In this study, we have demonstrated that basic surgical trainees are failing to meet modest targets for operative exposure as defined by the national body for surgical training in Ireland. Basic surgical training in Ireland at the time of this study was a 2-year programme comprising four 6-month training posts, of which at least two posts must be in general surgery and was designed to ensure trainees grasp basic surgical principles and are exposed to a range of specialities. To correct for variation in individual posts, we analysed the operative exposure of trainees throughout the full 2-year BST programme but the training targets outlined herein apply to individual (6-month) posts. The operative experience accumulated by the majority of trainees over the two-year period failed to meet the targets for an individual 6-month rotation alone. This clearly highlights a worrying lack of operative exposure amongst basic surgical trainees.
Basic surgical training in Ireland is similar to that in the United Kingdom and shares some features in common with programmes in Europe and the United States . Upon completion of basic surgical training, aspiring surgeons compete for entry into 6 years of specialty surgical training. Recent data from the United States has shown concerning deficiencies in the operative exposure of general surgical trainees upon the completion of training . Similar trends have recently emerged for senior trainees in general surgery [6, 7] and orthopaedics [8–11] from the United Kingdom. We have now shown that operative exposure during basic surgical training is sub-optimal. This is of particular importance as there is evidence that work hour restrictions in the United States affect the operative exposure of junior surgical trainees to the greatest extent compared with senior trainees [4, 5].
Our data shows, that while trainees may not achieve individual targets for operative procedures, their overall caseload is potentially sufficient to allow them to meet the majority of targets if they were given greater opportunity as the primary operator. Thus, the time spent as the assistant represents a missed opportunity for surgical training for junior trainees. Similar to our findings, analysis of orthopaedic logbook data from the United Kingdom has shown that there are significant missed opportunities for training in the operating room [8, 10, 11, 19] and this effect is greater the more junior the trainee . With challenges in the provision of operative exposure to trainees at all levels, it is possible that procedures traditionally performed by junior trainees have now shifted to more senior trainees.
Logbook data is validated by the individual consultant trainer responsible for the basic surgical trainee; however, we accept that some inaccuracies are likely to be present. It is difficult to quantify this but reports from the literature suggest up to 10% of the data recorded may contain inaccuracies  and ensuring completeness of data is likely to be an on-going challenge. Under-reporting of operative procedures may explain the relatively low number of certain common surgical procedures recorded, such as abscess drainage and wound debridement. It has been suggested that trainees under-report cases by up to 20% . Another possible source of inaccuracy may result from inappropriate recording of the trainee's role in the operation, or limitations of the logbook in recording specifically the operation that was ultimately performed. Furthermore, the logbook only records complete operations and does not recognize where the trainee performed specific elements of an operation even though they were not the primary operator. Indeed, a component-based approach to recording operative exposure may be more useful than crudely measuring numbers of procedures, particularly at junior trainee level and has been developed within the logbook for neurosurgical procedures.
The operative targets used in this study are entirely arbitrary and are defined by the national training body as a reasonable minimum requirement for trainees. These targets do not, however, give any indication as to an individual trainees' proficiency or competency and logbook data should be used as part of a global assessment framework rather than in isolation. While confirmed progression to proficiency would be preferable to quantity of procedures in determining progress through training, objective assessment of technical skill and proficiency in surgery is challenging. Logbooks have traditionally acted as a surrogate marker of proficiency, however it is clear that the level of operative exposure required for proficiency will vary greatly amongst individuals. Increasingly it is recognized that the use of surgical simulators allows not only the attainment of skills for commonly performed procedures but also the objective assessment of an individual's proficiency. Attainment of skills in a surgical simulation laboratory can shorten the learning curve and improve performance in the operating room [22–24]. The validation of simulation in surgical training marks a turning point and the potential now exists to train a surgical trainee to a high level of objectively measured skill before they are permitted to operate on a patient. A key aspect of surgical training in the future will be the adoption of a proficiency-based, progression training paradigm that encompasses objective structured assessment of technical skills in the simulation laboratory  and traditional logbooks of operative experience.
Work hour restrictions for residents were put in place by the Accreditation Council for Graduate Medical Education (ACGME) in the United States in 2003 (80 hours per week) and by the European Union as apart of the European Working Time Directive (EWTD) in 2009 (48 hours per week). A significant number of reports have examined operative volumes as a result of the restrictions, with conflicting results , with published studies demonstrating an improvement [27, 28], no change [28–30] or a decrease in operative exposure [4, 5, 31]. Limited evidence from the United Kingdom suggests that EWTD is adversely affecting trainee operative exposure in general surgery [7, 32] and also orthopaedics . This enforced change represents an opportunity to reconsider how surgical training at all levels is delivered to maximize training within the constraints of a shorter working week.