Adapting for the future: flexibility of UK postgraduate training

Postgraduate surgical training has undergone repeated reforms alongside changes in terms of employment. The broad structure of progression from Foundation years through core and specialist training to the award of a Certificate of Completion of Training is likely to continue for the foreseeable future. Technological developments including robotics, genomics and artificial intelligence together with an extension of the surgical team are likely to alter dramatically the nature of surgery in the future. Surgical training will need to incorporate training in new technologies, including simulation, which will be provided in the workplace, academic institutions and commercial facilities. There will be greater emphasis on non-technical skills and human factors, especially in relation to the use of new technologies and working in wider teams, including non-medical staff. Genomics will play an increasing role in determining individualized patient care, with a need for surgeons to have an understanding of this field and communicate this to their patients. Surgical training will need to be suitably flexible in order to accommodate these developments, to allow more part-time working and portfolio careers, and to encourage recruitment and retention.     

Advanced Imaging Technology in Surgical Innovation

ABSTRACT

Advanced imaging technologies including computed tomography (CT) and magnetic resonance imaging (MRI) have immensely expanded possibilities in imaging and surgery. The accurate visualization of bones and soft tissue has transformed the surgical management of numerous diseases, including middle ear disease, orthopedic and reconstructive cases, and cancer. In fact, in surgical subspecialties such as neurosurgery, CT and MRI are the diagnostic modalities of choice for preoperative evaluation of patients. Furthermore, the ongoing development of the newer imaging technologies continues to expand image-guided surgical treatments. The development of new radiological modalities combined with the modern training of surgeons will provide an exciting landscape for future practicing physicians.     

Formal training in advanced surgical technologies enhances the surgical residency

INTRODUCTION: Surgeons have been consistently instructed to use better tools by which to improve upon a patient's medical care. Since the first laparoscopic cholecystectomy, the desire for advanced surgical technologies has continued. This surgical breakthrough has been one of many changes in modern surgical and medical therapy that now represents the standard of care. The aim of this article is to examine the changes in surgical technologies that occurred in the past 15 years, evaluate the possible solutions that have been discussed and formally present the results of a formal training rotation in advanced surgical technologies at the University of Louisville, Department of Surgery. METHODS: Questionnaires were sent to 36 former residents who had completed the residency and the advanced surgical technologies rotation to evaluate the success of their training. RESULTS: From its inception in 1998 to 2004, the residents have performed a total of 1097 procedures, or an average of 35 cases per month. Much of the exposure was gained in advanced laparoscopy, including laparoscopic nissen fundoplication, gastric band, gastric bypass, splenectomy, colon resection, small-bowl resection donor nephrectomy, and hepatic ablation. Similarly, an evaluation of the 2 procedures that in the late 1990s were considered advanced surgical procedures--sentinal node biopsy and endovascular procedures--shows that the number of these procedures performed on this rotation has fallen over the past 2 years. The overall impression of the rotation from these former residents was either integral or essential in 70% and was helpful in 20%. CONCLUSION: The number of demands impacting medical education have never been this numerous or complex. The rapid advances in science, systems, and information technology provide numerous advances in surgical training that continue to be the requirement and responsibility of general surgical training. The cultural changes in surgery include the team approach to provide services in surgical technologies, focus on the aging population, and outcomes assessment. The learning curve, for any and all of these procedures, is inevitably steep, and traditional resident training too often focuses on the more conventional procedures done in routine rotations. The need for formal training in advanced surgical technologies continues to be of utmost importance in these rapidly evolving times.     

New Technologies for the Surgical Curriculum

The aim of a surgical residency program is to produce competent professionals displaying the cognitive, technical, and personal skills required to meet the needs of society. Current changes to the delivery of healthcare necessitate the development of new models of training. These can be supported with the development of new technologies to train and assess surgical practitioners. This article describes recent developments within Imperial College London with regard to eye tracking, noninvasive brain imaging, and an innovative mentoring scheme for the new surgical curriculum. The concept of eye tracking is described, together with surgical application for this technique in terms of dexterity analysis during minimally invasive procedures. We have also begun to understand spatial localization within the brain cortex during surgical knot-tying tasks. The aim is to develop a map of the cortex with regard to surgical novices and experienced surgeons and then to develop the hypothesis that a translational process of cortical plasticity occurs during training. Finally, the article is intended to describe a training scheme that goes beyond dexterity, and moves toward the development of a successful surgeon through surgical mentoring. It is hoped that some of these tools will enhance the training of future surgeons in order to continue to provide a high-quality service to our patients.     

