Challenges in creating the educated surgeon in the 21st century: Where do we stand?

To the Editor: Improved performance, which remains a constant concern in the health service and places a heavy burden and responsibility on health planners, has become an increasingly difficult task in view of the fast changes in society in general and medicine in particular.¹ The rate of change in medicine nowadays resembles those associated with the Industrial Revolution in England, 150 years ago.² In the field of surgery, two major changes have occurred: the increasing importance of less invasive technologies, and the growing awareness of the importance of “systems” in surgical care. To cope with these challenges, the traditional educational strategies in surgery need to be altered to keep pace with recent developments in minimally invasive surgery.

We examined problems in the current surgical residency training programme (SRTP) at King Khalid University Hospital (KKUH) by two approaches: 1) a quantitative semi-structured focus group study conducted through direct contact with the individuals involved in the SRTP, including 11 residents, 3 programme directors, and 7 consultants involved in the training and education of the trainees, and 2) a review of the literature on problems in surgical education and training, using a computer-based literature search (Medline).

Most of the residents in the current surgical training program agreed that there are a limited number of clinical cases for practice and training, and that they are not satisfied with the quantity and quality of operations they are performing during their training as first surgeons. They also think that a resident off-day and a study leave should be made mandatory to enable them to attend conferences, symposia and surgical courses. Programme directors and consultants emphasized that the number of cases for practice and training of residents is small. They think that our senior surgical residents do not show full competence after graduation and cannot be relied upon to perform many major operations with confidence. They suggested that effort should be made to find alternatives in training to fill the current deficiencies and to cope with the shortage in clinical cases. They also emphasized importance of one-to-one contact, especially for the junior residents.

The decreasing patient population continues to be a major concern in many other surgical programmes⁷ and has created a need for formal training outside the operating theatre.^8,9 The lack of full competence in graduate surgical residents has also been documented in other programmes.^10–11 Weigett et al¹¹ in 1998, in a large survey of 954 general surgeons involved in the training of surgical residents, concluded that changes were needed because the current system of resident education allows chief residents to graduate with significant deficiencies in their education. Alternatives have been suggested for many surgical programmes,^12–15 but not in our programme. There is very little locoregional data regarding the current surgical residency training programmes to reflect such problems and then to raise proposals to improve performance and outcome.

Medical education continues to face pressure to re-engineer itself. These pressures include the decreasing patient population at academic medical centers, competing care systems, correlating student output with market needs, identifying the best way to train physicians, and the best location for training.^16–21 Rapid developments in technology have generated an increasing need to develop methods of technical skills instruction outside the operating theaters, in the form of courses or workshops,²⁴ which are now considered a mainstay of continuing education programmes for surgeons. Some training programmes provide sporadic teaching and practice opportunities for their residents outside the operating room.^25,26 Lossing et al, detailed the technical skills programme for first-year residents in general surgery,²⁵ which consisted of introductory didactic sessions and wet labs. The latter included instructions on the preparation of the patient and draping, aseptic technique, the principles of bowel anastomosis, incisions, the use and handling of instruments, principles of hemostasis, intraoperative surgical emergencies, surgical assisting and theatre etiquette. The live animal has often been used for providing living simulations.^25,27,28 Bench models, which are becoming popular for teaching specific surgical skills,^29–33 have the advantages of low cost, portability, ability to use in an unsupervised practice, and they provide unlimited practice for residents. The feasibility of residency bench and wet laboratory training in essential technical skills in a human cadaver model has been demonstrated.^24–25 Descôteaux and Leclère³⁴ have summarized the theories and principles of motor skill learning as they apply to surgical training. Thomas et al³⁵ concluded that synthetic tissues can provide a useful and functionally reproducible means for learning basic surgical skills. It must be emphasized that the introduction of laparoscopic techniques made the teaching of operative skills more difficult, due to many factors, including the complexity of the procedure, the time required in teaching, and medicolegal concerns. Nonetheless, Rossers have shown that concentrated didactic training in laparoscopy in a brief course unrelated to prior surgical experience can improve skills in both residents and established surgeons.³⁶

Advances in computing, imaging and information transfer have allowed the use of virtual reality in the performance and teaching of surgery.³⁷ For example, the minimally invasive surgery–trainer virtual reality (MIST-VR) system allows tasks to be performed using laparoscopic instruments connected to a computer, where the movement of the instruments can be both measured and translated into a graphical display.³⁸ Anaesthesiologists have pioneered the use of operating room simulators to improve crises management skills.³⁹ Such methods will help overcome problems of decreasing number of clinical cases in medical teaching centers and the increasing importance of minimal access surgery. In this way, we will have in our hands practical and convenient methods that can be applied in our surgical training programme to overcome similar problems.

The traditional educational strategies in the current surgical training programme need to be changed to cope with recent developments in minimally invasive surgery, and the decreasing number of clinical cases in medical education centers. The need for change should first be confirmed by surveying surgical consultants involved in the training and education of surgical residents, and obtaining their feedback.