operative care is often provided by junior doctors. Trainees’ confidence in the recognition of frailty did not correlate with training grade; junior trainees reported greater confidence in the recognition and management of frailty than their senior counterparts. While this may reflect a greater breadth of medical knowledge as a result of a shorter time from graduation and more recent experience of working in medical specialties, the phenomenon of juniors' tendency to overestimate their skills and knowledge is recognized.23 Therefore, escalating care with earlier involvement of a consultant will not be sufficient; rather the involvement of an appropriate clinician is vital. Respondents reported particularly low levels of confidence in the management of common peri-operative issues surrounding prescribing, delirium, mental capacity assessment, and suboptimal nutrition. Despite the high prevalence of delirium in post-operative patients,24 only 6% of respondents in our study were able to identify the three diagnostic features for this condition. Therefore, delirium may be unrecognized and mismanaged, with potential effects on morbidity and mortality.25 This finding is consistent with an earlier study of general surgical trainees,16 suggesting that the problem is not limited to trainees in obstetrics and gynecology. Encouragingly, obstetrics and gynecology trainees performed much better when asked to answer knowledge-based questions on ascertaining mental capacity. Legal issues regarding valid consent are included in the core obstetrics and gynecology curriculum, inferring that knowledge of the management of other peri-operative issues could improve if formally incorporated into the curriculum.
Trainees implicitly adopted a multidisciplinary approach in managing frail patients with 90% seeking help from other specialists. Anesthetists and general physicians were more often consulted than geriatricians, which may reflect the ease of access to other specialist and/or inadequate recognition of the value of geriatricians in peri-operative care. Geriatric–surgical liaison services in other surgical subspecialties have demonstrated that, once embedded, they can reduce complications and length of stay in older patients.26–29 In our study, trainees also believed that engagement of the wider multidisciplinary team also has the potential to improve morale and educational opportunities (Figure 2).
The Shape of Training review30 emphasized the need for doctors to be able to provide broad-based care in a range of settings and a move towards holistic care. As a result of this paper and the need for radical changes to meet the needs of a changing population outlined in the Future Hospital report in 2013,31 specific learning modules have been developed for general medical and geriatric medicine trainees in peri-operative care. In both the core surgical and obstetrics and gynecology curricula in the UK there is as yet no specific section on the care of the older surgical patient.
Strengths and Limitations
Our study surveyed 666 junior doctors from across the UK and Ireland and therefore represents an estimated one-third of all trainees working in obstetrics and gynecology in these nations. This is the first survey of this kind in obstetrics and gynecology, and trainees of all grades were surveyed to give a true cross-sectional impression of trainees’ confidence and competence in this area. Regional representatives were enlisted to improve response rates. The response rate to this survey is similar to other web-based surveys.32 As the exact number of eligible trainees receiving the link via social media, email networks, and face-to-face meetings could not be accurately established, the response rate when measured against the actual number receiving the link may be significantly higher.
As with any survey-based study, it is limited by potential selection bias and non-response bias. In cases of partial non-response, we ensured that the presented findings were adjusted for the non-responders. While surveys relating to areas with the potential for quality improvement or the contribution to clinical knowledge are more likely to receive higher response rates,32 clinicians as a group tend to have very homogenous knowledge, behaviors, attitudes, and training.33 It has been suggested that variations that do exist are less likely to be associated with willingness to respond or the survey content and are more associated with time pressures.33
Conclusions and Recommendations
To improve patient outcomes, frail patients require a clinical team with the necessary skills and training to be able to recognize and manage their complex medical and social needs. Our study has highlighted that obstetrics and gynecology trainees lack proficiency and confidence in the peri-operative management of these patients. We have identified a need for: (1) routine use of validated frailty assessment tools in the peri-operative period to aid recognition of frailty in gynecological oncology patients; (2) incorporation of a specific training module on the management of older surgical patients into the national obstetrics and gynecology curriculum to ensure trainees are equipped with the knowledge and skills to manage an aging population; and (3) formal engagement of geriatricians and specialist frailty services in the management of these patients.
Acknowledgments
The authors would like to thank the UK Audit and Research Collaborative in Obstetrics and Gynaecology (UKARCOG) for assistance with distributing the survey.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @jamesybeirne, @drsadiejones, @RasiahBharathan
Collaborators All authors are part of the Audit and Research in Gynaecological Oncology (ARGO) Collaborative.
Contributors RB, GLO, VS, Y-LLW: designed and implemented the study, interpreted the data, drafted and revised the final manuscript. MA, JPB, DB, AC, RD, JD, MF, DF, NG, SH, NI, EJ, SEFJ, TK, EL, MO, LP, MPR, NR, PS, LS, MW, SW: acquired data via participant recruitment, revised and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request to gemma.owens@manchester.ac.uk.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.