Improving Surgical Training

Improving Surgical Training is a programme piloting an innovative, evidence-based approach to training. It was developed in response to the Shape of Training report which reviewed postgraduate training and recommended changes in medical education to meet the demands of the modern NHS. A series of initiatives have been developed to enhance the experience for surgical trainees not only to encourage a more focussed and supported method, but also to improve their job satisfaction. The initiatives have combined a greater emphasis on time for training provided by trainers with allocated time for training with multidisciplinary teamworking and the use of technology enhanced learning with simulation of both technical and non-technical skills. The pilot started in 2018 with core training in general surgery and has been expanded to include vascular surgery, urology and trauma and orthopaedics over the last 2 years. Initial feedback from both trainees, trainers and schools of surgery have identified different challenges to aid implementation. The programme is being very carefully evaluated by an independent company as well as careful oversight by the General Medical Council which are paramount to its success.     

Simulation for early years surgical training

The shift from traditional apprenticeship models to competency-based curricula, compounded by working hour restrictions and rapid advances in surgical technology, has altered the delivery of early years surgical training. Simulation has been widely incorporated in other high-risk, high-reliability industries, but it has only just begun to be embedded in surgical programmes over the last two decades. In this article, we review key concepts in surgical simulation. Using Scotland's Core Surgical Training Programme as an example, we demonstrate the implementation of these concepts into a national integrated simulation strategy for early years surgical training. We highlight other global examples of simulation use in surgical curricula. The key messages for all stakeholders in surgical training are: (i) simulation is an adjunct to clinical training; (ii) simulation is a tool; however, it is not the tool that should be the main object of interest, but the learning for which it is used; and (iii) in the absence of a constructively aligned and purposeful programme that is valued by trainees, trainers and the training system, it is not enough to issue the kit, no matter how good the simulators are.     

Role of simulation in surgical education and training

There are several challenges facing surgical education and training that simulation may help to address. A conceptual framework is required to allow the appropriate application of simulation to a given level and type of surgical skill and this should be driven by educational imperatives and not by technological innovation. Simple simulation is required for core skills training. Cognitive simulation is introduced as a way in which procedural skills training can be achieved. Virtual world simulation opens up significant opportunities for team skills training. A role for simulation in surgical education and training appears assured, but its success will be determined by the extent to which it is integral to high quality curricula, its importance determined by its contribution to both learning and assessment, and its sustainability determined by evidence of its advantages and cost‐effectiveness.     

Simulation‐based surgical education in cardiothoracic training

Simulation has emerged as a feasible adjunct to surgical education and training for most specialties. It provides trainees with an immersive, realistic way to learn a variety of skills in a safe environment with the end goal of improving patient safety. There are three broad types of simulators: full mannequin simulators, part‐task trainers or bench models and virtual reality systems. This review aims to describe the current use of simulation in cardiothoracic surgical education and training. We identified multiple procedures that can be simulated in cardiothoracic surgery using a combination of the above simulators, three‐dimensional printing and computer‐based simulation. All studies that assessed the efficacy of simulators showed that simulation enhances learning and trainee performance allowing for repetitive training until the acquisition of competence but further research into how it translates into the operating theatre is required. In Australia, cardiac surgery simulation is not yet part of the training curricula, but simulators are available for certain tasks and procedures.     

The surgical care practitioner: a dual perspective

The ongoing balance of service delivery and training offset with the European Working Time Directive has resulted in a requirement to review the surgical workforce and new ways of working. The extended surgical team can be utilized to support the delivery of surgical services. Surgical care practitioners are trained to care for surgical patients across the whole patient pathway: in clinics, theatre and on the ward. They are continual members of the surgical team and can support both the service and training due to the flexible nature of the role. This article gives an overview of the role of the surgical care practitioner (SCP) and how the role impacts surgical training.     

