Wyn Griffith Lewis

Trust is defined as an assured reliance on the character, ability, strength, or truth of someone or something [ 1]. Few arenas hold interpersonal trust in higher regard than medicine. Trust underpins clinician–clinician and patient–clinician relationships, especially related to consent, where respect and mutual understanding are critical. Treatment-related morbidity, mortality, and accountability are increasingly subject to national scrutiny, with patients’ lives and doctors’ reputations on the line, and rightly so. Moreover, trust is crucial to all forms of social relationships, organizations, economic exchange, and political influence. Building lasting effective trust at work is critical in generating positive, high performing workplace cultures and teams. Trust stimulates collaboration, communication, and teamwork, promoting better professional outcomes. Paul Zak reported that compared with employees at low-trust companies, employees at high-trust companies showed 11% more empathy for workmates, 106% more energy at work, 70% more alignment with their companies’ purpose, 76% more engagement, 40% less stress, and 50% more productivity [ 2]. Similarly, few things damage teamwork more than a lack of trust. Patrick Lencioni, in his 2002 book, described a lack of trust as the foundation for five dysfunctions of a team [ 3]. Despite trust’s importance and delicate nature, it is legendarily elusive, famously intangible, and notoriously difficult to measure. Most metrics rely on surrogate measures such as psychological safety, esteem, collaboration, and engagement, all with significant overlap. Roderick Kramer [ 4] reported two contrasting images, or models, of organizational trust, rational and relational: the first model described trust as a rational choice, with individuals able to trust one another, provided they have sufficient reason to believe in each other’s self-interests in the outcome of the specific interaction in question. This model of trust, as a primarily cold, cognitive estimation, requires little more than the information needed to assess, or even manipulate, the interests of the parties involved. The second model described trust as a relational concept between trustor (an entity that creates and opens up a trust) and trustee (a synonym for anyone in a position of trust); an affective, intuitive, collective property relating to longer term interpersonal, intergroup, and intersociety perceptions and relationships. Arguably, this latter model considers social and emotional influences related to decisions of trust in a better way, and although complex, is more resilient and communal.

Neurotypicality (NT) and neurodiversity (ND) are two terms used to describe separate ways of thinking and experiencing the world. The prevalence of ND within surgery and allied professions is poorly studied or understood but is likely to be significant and increasing. If our aim is to be truly inclusive, ND's effects on teams and our willingness and ability to adapt adequately must improve.

Background: This study aimed to evaluate core surgical training (CST) differential attainment related to coronavirus disease 2019 (COVID-19), gender and ethnicity. The hypothesis was that COVID-19 adversely influenced CST outcomes. Methods: A retrospective cohort study of 271 anonymised CST records was undertaken at a UK Statutory Education Body. Primary effect measures were Annual Review of Competency Progression Outcome (ARCPO), Membership of the Royal College of Surgeons (MRCS) examination pass and Higher Surgical Training National Training Number (NTN) appointment. Data were collected prospectively at ARCP and analysed with non-parametric statistical methods in SPSS. Results: CSTs numbering 138 completed training pre-COVID and 133 peri-COVID. ARCPO 1, 2 and 6 were 71.9% pre-COVID versus 74.4% peri-COVID (P=0.844). MRCS pass rates were 69.6% pre-COVID versus 71.1% peri-COVID (P=0.968), but NTN appointment rates diminished (pre-COVID 47.4% vs. peri-COVID 36.9%, P=0.324); none of the above varied by gender or ethnicity. Multivariable analyses by three models revealed: ARCPO was associated with gender [m:f 1:0.87, odds ratio (OR) 0.53, P=0.043] and CST theme (Plastics vs. General OR 16.82, P=0.007); MRCS pass with theme (Plastics vs. General OR 8.97, P=0.004); NTN with the Improving Surgical Training run-through programme (OR 5.00, PP=0.014) with pan University Hospital rotations performing better than Mixed or District General-only rotations (OR 6.63, P=0.018). Conclusion: Differential attainment profiles varied 17-fold, yet COVID-19 did not influence ARCPO or MRCS pass rates. NTN appointment fell by one-fifth peri-COVID, but overall training outcome metrics remained robust despite the existential threat.

