The future of surgical education

Abstract

Surgical education is not a new field. Surgeons have been educators for more than two centuries since the Royal Colleges were formed. The technical skills of the surgeon have been passed on and absorbed by surgeons and apprentice surgeons over time. Demonstrably, this has served society, in general, well. In Australia and New Zealand, the Royal Australasian College of Surgeons (RACS) has been the responsible organization since it was formed in 1927–1930. Excellence in surgical education and practice remains its raison d'etre. What is surgical education in 2013? Recent monographs,1 as well as recent international conferences, have described and charted this field. The first International Conference on Surgical Education and Training (ICOSET) was hosted at RACS by Professor John Collins, as Dean, in March 2008. The second ICOSET was held in Ottawa in October 2012. Having attended both meetings, and reviewed the book,1 I can certainly state that the field is established; its dynamism is based on the conversations and collaborations of surgeons and educators. There is recognition within surgery that the field is far more than technical operations. Surgicon, another meeting in Europe (first held in 2011), will be held for the second time in June of this year. RACS is well represented there, with presentations and four book chapters in the related book about surgical education. Surgeons with education qualifications are emerging; although, in 2010 there were less than 20 in our College.2 What is driving ‘surgical education’, as it emerges as a respected field within health professional education, are the special attributes that relate to the concepts that define surgery and the work of surgeons. Surgery is a craft; it requires decision making; surgery occurs with participation in, and support from, teams.3 The interplay between the craftwork and the complexity of surgical decision making has recently been described and developed as a modular course by RACS.4 The teamwork required has been described within the Non-operative Technical Skills for Surgeons (NOTSS) course. Overlying all of this is the innovative leadership required by the surgeon.5 The educator role is constantly interwoven in surgical training, as the facilitation of learning occurs alongside clinical service. The learners include medical students, doctors in pre-vocational years, SET trainees, as well as colleagues and members of all the health professions. Indeed, on more than one occasion, the author has counted 20 people in the operating room during his previous public hospital practice in colorectal surgery. Recently, professionalism has been thoroughly discussed, as this subject applies to surgeons. The professionalism statement6 included ‘… to put the interests of existing and future patients ahead of the practitioner, the profession and other bodies …’ Implicit here is both the development of the field and the education of the future surgeons. The statement notes the traditional values and describes contemporary influences. The latter are impacting the approach to surgical education. Overlying professionalism is recognition of the importance of all of the RACS competencies that describe surgical practice.7, 8 Only two of these relate to technical and medical expertise. As the surgical speciality societies increasingly are responsible for these content areas, the College retains an important current and future role in making sure that the remaining seven competencies are learned well, and that this learning is seen to be beneficial to practice. Potential developments relating to revalidation will reinforce the need for surgeons to perform well in all competencies, with peer practice visits and hospital/practice multisource feedback likely to inform. Who will be responsible for linking these influences upon surgeons to the future generation, the trainees of this year and the years to come? The surgeons who educate and supervise in the clinical environment have this responsibility. Not all surgeons are involved in such roles, with only one third of Australasian surgeons doing ‘a lot’ (defined as more than 5 h/week) and one third doing ‘a little’ (less than 5 h). The remainder had virtually no educator or supervisor function.9 The profession's collective responsibility should encourage greater involvement from all Fellows. But quality education and supervision can be difficult, even for experienced clinical surgeons. Future College directions include the immediate development of a generic educator/supervisor course, modular in style, to provide support for the clinical surgeon, faculty on courses and specialty supervisors. This will address facilitation of learning, teaching skills, feedback and assessment, as well quality and safety for the patient, and oversight leading to progressive independence of the trainee. It is hoped that this could be a one-day course for educators, with two add-on supervision modules. There are tensions in the roles of the supervisor. Good active supervision is important although noted recently to vary between jurisdictions.10 Global directions in surgical education are exciting. How surgeons learn, including concepts such as imitation, the role of simulation and deliberate practice,11 is currently being researched and will inform surgical education. The development of expertise may relate to repeated practice and immersive experience, but the complexity of surgery and the immediacy of the changed patient course of illness demand more work. Cognitive load concepts, as well as experts thinking aloud and sharing thoughts, will also inform surgical education. Mapping and describing progress8 will inform progress in competency-based programmes as well as be useful for identifying borderline or failing trainees. Use of entrustable professional activities12 may supplement current methods of work-based assessment and be more acceptable as well. Metacognitive approaches such as mindfulness and self-monitoring of performance are increasingly described in experts; the future will include making such implicit thinking processes into explicit programmes than can potentially be taught.4 Further work on automatic and effortful thinking13 should also help unravel both the human and expert aspects of being a surgeon. This will need to be incorporated into training as its worth is increasingly shown. The research dovetails well into situational awareness concepts as described in NOTSS. Postgraduate courses in health professional education have been available in Australia for about 20 years. Recently, Masters in Surgical Education has been jointly established by RACS and the University of Melbourne,14 with the first cohort of surgeons commencing in 2012. This follows the Imperial College London programme as well as Edinburgh University. The second cohort of the local course includes two trainees; it is expected that some trainees may take such an ‘education’ option alongside their SET training, just as some enhance their training with periods of academic research. Finally, RACS cannot and does not pretend to do this alone. The international surgical education community is shaped by surgeon educators who collaborate. It is about facilitating the learning required to become a surgeon as well as that required to evolve as a surgeon during the years of practice. We all need to seize this opportunity … as advised by a note from my youngest child ‘… even if you're on the right track, you'll still get run over if you just sit there …’ This College has a proud history – now we should all work towards the future of surgical education.