INTRODUCTION:Upon graduation, newly qualified doctors are expected to manage complex and unwell patients, and adapt their prior learning to navigate an often-nuanced healthcare workplace environment. Surgical rotations can bring a unique set of learning curves and challenges to this already demanding transitional period. The aim of this study was to identify the training needs of medical students and early-career doctors in surgical skills, incorporating viewpoints from all stakeholder groups to provide a holistic insight into the provision of surgical education currently, and how it can be optimized to improve work preparedness. METHODS:Final-year medical students, interns and clinical educators from five clinical schools affiliated with the University of Melbourne were recruited for semi-structured interviews. Following transcription, multi-phased thematic analysis was performed to identify key themes. RESULTS:Thirty-seven participants were interviewed (18 students, 8 interns and 11 clinical educators). Outside of commonly utilized procedural skills, different emphases were placed on non-technical skills by students and interns, compared to clinical educators. Increased hands-on learning and structured teaching were thought to be key to increasing confidence and work preparedness. CONCLUSION:This qualitative study interviewed key stakeholders to identify important skills in order to help newly qualified interns to thrive in a surgical rotation. These skills in particular included more supervised hands-on practical teaching. Future studies involving graduates from other medical schools may provide a better understanding of surgical education in the wider Australian context.

BACKGROUND:Acute biliary pain is the most common presentation of gallstone disease. Untreated patients risk recurrent pain, cholecystitis, obstructive jaundice, pancreatitis and multiple hospital presentations. We examine the outcome of implementing a policy to offer laparoscopic cholecystectomy on index presentation to patients with biliary colic in a tertiary hospital in Australia.METHODS:This is a retrospective cohort study of adult patients presenting to the emergency department (ED) with biliary pain during three 12-month periods. Outcomes in Group A, 3 years prior to policy implementation, were compared with groups 2 and 7 years post implementation (Groups B and C). Primary outcomes were representations to ED, admission rate and time to cholecystectomy.RESULTS:A total of 584 patients presented with biliary colic during the three study periods. Of these, 391 underwent cholecystectomy with three Strasberg Type A bile leaks and no bile duct injuries. The policy increased admission rates (A = 15.8%, B = 62.9%, C = 29.5%, P < 0.001) and surgery on index presentation (A = 12.0%, B = 60.7%, C = 27.4%, P < 0.001). There was a decline in time to cholecystectomy (days) (A = 143, B = 15, C = 31, P < 0.001), post-operative length of stay (days) (A = 3.6, B = 3.2, C = 2.0, P < 0.05) and representation rates to ED (A = 42.1%, B = 7.1%, C = 19.9%, P < 0.001). There was a decline in policy adherence in the later cohort.CONCLUSION:Index hospital admission and cholecystectomy for biliary colic decrease patient representations, time to surgery, post-operative stay and complications of gallstone disease. This study demonstrates the impact of the policy with initial improvement, the dangers of policy attrition and the need for continued reinforcement.

Hepatorenal syndrome (HRS) is a life-threatening yet potentially reversible cause of renal dysfunction occurring in patients with advanced cirrhosis, ascites, and liver failure.1 It is characterized by functional renal impairment due to renal arterial vasoconstriction in the setting of major disturbances in circulatory function.1, 2 There are two forms of HRS: type 1 is characterized by an acute progressive decrease in kidney function with a median survival time of 2 weeks without treatment, whereas type 2 features more stable and less severe kidney failure and longer survival compared with type 1.3 Liver transplantation remains the only effective long-term therapy for HRS.4 Pharmacologic treatment with vasoconstrictors targeted to reverse splanchnic vasodilation, together with albumin, is effective in reversing renal dysfunction in 34%-44% of patients with type 1 HRS and improves survival in this group.4, 5 The European Association for the Study of the Liver (EASL) recommend terlipressin (1 mg/4-6 hourly as intravenous bolus) together with albumin as first-line treatment for patients with type 1 HRS.6 Traditionally, this is done as an inpatient where cardiovascular parameters can be monitored. Multiple case reports now exist describing continuous terlipressin infusion as an alternative to intravenous bolus administration,7, 8 with similar efficacy and often using a lower total dose, representing a potential cost saving.7 We present the first reported case of an outpatient continuous terlipressin infusion for treatment of recurrent HRS as a bridge to successful liver transplantation. A 59-year-old man with Child-Pugh C cirrhosis due to previous alcohol consumption complicated by recurrent encephalopathy, diuretic-resistant ascites, and hepatocellular carcinoma was admitted to our unit with a rapid deterioration in renal function. This was on a background of three recent admissions with type 1 HRS. On each previous occasion he was treated successfully with bolus administration of terlipressin as per EASL guidelines, resulting in a return of his renal function to baseline (Fig. 1). A terlipressin infusion, consisting of 3 mg terlipressin in 50 mL 5% dextrose delivered by a GemStar pump at a rate of 2.1 mL/h through a peripherally inserted central venous catheter was begun. Dextrose was chosen as the solute based on evidence that it was superior to normal saline at maintaining optimal pH for terlipressin.9 The patient initially received a terlipressin infusion as an inpatient, enabling the dose to be titrated and the patient to be screened for complications. During this time the patient's serum creatinine returned to his baseline level (Fig. 1). On day 6 the patient was discharged home with an ambulatory terlipressin infusion under the supervision of our Hospital-in-the-home program. The patient was reviewed in an outpatient clinic twice per week and had renal function monitored at each visit. This continued for a further 22 days at which time the patient underwent successful liver transplantation. Both outpatient terlipressin infusion and inpatient bolus terlipressin were well tolerated by our patient with no adverse effects noted; larger studies would address whether there is a difference in overall adverse events between the two modes of delivery. Posttransplantation, a renal-sparing immunosuppression regimen consisting of basiliximab, mycophenolate mofetil, and low-dose tacrolimus was implemented. The patient was discharged 10 days posttransplantation with a serum creatinine of 117 μmol/L and has remained stable to day 120 postoperation (Fig. 1). Liver transplantation remains the mainstay of therapy for type 1 HRS; however, vasoconstrictor therapy with terlipressin is recognized as an effective short-term treatment.4, 5 Terlipressin is traditionally given using a bolus regimen in a hospital setting. This case illustrates the successful use of a continuous outpatient terlipressin infusion in a patient with type 1 HRS over a 4-week period as a bridge to liver transplantation, demonstrating that in the appropriate clinical scenario and under close supervision, outpatient terlipressin is feasible, and in this case efficacious and well tolerated.