The making of a surgeon

Introduction 

Surgical training and education is under significant pressure in the changing environment in which surgery is being practiced today. In the past surgical training was undertaken on the basis of apprenticeship, but this is no longer credible or tenable in the current circumstances and there is a need for a clearly defined curriculum and training programme that will ensure surgical training is fit for purpose. Both trainers and trainees need to be aware of what is required of them at varying stages of surgical training and these criteria need to be defined for each of the surgical specialties. It is crucial that in a climate of change the essential requirements of surgical education are clearly defined and effectively delivered.

The fundamentals of surgical training 

There needs to be absolute clarity in the fundamentals of a surgical training programme. Therefore what are the essential components of training that are required in the making of a surgeon. These components should include:

All these fundamental components need to be addressed urgently to ensure their effective delivery as part of the responsibility of today’s trainers in order for the baton of surgical expertise to be passed onto the next generation and an environment created that will allow safe but innovative surgery to be performed. Advances in the art of surgery require that the next generation of surgeons are soundly taught and yet are encouraged to think innovatively and ‘outside the box’, while at all times keeping patient safety as the highest priority within their practice.

The selection process 

The debacle that surrounded selection into specialty training based on the Medical Training Application Service (MTAS), completely undermined confidence in the selection process and resulted in an erosion of morale amongst trainees. This prompted the Tooke report, an independent enquiry that called for a new and different engagement, in that all should be ‘Aspiring to Excellence’ when it came to medical/surgical training (see Russell, The Tooke Report and Government Response, this issue).

For the selection process to regain any credibility, it is imperative that selection is open, fair, transparent, impartial, sustainable and reliable. In some smaller specialties there is a desire to select on a national basis, while in the larger specialties, selection is at Deanery level. What is crucial is that there is a consistency of standards across the country, and this will require that selection is:

In order to achieve these criteria, selection centres have been suggested that will allow an in depth but fair assessment of all applicants in order for the best and most suitable candidates be selected into the generic specialty of surgery. It is highly likely that a further selection process will be required at year ST3 into the surgical specialties, although some specialties like neurosurgery want to select straight from foundation years. There is still a great deal to be done before all can have complete confidence in the selection process.

The learning environment 

In designing a postgraduate training programme for surgery, the principles of adult education need to be clearly understood. Such a curriculum must be explicit in its requirements but also allow for that essential combination of clinical experience and reflective practice. Any training scheme that focuses just on experience runs the danger of being simply service orientated, while a programme that is merely reflective is in reality mere pedantry – both extremes are unacceptable.

All too often the major concerns of trainees are the lack of sufficient time in the operating theatre and exposure to the right selection of clinical cases that are appropriate for their surgical specialty and their stage in training. In the past a trainee gained vast clinical experience by following cases through from presentation, to treatment and subsequent follow-up and noting any complications and their management en passant. However a trainee may now only see a patient at one stage of the pathway of care and this can fragment their learning experience. There is then a danger that a trainee will not be able to construct an experience based understanding of the course and management of a disease process and therefore their clinical practice will tend to be ‘book’ based and potentially inadequate.

Therefore at the outset of each stage of training, a learning agreement is created by the trainee and their assigned educational supervisor (AES). This includes the strategies required in order for the learning aims and objectives to be achieved by the end of the attachment. This may require some innovative planning on behalf of the AES and Programme Director (PD) to ensure that the trainee gets exposure to the correct clinical material. The learning process is largely trainee led and they are responsible for ensuring that they make the most of every training opportunity that arises. However the trainer has the responsibility for ensuring that these opportunities are provided.

An explicit surgical curriculum 

The Surgical Royal Colleges in the UK and the Joint Committee on Surgical Training have now developed the Intercollegiate Surgical Curriculum Programme which was designed to:

The major undertaking at the outset was to develop the standards and the basis for these standards. In order for these standards to be defined, surgical training was addressed in a modular manner looking at four blocks of training time, based on the current framework of training at the time (Figure 1). For each of these blocks of training time, explicit standards were defined in each module for:

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Figure 1. Curriculum Model: Progress through Seamless Training.

