One surgeon's philosophy of surgical education

The concept of a philosophy of surgical education provides a vehicle for ensuring that there is a united and comprehensive approach to surgical training. This is important because none of the current approaches to higher education provides a suitable model for surgical training and it is dangerous to uncritically adopt every prevailing fashion in education.     

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.     

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.     

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.     

Gender Incongruence: Current Concepts in Gender-Affirming Surgery Postgraduate Training

Background  Recent advocacy efforts and expanded insurance coverage has increased health care utilization among transgender patients. Therefore, it is pivotal that surgical residents are properly trained to care for transgender patients in both clinical and surgical settings. Yet, no formal curriculum or training requirements exist for surgical residents. The aim of this systematic review is to understand the surgical trainee''s postgraduate education and training with respect to transgender health and gender-affirming surgeries (GAS). Methods  A Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)-compliant literature search was performed on December 04, 2020 in PubMed, Elsevier Embase, and Wiley Cochrane Central Register of Controlled Trials. The retrieved hits were screened and reviewed by two independent reviewers. Results  Our literature search identified 186 unique publications, of which 14 surveys and one interventional study from various surgical specialties including plastic surgery, urology, otolaryngology, oral and maxillofacial surgery (OMS), dermatology, and obstetrics and gynecology (OBGYN) were included in this study. The majority of residents and program directors in surgical specialties believe education related to transgender health is important, and the current exposure in surgical training does not sufficiently prepare surgical residents to care for this marginalized population. Conclusion  Current postgraduate surgical training in gender-affirming surgery is nonuniform across surgical specialty, geographical region, and individual program. Incorporating training modules and hands-on experiences into surgical trainee education will better prepare residents for the numerous clinical and surgical interactions with transgender patients. Further research is required to better understand how to best incorporate these experiences into existing surgical curriculums.     

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.     

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.     

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.     

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.     

Educational interventions aimed at the transition from surgical training to surgical practice

The transition from surgical training to surgical practice is a critical juncture in the career progression of surgeons. This period is associated with myriad challenges that need to be addressed through specific educational interventions to ensure delivery of safe care to patients and to support the career aspirations of junior surgeons entering the practice environment. These interventions should be based on principles of contemporary surgical education and training, and focus on the needs of surgery residents and junior surgeons entering practice. The specific systems of patient care in which the junior surgeons will work should also be considered while planning and implementing such educational interventions. Senior surgeon colleagues within these systems should play key roles in supporting the junior surgeons entering practice, and may require special training to serve as effective mentors, preceptors, and coaches. Professional societies should play a key role in establishing national standards regarding the educational programs aimed at this transition and develop programs to complement local efforts to address various needs. The American College of Surgeons Division of Education has developed a spectrum of innovative programs that are aimed at this important transition.     

Surgical Training in India

BACKGROUND: The quality of surgical training and competence defines the quality of patient care. The developed world evolved its surgical training over a long progressive period, whereas countries in the developing world, of which India is a reasonable example, were jettisoned into the waters, to hurriedly create their own training. METHOD: Surgical training is but part of the picture of any countries medical education. Keeping stastics to a bare minimum, an attempt is made to trace the evolution, progress and current state of surgical training in India. Shortcomings in the training program in a country with such a tremendously wide economic spectrum, and their possible solutions, are evaluated. RESULTS: In a country as vast, populous and complex as India no one article could even remotely do justice to this subject. What is lost in depth and pragmatism here is hopefully compensated, to some small degree, by the 50 year personal experience (and perhaps philosophy) of one of the authors (T.E.U.). CONCLUSIONS: Surgical Training has to be tailored to the specific needs of each country. Surgery is a humanitarian science. The thrust of surgical training in India should be, and hopefully will be, not just to be on par with the developed world, but more important, to ensure good surgical care to all Indians, in all places.     

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.     

