Surgical training

BMJ 1997; 315 doi: http://dx.doi.org/10.1136/bmj.315.7100.124a (Published 12 July 1997) Cite this as: BMJ 1997;315:124

Training must be of highest possible quality

  1. Dermot C O'Riordan, Presidenta,
  2. Nick Shaper, Honorary secretarya
  1. a Association of Surgeons in Training, London WC2A 3PN
  2. b Royal College of Surgeons of Edinburgh, Edinburgh EH8 9DW

    Editor—T J Crofts and colleagues articulate many of the concerns of surgical trainees.1 The outcome of surgical training is a function of both the quality and the quantity of the training. Concern about surgical training tends to concentrate on the quantity of training, particularly the shortened training period and reduced hours of work. If these are considered in isolation it is easy to become alarmed by the prospect of underqualified surgeons coming off the production line. The changes brought about with the introduction of the specialist registrar grade and the new deal must be accompanied by an improvement in the quality of surgical training. Without adequate funding and an increase in the number of consultants the experiment will fail.

    The indicator operations listed by Croft and colleagues are mostly elective procedures. A one in two rota would not rectify the potential deficit in the number required for training. To correct the 60% cut in surgical training by dramatically increasing the length of training is neither practicable nor desirable. What the authors have shown is that in their training scheme they are unable to train their existing trainees adequately. If suitable changes cannot be made within the hospitals in Lothian perhaps the number of trainees should be reduced. Trainees cannot afford to spend a year in a post that does not offer sufficient exposure to training. The suggested numbers of operations were derived from questionnaires that elicited low response rates, and possibly the respondents were unrepresentative.

    Trainees and trainers should aim to increase the number of operations performed with help that are logged in their logbook. Trainees performing parts of operations under supervision can gain quality, safe training without unduly prolonging the procedure—for example, in the early stages of training in laparoscopic cholecystectomy a trainee might concentrate on establishing a pneumoperitoneum and dissecting out the gall bladder.

    We must consider what we are training general surgeons to become. Previously, most general surgeons would have had a special interest and broad experience in all the subspecialties. In the future, trainees will not have this breadth of experience at the end of their training. This has important implications in both the organisation of training schemes and the provision of consultant services in the future.

    The new deal and the specialist registrar grade are here to stay. We should ensure that training is of the highest possible quality and is focused to provide the specialists that our patients are rightly beginning to demand.


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    Structured training is now being used

    1. Robert Shields, Presidentb,
    2. D A D Macleod, Chairman, training committeeb,
    3. R W Porter, Director of education and trainingb
    1. a Association of Surgeons in Training, London WC2A 3PN
    2. b Royal College of Surgeons of Edinburgh, Edinburgh EH8 9DW

      Editor—We are writing from the Royal College of Surgeons of Edinburgh in response to T J Crofts and colleagues' contribution to the debate about the scope for performing elective operations in basic and higher general surgical training.1 The college agrees that maintaining high standards of training is a priority. Discussions should be based on a realistic appraisal of training opportunities to minimise frustration among trainees and trainers while satisfying service demands. Most general surgical trainees work a rota with at least three elective operating theatre sessions a week. Maximising training opportunities demands innovative approaches.

      It is no longer realistic to accept the conventional logbook as the principal measure of operative experience or competence. We have developed the concept of structured training, breaking down operations into logical components (incision, exposure, procedure, and closure) and assessing competence in each part. Training will proceed on the basis of competence being recorded in all component parts of an operation before the trainee performs the full procedure.

      The college is pursuing the concept of structured training for surgical trainees by identifying key operations and their component parts. Before an operating session the trainer and trainee agree on what the trainee will undertake. The rest of the operation is performed by the trainer, so that the service demands are met. The principles identified apply equally to basic and higher surgical training. On the basis of the key training operations available in an individual unit it will be possible for basic or higher surgical trainees and their trainers to agree, prospectively, what operative experience and level of competence can realistically be achieved in a six or 12 month attachment.

      The Royal College of Surgeons of Edinburgh has been in the forefront of recognising the priority of ensuring excellence among trainers to maximise training opportunities. In conjunction with its sister colleges it has promoted courses on “training the trainer” since 1995.2

      The numbers of procedures identified by Crofts and colleagues as necessary to train a general surgeon merit careful interpretation rather than despair. A positive approach to structured training and training the trainers will help meet the challenges.


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