Anatomical endoscopic enucleation of the prostate: The next gold standard? No! (or not yet!)

Most cases of lower urinary tract symptoms due to benign prostatic hyperplasia are initially managed through medical therapy. In cases that surgery is indicated, the anatomical endoscopic enucleation of the prostate (aEEP), first described in 1983, allegedly presents the same safety profile as the best endoscopic non-enucleating procedures and the same long-term functional outcomes as simple prostatectomy. Thus, why aEEP has not yet been consolidated as the gold-standard BPH surgical treatment? The main reasons are as follows: (a) Multiple energy sources and techniques; (b) High costs; (c) Steep learning curve; (d) Rare in-residency training; (e) Reimbursement issues; (f) Outcomes and (g) Complications. We do believe aEEP is an important advance and a “practice-changing” procedure that will play an important role in the BPH surgical options arsenal, especially for larger prostates. However, there is a need to start an in-residency training program, with a mentor guidance, and, over time, the cost will likely be reduced due to greater competition between companies and greater support from health insurers. Considering these points, in the future, EEP may be considered the gold-standard treatment for BPH… but not yet.     

Technical competence in surgeons

In this paper, we review the literature to date on technical competence in surgeons; how it can be defined, taught to trainees and assessed. We also examine how we can predict which candidates for surgical training will most likely develop technical competence. While technical competency is just one aspect of what makes a good surgeon, we have recognized a need to review the literature in this area and to combine this with broader definitions of competency. Our review found that several methods are available to objectively measure, assess and predict technical competence and should be used in surgical training.     

ASERNIP‐S: unusual acronym,outstanding results

In the late 1990s, concerns regarding the introduction of new surgical procedures arose following the rapid uptake of some minimally invasive procedures. At that time, the evidence was not clear on the safety and effectiveness of these new procedures, and it was recommended that data be collected to look at both short‐ and long‐term outcomes. Based on a UK group, ‘the Safety and Efficacy Register of New Interventional Procedures (SERNIP)’, the Australian SERNIP was born under the auspices of the Royal Australasian College of Surgeons, with ‘‐S’ added to the acronym to highlight the focus on surgery. ASERNIP‐S was established to review the evidence on new interventional procedures before their introduction into the Australian healthcare system. The programme operated with initial national government funding for 7 years. Following establishment of the Medical Services Advisory Committee, ASERNIP‐S became a contractor and remains so today. ASERNIP‐S was an also an early adopter of Horizon Scanning, a key activity informing of new procedures/technologies on the verge of introduction into our healthcare system. A strong international reputation of ASERNIP‐S is recognised, both by lead roles of international networks and in working relationships with overseas agencies. In recent years the remit of ASERNIP‐S has expanded to include research and evaluation services across the Royal Australasian College of Surgeons (including committees) and for Specialty Surgical Societies. Externally funded work is growing, including for the Federal Office of Public Health in Switzerland and the Ludwig Boltzmann Institute in Austria. It is unknown what the future will be for this unusually titled programme, but its long history in promoting and supporting surgical evidence and innovation is clear.     

Identification and management of the underperforming surgical trainee

Most surgical trainee make steady progress, delivering a safe and reliable service at an appropriate level at the same time as they as learn new skills under supervision. Trainees learn at different rates, and progress that is safe and steady although slower than the norm should not be classed as underperformance. Clinical performance issues may arise at any stage of a doctor’s cancer, and should be addressed promptly and constructively. Factors that may impact on performance, such as the personality of the trainee, their personal pressures, and the training and working environment, should be considered and where possible mitigated. Enhanced supervision; regular constructive feedback; psychological support; coaching and mentoring may all be required. A change of trainer or working environment may sometimes be necessary, and the duration of training may need to be extended. A supportive working and learning environment with a sound educational framework will help to ensure that trainees in difficulty are identified early and managed supportively and constructively.     