Training outside of the box

Background: Developments in surgical training in Australasia allow for individualization of training to suit individual requirements. One uncommon career track is medical aid or missionary surgery in the developing world. It is difficult to receive appropriate training for this type of surgical practice in Australasia. The present paper describes a novel approach to preparing for this kind of work by spending a 6 month rotation in a mission hospital in rural East Africa. Methods: The surgical trainee spent 5 months working at Kijabe Hospital in Kenya. This is a large mission hospital with a busy general surgical workload and adequate staffing for training. Results: The trainee performed 214 major cases, in a broad range of general surgery, under appropriate supervision. He also took part in regular educational sessions, surgical audit, and helped to develop one of East Africa's pioneering laparoscopic surgical ­programmes. Conclusions: The present paper demonstrates that it is possible for Australasian trainees to gain useful experience in the rural African environment, in hospitals where appropriate surgical supervision is available.     

Equipping surgeons as educators*

There is a developing interest in equipping surgeons as educators but a perceived lack of knowledge and evidence about how to do this effectively, or how to reward and recognize educational expertise within the surgical career structure. A brief consideration of the surgical educator role is offered. The findings and conclusions of a meta‐analysis of the influence of faculty development in medical education are summarized. Various sources are drawn on to present an overview of master’s level provision in medical education and a master’s in surgical education is outlined. Issues relating to developing suitable curricula, educational accreditation, recognition, reward and career structure are raised and some UK approaches to these areas summarized. Evidence indicates the importance of context in training medical educators, the value of experiential learning, training that is spread over time and training that mixes theory, practice and reflection. A schema for recognizing educational expertise, created as an outcome of analysis of the evidence and current provision, is presented. The effect of a possible change from educational training being voluntary to the introduction of a compulsory regime is raised as an area requiring further discussion and evidence collection. Mechanisms by which to acknowledge, reward and recognize education expertise in surgeons do not generally exist; it is suggested their development would be timely.     

Computer-based logbook for surgical registrars

Background : The documentation and monitoring of operative experience is an important component of advanced surgical training. The Royal Australasian College of Surgeons (RACS) monitors the adequacy of training by use of the surgical logbook. The logbook has been a paper‐based record that does not permit longitudinal evaluation of the progress of an individual trainee or comparison of different surgical units. Methods : An electronic logbook has been developed in FileMaker Pro version 5.03 (FileMaker, Santa Clara, California, USA). Results : The electronic logbook has been employed for 1 year and has been used on both Windows and Macintosh platforms without difficulty. Appropriate summaries of the training experience were provided for the RACS at the conclusion of each rotation. Conclusions : The use of a relational database for logbook purposes provides trainees with a convenient and versatile record of their experience while meeting RACS requirements for documentation of surgical experience.     

Surgical Education and Training in Australia and New Zealand

Surgical education for medical students in Australia and New Zealand is provided by 19 universities in Australia and 2 in New Zealand. One surgical college is responsible for managing the education, training, assessment, and professional development programs for surgeons throughout both countries. The specialist surgical associations and societies act as agents of the college in the delivery of these programs, the extent of which varies among specialties. Historically, surgical training was divided into basic and specialist components with selection required for each part. In response to a number of factors, a new surgical education and training program has been developed. The new program incorporates a single merit-based national selection directly into the candidate's specialty of choice. The existing curriculum for each of the nine specialties has been remodeled to a competence-based format in line with the competence required to undertake the essential roles of a surgeon. New standards and criteria have been produced for accreditation of health care facilities used for training. A new basic surgical skills education and training course has been developed, with simulation playing an increasing role in all courses. Trainees' progress is assessed by workplace-based assessment and formal examinations, including an exit examination. The sustained production of sufficient competent surgeons to meet societal needs encompasses many challenges including the recruitment of appropriate graduates and the availability of adequate educational and clinical resources to train them. Competence-based training is an attractive educational philosophy, but its implementation has brought its own set of issues, many of which have yet to be resolved.     