The defining of generic professional skills has been based on the ‘CanMeds’ model (Figure 2) which has been developed by the Royal College of Physicians and Surgeons of Canada. They defined 7 key roles for a doctor, with the concept of a Medical Expert at the centre covering the surgical specialty aspects of the curriculum as described above. The other aspects of the role cover such generic skills as:

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Figure 2. The CanMeds model.

These generic professional skills correspond closely to those laid out by the UK General Medical Council in their publication Good Medical Practice.

The curriculum is now an interactive web-based operation. The web-site clearly lays out what is required from a trainee at each stage and for each specialty, and trainers and trainees use this to identify and plan learning agreements. It provides a record of progress, promotes reflective practice, allows planning of learning opportunities and records outcomes of assessments. It is of necessity trainee driven with triggered assessments and an annual review for competency progression (ARCP), in which the learning agreement is reviewed and the results of the assessments examined before a trainee is able to progress.

Trained trainers 

Faculty development is essential to underpin such a programme, and therefore trainers should be fully equipped with specialist knowledge, surgical skills, an appropriate understanding of surgical education, a clear and detailed knowledge of the curriculum relating to their specialty, and then the time and resources to deliver the package. It is likely that in the future not all ‘consultant surgeons’ will be assigned as educational supervisors. However all will have a role in education and training in the capacity of being the ‘man on the spot’ and taking every opportunity to make a clinical case a learning experience.

The time factor is a major issue with regard to faculty availability. For those involved as assigned educational supervisors, it is essential that time for training is written into job plans, otherwise it will be engulfed within the enormous pressure of clinical practice. It is recognized that a vast amount of learning can and does go on during regular clinical practice without additional time being allocated for education, but it is essential that a properly constructed educational curriculum is supported by the necessary infrastructure for its delivery and that this is audited on a regular basis to ensure that it is delivering to the required standard. Such quality assurance is necessary for the credibility of the process and for external scrutiny.

An objective assessment of competency progression 

One of the major challenges in surgical training today is as to what constitutes competency and how is competency progression reliably assessed. Competency is very situation specific and time related, and is therefore a moving target. Competences need to be defined within a curriculum for each surgical specialty and for each stage in a training programme. This requires each surgical specialty to identify these competences, and then to declare explicitly what a trainee should know, be able to do and the conditions that they should be able to manage for each stage of their training.

Trainees will then be assessed in the workplace to ascertain their competency progression. This assessment will utilize a number of generic and specialty specific assessment instruments and their use will vary depending on whether the trainee is in core or specialty training. In the earlier stages of training the assessment tools will be similar to those used in foundation years, namely:

As the trainee progresses into specialty training, DOPS is replaced by PBA (Procedure Based Assessment) which involves direct observation of surgical skills such as endoscopy, biopsy, minor surgical procedures or parts of procedures. Specialty PBA is a more advanced tool which is applicable during specialty training and involves observation of intermediate and advance surgical procedures such a total hip replacement, laparoscopic cholecystectomy etc. Trainers should be allotted adequate time for these assessments and trained in the use of these instruments in which trainees are scored according to clearly defined criteria.

Once a year each trainee will undergo an annual review of competency progression (ARCP). This will review an individual’s portfolio (logbook), the outcome of their assessments, and progress against the learning agreement. A trainee’s progression is therefore dependent on the outcome of the ARCP.

Conclusion 

The UK Intercollegiate Surgical Curriculum went live in August 2007, and now has over 15,000 registered users including assigned educational supervisors, programme directors, clinical supervisors as well as approximately 3,500 validated trainees. This latter number is due to increase as currently the curriculum is only rolled out to trainee years 1-3, but as they progress it will cover all 6 years of training. Inevitably there have been ‘teething problems’ but as more and more trainees and trainers become familiar with the programme and the web site, the greater the value of the curriculum is being recognized.

The ‘Making of a Surgeon’ therefore involves preparing the trainees of today not only to practice innovative and safe surgery in the future, but also to be the trainers of tomorrow and to enable them, to further pass on the baton of the profession to the generations of the future.