Surgical training 2.0: How contemporary developments in information technology can augment surgical training

BackgroundThe current surgical trainee is faced with reduced training time compared to predecessors as a result of changes in working practices. The past decade has seen marked developments in the information technology sector. This editorial will review how modern technological innovations could augment current surgical training.MethodsWe review the literature and summarize important developments in information technology that could assist the modern surgical trainee. We also look at some of the challenges faced by use of this technology.FindingsDevelopments in mobile internet connectivity will improve access to online resources for the surgical trainee. Web 2.0 will revolutionise the way trainees interact with textbooks, journals, webpages and each other. Simulators could help to fill gaps created by reduced operating hours. To maximize the effectiveness of these resources they need to be accessible and incorporated into training in a structured way, ensuring patient safety and accuracy of information.ConclusionContemporary developments in technology offer benefits to the surgical trainee and could fill gaps left by reduced operating times. In order to ensure efficient use of technology and patient safety, bodies such as the Royal Colleges and Training Programmes must embrace these developments.     

Training of general surgical residents: what model is appropriate?

The training of general surgical residents has been a relatively stable process for the past several decades. However, a variety of forces have caused several recent changes in the education of general surgeons and more potentially radical alterations have been recommended by some surgical leaders. Much of the initiative for changing training is due to the inexorable forces of specialization and the increasingly vigorous competition for qualified trainees in various surgical disciplines. Decisions made within the next few years will likely decide the future of general surgery as a specialty.     

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.     

Increased working hours,simulation technology or competency based progression? What is the solution for surgical training?

Surgical training has changed in recent years. Surgical-skill training is considered suboptimal as early as medical school. Changes to medical team structure and societal demographics have also negatively impacted training. To counteract this, the following options are explored: (i) working hours; (ii) competency-based assessment (CBT); and (iii) surgical simulation. With the current requirement of service provision in the health service and political pressures, increasing working hours is not feasible. All stages of training are saturated with CBT. Increasing its use may be unwise, however adjusting it to further emphasize surgical skill may be beneficial. Whilst simulation is not a new concept in surgery, technological advancements have resulted in increased accessibility of computer based simulators. These have been shown to improve surgical skill so should be considered. Surgical training requires reform and trainees need to be involved from the outset. CBT should increase surgical emphasis and simulation should be assessed for integration into training.     

Technische und digitale Weiterentwicklung in der laparoskopischen/offenen Chirurgie

Technological innovations have initiated a fundamental change in invasive therapeutic approaches which has led to a welcome reduction of surgical trauma but was also associated with a declining role of conventional surgery. Active utilization of future technological developments is decisive to promote new therapeutic strategies and to avoid a further loss of importance of surgery. This includes individualized preoperative therapy planning as well as intraoperative diagnostic work-up and navigation and the use of new functional intelligent implants. The working environment “surgical operating room” has to be refurbished into an integrated cooperating functional system. The impact of new technological developments is particularly obvious in minimally invasive surgery. There is a clear tendency towards further reduction in trauma in the surgical access. The incision will become smaller and the number of ports will be further reduced, with the aim of ultimately having just one port (monoport surgery) or even via natural access routes (scarless surgery). Among others, improved visualization including, e.g. autostereoscopy, digital image processing and intelligent support systems, which are able to assist in a cooperative way, will enable these goals to be achieved.     