Promoting Undergraduate Surgical Education: Current Evidence and Students’ Views on ESMSC International Wet Lab Course

Background: Undergraduate Surgical Education is becoming an essential element in the training of the future generation of safe and efficient surgeons. Essential Skills in the Management of Surgical Cases (ESMSC), is an international, joint applied surgical science and simulation-based learning wet lab course. Methods: We performed a review of the existing literature on the topic of undergraduate surgical education. Following that, we analyzed the feedback questionnaire received 480 from 2 recent series of ESMSC courses (May 2015, n = 49 and November 2015, n = 40), in order to evaluate European Union students' (UK, Germany, Greece) views on the ESMSC course, as well as on the undergraduate surgical education. Results Using a 10 point graded scale, the overall ESMSC concept was positively evaluated, with a mean score of 9.41 ± 0.72 (range: 8–10) and 8.94 ± 1.1 (range: 7–10). The majority of delegates from both series [9.86 ± 0.43 (range: 8–10) and 9.58 ± 0.91 (range: 6–10), respectively] believed that ESMSC should be incorporated in the undergraduate surgical curriculum. Comparison of responses from the UK to the Greek Medical Student, as well as the findings from the third and fourth year versus the fifth and sixth year Medical Students, revealed no statistically significant differences pertaining to any of the questions (p > 0.05). Conclusions: Current evidence in the literature supports the enhancement of surgical education through the systematic use of various modalities that provide Simulation-Based Training (SBT) hands-on experience, starting from the early undergraduate level. The findings of the present study are in agreement with these previous reports.     

Simulation‐based surgical education

The reduction in time for training at the workplace has created a challenge for the traditional apprenticeship model of training. Simulation offers the opportunity for repeated practice in a safe and controlled environment, focusing on trainees and tailored to their needs. Recent technological advances have led to the development of various simulators, which have already been introduced in surgical training. The complexity and fidelity of the available simulators vary, therefore depending on our recourses we should select the appropriate simulator for the task or skill we want to teach. Educational theory informs us about the importance of context in professional learning. Simulation should therefore recreate the clinical environment and its complexity. Contemporary approaches to simulation have introduced novel ideas for teaching teamwork, communication skills and professionalism. In order for simulation‐based training to be successful, simulators have to be validated appropriately and integrated in a training curriculum. Within a surgical curriculum, trainees should have protected time for simulation‐based training, under appropriate supervision. Simulation‐based surgical education should allow the appropriate practice of technical skills without ignoring the clinical context and must strike an adequate balance between the simulation environment and simulators.     

Comparison of skill training with robotic systems and traditional endoscopy: implications on training and adoption

BACKGROUND: Robotic systems are being used by an increasing number of surgeons. This environment is markedly different from that of traditional surgery and involves videoscopic guidance, remote surgical control, and the loss of haptic feedback. Defining how surgeons learn with these systems is necessary to establish training protocols for this technology. This study compared the learning curve for a robotic surgical system with that of traditional endoscopy in the performance of two standardized skill drills. MATERIALS AND METHODS: Twenty participants (average age 27 +/- 4 years, six females) repeated two standardized endoscopic dexterity and depth perception drills for 15 repetitions with the ZEUS robotic surgical system and manual endoscopic instruments (MAN). A score combining time and precision was given for each repetition. The learning curves and overall performance with and without robotic assistance were compared. RESULTS: For both MAN and ZEUS, improvements in performance were significantly greatest during the first five repetitions (P < 0.01, for both). Participants reached the training curve plateau faster with ZEUS than with conventional instruments (8th versus 10th for both drills). Using robotic assistance, dominant and non-dominant hand performance were statistically similar. The number of errors committed with ZEUS were significantly fewer for drill two (0.09 errors/repetition versus 0.24 errors/repetition, P = 0.002) compared to manual technique. CONCLUSIONS: This study demonstrated that training curves for conventional and robotic-assisted systems are remarkably similar. This should prove useful in the training and education of this new technology. This study further suggested that robotics may increase ambidexterity by improving non-dominant hand performance.     

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.