The extended surgical team

The extended surgical team encompasses a variety of non-medical healthcare practitioners who work alongside junior doctors in delivering care to patients. In large part, their roles have developed in response to workforce shortages and working time changes. A variety of roles exist including Physician Associates, Surgical Care Practitioners, Advanced Clinical Practitioners and Surgical First Assistants. These roles have different training pathways and different regulators. They work across the emergency and elective surgical patient pathway with some roles being primarily theatre based. There is evidence that they enhance training for junior surgical trainees by enabling better attendance at daytime training sessions in the operating theatre and the outpatient clinic. They also appear to be well received by patients.     

Learning the surgical craft: a review of skills training options

Surgical practice is undergoing fundamental changes, and this is having a significant effect on the training of surgeons. Learning the craft of surgery is threatened by reduced elective operative exposure and general service cuts within public teaching hospitals, safer working hour legislation and pressures to accelerate the training of young surgeons. Rapid technological changes mean that 'old dogs' have to teach 'young dogs' many new tricks in a relatively adverse environment. This review outlines the great variety of resources available for skills-based training outside the operating room. These resources are ready to be used as a necessary adjunct to the training of competent surgeons in Australasia.     

Caseload in rural general surgical practice and implications for training

Background : Despite increasing specialization within general surgery, many general surgeons, particularly in rural practice, continue to treat a wide range of conditions. The aim of the present paper was to provide accurate information on three rural surgeons’ caseloads to illustrate the spectrum of surgery encountered and to assist in the planning of rural general surgical training. Methods : A review was conducted of a prospectively maintained database of operations performed by three rural general surgeons in different parts of Victoria, Australia over a 5‐year period. Results : A large volume and wide range of procedures was performed by each surgeon, who averaged more than 500 operations per year (excluding endoscopies). Although most were within the range of procedures covered in the Royal Australasian College of Surgeons (RACS) Fellowship in general surgery, some encroached upon other specialties such as orthopaedics, urology, paediatric surgery and obstetrics/gynaecology. Operations outside of ‘general’ surgery reflected individual training and local community needs. Conclusions : The current RACS Fellowship in general surgery, augmented by training in other specialties as required, will help prepare general surgeons for rural practice.     

Novel method for assessment and selection of trainees for higher surgical training in general surgery

The aim of the study was to select surgeons for a higher surgical training in general surgery programme at the Royal College of Surgeons in Ireland (RCSI) using an objective, transparent and fair assessment programme. Thirty-two individuals applied for higher surgical training in general surgery in Ireland in 2006. Sixteen applicants were short-listed for interview and further assessment. All applicants were required to report on their education performance at undergraduate level and their postgraduate professional development. Applicants were scored on their training record during basic surgical training, structures references, clinical experience, approved technical skills courses, validated logbook and consolidation sheet. Assessments of their research and academic surgery included, the award of a higher degree by thesis, and other surgically relevant degree's or diplomas that had been obtained through part-time studies and were awarded by educational establishments recognized by RCSI or the Irish Medical Council. Short-listed applicants completed validated objective assessment simulations of surgical skills, an interview and assessment of their suitability for a career in surgery. The nine individuals who were selected for higher surgical training in general surgery consistently scored higher than those candidates who were not, in post-graduate development (P < 0.001), surgical skills (P < 0.002), interview scores (P < 0.007) and suitability for a career in surgery (P < 0.002). All performance assessment elements except undergraduate education showed high internal reliability alpha = 0.89 and good statistical power (range 0.95-0.99). The statistical power of undergraduate education was 0.7. The objective assessment programme introduced by RCSI for selection of candidates for the programme in higher surgical training in general surgery reliably and consistently distinguished between candidates. Candidates selected for further training consistently outperformed those who were not in good concordance between measures. This common selection process for higher surgical training is now being rolled out for selection into higher surgical training across all surgical specialties in Ireland.     