Surgical Education in Greece

Nowadays, many important changes to residents' education are being introduced, including the regulation of working hours, the waiting time to start specialization, the training programs in new technologies, the heterogeneity of trainers and educational centers, and the existence of many different subspecializations. In Greece we have not yet established all the arrangements needed to meet the European Community's legislation concerning working hours apart from the extremely long waiting time to begin surgical training. There is an enormous heterogeneity among hospitals that provide surgical specialties, but there is no educational program that all residents have to follow to complete their training. Only in major university or general hospitals are the residents enrolled in a specific educational program and complete an adequate number of surgical procedures. With respect to training in new technologies, there is a lack of experienced surgical departments around Greece that provide this type of education to all residents. Of course, efforts have been made to meet the international educational criteria and there are many major general hospitals that can provide an adequate and up-to-date surgical education, although much still needs to be done to meet the international standards.     

Foundation Year 3: the growing trend. What effect is it having on surgical recruitment and how can we ensure a future generation of surgeons?

The Foundation Programme is intended to bridge the gap between medical school and specialty training. Many doctors choose to bridge this gap further which has led to the term Foundation Year 3 (F3). In 2018 just 37.7% of successful Foundation Year 2 Doctors (F2) entered specialty training (over 70% in 2011). Whilst the F3 Year is growing so are applications to Core Surgical Training with numbers increasing by almost 50% since 2013. However, there has been an increasing number of higher-level surgical trainees leaving the profession with female surgeons having a particularly high attrition rate.This article discusses the benefits and drawbacks of an F3 Year and the effect on surgical recruitment. Future changes are also discussed including the Improving Surgical Training (IST) pilot and pledges from the House of Commons to increase the number of doctors but with an emphasis on general practice.To ensure a future generation of surgeons interest in surgical specialties must be encouraged from medical school level. Furthermore, in order to keep surgeons in the profession we need to listen to trainees and address short comings in training. The number of female trainees leaving Higher Surgical Training is particularly worrying.     

In touch with robotics: neurosurgery for the future

The introduction of multiple front-end technologies during the past quarter century has generated an emerging futurism for the discipline of neurological surgery. Driven primarily by synergistic developments in science and engineering, neurosurgery has always managed to harness the potential of the latest technical developments. Robotics represents one such technology. Progress in development of this technology has resulted in new uses for robotic devices in our discipline, which are accompanied by new potential dangers and inherent risks. The recent surge in robot-assisted interventions in other disciplines suggests that this technology may be considered one of a spectrum of frontier technologies poised to fuel the development of neurosurgery and consolidate the era of minimalism. On a more practical level, if the introduction of robotics in neurosurgery proves beneficial, neurosurgeons will need to become facile with this technology and learn to harness its potential so that the best surgical results may be achieved in the least invasive manner. This article reviews the role of robotic technology in the context of neurosurgery.     

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.     

How Will the Introduction of Primary Certificate Training Programs Change Vascular Surgery Training Programs?

New requirements for vascular surgery training allow several routes to Board eligibility in the specialty. Individuals can enter vascular residency directly from medical school, after 3 years of surgical residency, or after completion of the traditional 5 years of surgery training. Vascular surgery program directors will be faced with the challenges of obtaining institutional support, designing an acceptable educational program, and working closely with the general surgery program director to ensure both programs are successful. Faculty in the vascular program may find working with residents right out of medical school or after only 3 years of surgery training to be a challenge, especially in terms of developing the requisite technical skills. Residents must be able to demonstrate mastery of the six competencies in addition to the skills of vascular surgery. Because, in some ways, this new vascular training scheme is an experiment in redesigning all surgical education, the vascular community will need to carefully evaluate the results by monitoring the practices of those who graduate from these programs.     

Laser tissue welding: A comprehensive review of current and future

Laser techniques for joining tissue, in combination with other surgical technologies, will be a hallmark of surgery in the next century. At present, there are many clinical applications of tissue welding and soldering which are beginning to achieve wide spread acceptance. These exciting clinical developments are the result of many advances which have been made in the past few years in our understanding of the mechanism of laser tissue welding. Also contributing to this progress are many important technical refinements such as tissue solders and feedback control of the laser device. In this article, we describe in depth the history and development of laser tissue welding including key theoretical concepts as well as crucial experiments which have added to our insight into this phenomenon. We also review the evolving concepts of its clinical application and indicate clinical applications which are likely to become more important in the future. © 1995 Wiley-Liss, Inc.