Personal protective equipment (PPE) adversely affects pulmonary gas exchange and may result in systemic hypercapnic hypoxaemia and headache. This study aimed to determine what extent PPE affects cerebral symptoms, global cerebral blood flow, and cognitive functional performance. Higher surgical trainees participated in a randomized, repeated-measures, crossover study, completing 60 min of laparoscopic surgical simulation in both standard operating attire and type 3 PPE. Measurements were collected at baseline and after 60 min of simulation. The primary outcome measure was headache. Headache was examined using the validated visual analogue scale (VAS) and Environmental Symptoms Questionnaire C (ESQ-C), global cerebral blood flow with duplex ultrasonography, and visuospatial and executive gross/fine motor function with grooved peg board (GPB) and laparoscopic bead (LSB) board tasks. Thirty-one higher surgical trainees (20 men, 11 women) completed the study. Compared with standard operating attire, PPE increased headache assessment scores (mean(s.d.) VAS score 3.5(5.6) versus 13.0(3.7), P < 0.001; ESQ-C score 1.3(2.0) versus 5.9(5.1), P < 0.001) and was associated with poorer completion times for GPB-D (61.4(12.0) versus 71.1(12.4) s; P = 0.034) and LSB (192.5(66.9) versus 270.7(135.3) s; P = 0.025) tasks. Wearing PPE increased heart rate (82.5(13.6) versus 93.5(13.0) beats/min; P = 0.022) and skin temperature (36.6(0.4) versus 37.1(0.5)°C; P < 0.001), but decreased peripheral oxygen saturation (97.9(0.8) versus 96.8(1.0) per cent; P < 0.001). Female higher surgical trainees exhibited higher peripheral oxygen saturation across all conditions. No differences were observed in global cerebral blood flow as a function of attire, time or sex. Despite no marked changes in global cerebral blood flow, type 3 PPE was associated with increased headache scores and cerebral symptoms (VAS and ESQ-C) alongside impaired executive motor function highlighting the clinical implications of PPE-induced impairment for cognitive–clinical performance.

Women constitute 62 per cent of UK medical school entries, yet the percentage in higher surgical training is half this (32 per cent), and the proportion of female consultants on the specialist register is only 14 per cent¹. Hidden curricula are subtle value-based lessons with moral undertones; they are absorbed without explicit intention but may perpetuate and boost existing disparities such as gender bias. Gender stereotypes continue to prevail in modern cultures, with female attributes considered warmer and more caring than the colder and more confident male behaviour. Moreover, straying from such traditional dogma can lead to negative perceptions. Microaggression is also prevalent, and defined as subtle insults and hostility toward minority stigmatized groups, including women². Infertility among doctors is high, with one in four female physicians experiencing conception difficulties, compared with the general population rate of 9–18 per cent³. Challenging on-call rotas and long geographical commutes can make pregnancy daunting. Female surgeons, in particular, have been reported to have significantly higher rates of infertility, with 32 per cent of a cohort of female US residents experiencing difficulties⁴. Arguably, higher infertility may be due to decisions to defer starting families until training has completed, and Rangel et al. reported that 65 per cent of studied female surgeons delayed pregnancy because of training-related concerns⁵. The average age for their first pregnancy was 33 years, compared with 31 years in controls, and the effect of age on fertility is well recognized. Moreover, miscarriage rates among female surgeons have been reported to be 42 per cent, double that of the general population⁵. Rates of pregnancy complications (intrauterine growth retardation, placental abruption, preterm labour, and low birthweight) have also been reported to be significantly higher in female surgeons, with 48 per cent suffering major morbidity, compared with 27 per cent in non-surgeon partners⁶. Pregnant surgeons also suffered higher rates of emergency caesarean section, musculoskeletal disorders, and postnatal depression. Operating for 12 hours or more per week during the third trimester of pregnancy was shown to increase morbidity 1.5-fold⁵. Mohan et al. reported that 27.1 per cent of UK and Republic of Ireland female surgeons felt unsupported during pregnancy⁷.