Pediatric surgical training: an historic perspective, a formula for change

Background/purpose

American pediatric surgical education has more than a 65-year history of formalizing the organization and the curriculum of the training process. However, never before have so many simultaneous internal and external forces appeared on the horizon that have the collective potential of influencing the quality of future pediatric surgeons. It is the purpose of this study to identify and detail these opportunities, compare them with the historical past, and propose the beginnings of a strategy to control the destiny. The ultimate goal should be to continue to assure that pediatric surgeons are of the highest attainable quality that will optimize the surgical health of America’s children.

Methods and results

Using a current literature review, 7 specific influencing forces have been identified: a declining applicant pool, the generation-X factor, medical economics, early specialization of training, restricted residency work hours, pediatric surgical manpower, and competency-based surgical education. An effective response to these forces is multifactorial, but a first need might be consideration of a new educational oversight organizational structure for pediatric surgery. Thereafter, specific curricular reform is needed to match the strengths of the candidates as well as the training programs. Finally, as a specialty field we must assert the leadership needed to define optimal educational outcomes.

Conclusions

This report defines the educational history and the contemporary influencing forces, and it proposes a strategy to assure that pediatric surgical education exceeds the needs of America’s children into the future.     

Military trauma training performed in a civilian trauma center

BACKGROUND: In 1996, Congress passed legislation requiring the Department of Defense to conduct trauma training in civilian hospitals. In September of 1998 an Army team composed of surgeons, nurses, emergency medical technicians (EMTs), and operating room technicians (OR techs) trained in a civilian level 1 trauma center. This study analyzes the quality of the training. METHODS: The training period was 30 days. Before and after training all members completed a questionnaire of their individual and team ability to perform at their home station, at the civilian hospital, and in the combat setting. Surgeons maintained an operative log, which was compared with their prior year's experience. Primary trauma cases (PTCs) met Residency Review Committee criteria as defined category cases and were done acutely. Other personnel tracked the percentage of supporting soldier tasks (SSTs) they performed or were exposed to during the training period. RESULTS: Review of the questionnaires revealed a significant increase in confidence levels in all areas tested (P < 0.005). The three general surgeons performed a total of 42 PTCs during the 28 call periods, or 1.5 PTCs per call period. During the prior year, the same three general surgeons performed 20 PTCs during 114 call periods for 0.175 cases per call period (P = 0.003). The maximum number of PTCs performed during one call period at the civilian center was 4, compared with 5 PTCs performed by one Army surgeon during the Somalia 1993 mass casualty event. Performance of or exposure to SSTs was 71% for the EMTs, 94% for the nurses, and 79% for the OR techs. CONCLUSIONS: A 1-month training experience at a civilian trauma center provided military general surgeons with a greater trauma experience than they receive in 1 year at their home station. Other personnel on the team benefited by performing or being exposed to their SSTs. Further training of military teams in civilian trauma centers should be investigated.     

Postgraduate surgical education and training in Canada and Australia: each may benefit from the other's experiences

Canada and Australia share similar cultural origins and current multicultural societies and demographics but there are differences in climate and sporting pursuits. Surgeons and surgeon teachers similarly share many of the same challenges, but the health care and health-care education systems differ in significant ways. The objective of this review is to detail the different postgraduate surgical training programs with a focus on general surgery and how the programs of each country may benefit from appreciating the experiences of the other. The major differences relate to entry requirements, the role of universities in governance of training, mandatory skills courses in early training, the accreditation process, remuneration for surgical teachers and the impact of private practice. Many of the differences are culturally entrenched in their respective medical systems and unlikely to change substantially. Direct entry into specialty training without an internship per se is now firmly established in Canada just as delayed entry after internship is mandated by the Australian Medical Board. Both recognize the importance of establishing goals and objectives, modular curricular and the emerging role of online educational resources and how these may impact on assessments. The Royal Australasian College of Surgeons is unlikely to cede much responsibility to the universities but alternative academic models are emerging. Private health care in the two countries differs, but there are increasing opportunities for training in the private sector in Australia. In spite of the differences, both provide excellent health care and surgical training opportunities in an environment with significant fiscal, technological and societal challenges.     

