Apprentice surgeons

BMJ 1996; 312 doi: (Published 11 May 1996) Cite this as: BMJ 1996;312:1233
  1. Tony Smith

    The general public is often told that doctors want to be more open in explaining their decisions and recommendations—and in admitting their mistakes. My own experience as an adviser to consumer groups suggests that substantial problems need to be overcome if patients are to be fully convinced that paternalism is dead.

    Medical training, especially in surgery, has always been an apprenticeship system, with trainees working under supervision until judged competent to operate on their own. In theory the supervision should ensure that the patient comes to no harm, but the few research studies that have been done have found that trainee surgeons do have a higher rate of complications than the consultants who train them. For example, a recent study of hip replacement operations (Journal of Bone and Joint Surgery 1996;78B:178) found that 15 of the 16 patients who needed revision arthroplasties had had their operations done by trainees, though they had carried out only half the total.

    Until the introduction of the NHS patients knew whether or not they would be treated by doctors in training. They had three options: the private sector, the local hospital, or a teaching hospital. The consultant staff at the great teaching hospitals were unpaid but their status gave them great earning potential in private practice. So a patient who went into a teaching hospital knew that he or she would be used as “teaching material,” but the implied term to the contract was that the quality of the treatment would be higher than in the local hospital.

    The great achievement of the NHS was to reduce the differences between teaching and non-teaching hospitals, but at the same time training of would be consultants was extended to the whole of the health service. So long as the NHS remained a monolithic structure it could tell patients that they were all treated alike, and patients accepted that their consent forms did not name the surgeon who would operate.

    Times have changed, however, with hospital trusts and fundholding general practitioners, with audit and performance indicators. Increasingly patients are asking awkward questions about how many operations of a particular kind the surgeon does each year and whether or not a trainee surgeon may be going to do the operation.

    The revolution in surgery that has come with the development of minimally invasive techniques has also shown very clearly that anyone taking up a new procedure has to follow a learning curve. In some countries surgeons are allowed to acquire new skills by operating on animals; but in Britain surgery on animals is strictly limited to research procedures and the law excludes surgeons who want to practise a new skill. So trainee surgeons learn their craft on patients, “cutting their teeth” on procedures such as stripping varicose veins.

    The question no one wants to answer is who selects the patient for novice surgeons, novice physicians doing their first lumbar puncture, and so on. Is it simply a matter of chance, with some patients treated by newly appointed junior staff while a few months later others get the benefit of hard won experience? These are legitimate questions for the consumer advocates, but they seem to be rarely answered.—TONY SMITH, associate editor, BMJ