Modular surgical training for endoscopic extraperitoneal radical prostatectomy

OBJECTIVE: To develop a modular training scheme which enabled the use of individual steps of laparoscopic radical prostatectomy (RP) for teaching and training surgeons with varied experience, including residents with no experience in open RP, as in extending laparoscopic surgery to more complex operations like RP, the proper training of urologists is crucial. SUBJECTS AND METHODS: The technique of endoscopic extraperitoneal RP (EERP) was divided into 12 individual steps of differing complexity. The levels of difficulty were called "modules" and graded according to their requisite skills from module 1 (lowest level of difficulty) to module 5 (highest level). Based on this modular system we established a training programme whereby the trainee learns the procedure in a mentor-initiated schedule. During each training operation the trainee only performs the modules (steps) of the operation, which correspond with his or her actual skill level. The mentor performs all the other steps, with the trainee assisting. Four trainees with different surgical experience participated in the study. RESULTS: After a phase of assisting and camera holding during EERP, the trainees entered the modular training programme and required 32-43 procedures until they were considered to be competent. An analysis of the first 25-50 procedures done independently by the trainee showed mean operative times of 176-193 min and a transfusion rate of 1.3%. Complications during and after EERP requiring re-intervention were one each of recto-urethral fistula, haemorrhage, symptomatic lymphocele and anastomotic leak. The positive margin rate for pT2 disease was 12.2% and for pT3 tumours 37%. CONCLUSION: The modular concept for teaching EERP is an attractive concept, which overcomes many of the problems involved in complex laparoscopic procedures. Based on a highly standardized technique, this concept offers a short learning curve; it enables training on different sites in cooperation with a high-volume centre, and it makes it possible to start with this complex procedure as a beginner or with no experience in open RP.     

Mentoring in surgical training

Surgical mentors have helped trainees develop fulfilling and academically productive careers, while supervisors are formally assigned to impart skills and oversee training. This paper reviews the comparative roles of the supervisor and mentor and how they overlap, while exploring the impact of the ‘unknown’ mentor. While the supervisor's role in directing the student is formally recognized, the mentee will personally select a mentor who successfully models the career and life balance to which the mentee aspires. The unknown mentor is known only to the mentee. The mentee's commitment to communicating with both mentor and supervisor is crucial to success. Better processes can be used to guide the mentor relationship. Confusion between the two roles – mentor and supervisor – is due to their complementary nature as well as an overlap in roles. Both remain essential to the growth and development of the surgical trainee. The unknown mentor could give detached advice and guidance to the student, while acting as a positive role model.     

Workplace‐based assessment: assessing technical skill throughout the continuum of surgical training

The Royal Colleges of Surgeons and Surgical Specialty Associations in the UK have introduced competence‐based syllabi and curricula for surgical training. The syllabi of the Intercollegiate Surgical Curriculum Programme (ISCP) and Orthopaedic Curriculum and Assessment Programme (OCAP) define the core competencies, that is, the observable and measureable behaviours required of a surgical trainee. The curricula define when, where and how these will be assessed. Procedure‐based assessment (PBA) has been adopted as the principal method of assessing surgical skills. It combines competencies specific to the procedure with generic competencies such as safe handling of instruments. It covers the entire procedure, including preoperative and postoperative planning. A global summary of the level at which the trainee performed the assessed elements of the procedure is also included. The form has been designed to be completed quickly by the assessor (clinical supervisor) and fed‐back to the trainee between operations. PBA forms have been developed for all index procedures in all surgical specialties. The forms are intended to be used as frequently as possible when performing index procedures, as their primary aim is to aid learning. At the end of a training placement the aggregated PBA forms, together with the logbook, enable the Educational Supervisor and/or Programme Director to make a summary judgement about the competence of a trainee to perform index procedures to a given standard.