First-place essay—revolution: Surgical training: Time for a revolution

New challenges and opportunities of many forms are already affecting surgical education today, but the question remains: What changes should we be striving for in the near and distant future? Multiple external forces indicate that the magnitude and quality of necessary changes warrant a rebirth of surgical training—a revolution in terms of what training to be a surgeon means and entails.

The ever-expanding, ever-changing nature of cumulative medical knowledge suggests that the corpus of material learned in training will become obsolete at an ever-increasing pace. We need to change what we are asking surgeons to do. Just as the Institute of Medicine called for the nation to have a health care system that learns, the goal of surgical training should not simply be to produce graduates who know, but who think.1

Competency should be measured not by demonstrating recall of management algorithms that are often outdated even by the time of an examination, but rather by judgment and interpretation in using technology and all available resources in the care of patients, as well as the ability to adapt to and employ constantly evolving recommended practices. As has long been recognized outside of medicine, the human mind is not well-suited for recall, and within medicine, it is formally acknowledged that we need new practice models that avoid reliance on memory.2,3 All specialties will need new patient care technologies and delivery systems so that evidence-based knowledge is no longer impeded by the multi-year bottleneck between dissemination of information, retention by practitioners’ memories, and ultimate delivery of care. This current system has created disparities in health care quality that are due solely to variability in physicians’ declarative memories—disparities that must be eliminated.

New approaches to training

New modes of training should be developed. The immense amounts of data collected in clinical care could be used to build thorough training modules for practicing episodic and longitudinal management of patients, simulating much of the guess-and-check kind of learning now conducted on hospital wards. Simulated patient management eliminates risk to real patients and offers trainees experience handling a wide range of scenarios in a far more efficient manner. Similarly, trainees could learn procedures through interactive video tutorials and other simulations, and direct patient care and operating privileges could be contingent on passing multimodal standardized modules in clinical management, surgical skills, and procedure simulations. Time spent on actual patient care would be to demonstrate competence and would be far more effective and efficient for all involved. The goal of training should be to get the best care to patients and not to simply get the most knowledge into trainees’ heads; only with a new role for technology and a new professional identity can it be distinguished that these are not synonymous.

Focus on quality should also change the requirements for breadth of experience in current training. As the field of surgery has grown, general surgery graduates now pursue fellowships because of interest in subspecialty fields, and the current efforts in tracking training based on career intent can thus be augmented.4,5 Future endocrine, breast, or vascular surgeons should no longer need to acquire competency in hernia repairs and cholecystectomies; currently, these unnecessary requirements take away valuable training positions that could be used to compensate for the general surgeon shortage.6 Comparably, those residents who want to enter the most in-demand disciplines should not have to demonstrate proficiency managing conditions for which they will not bear responsibility in their careers. With these factors in mind, modular training can be constructed to fit an individual’s professional intentions—programs which likely would not require five to seven years of training.

Improving the efficiency, safety, and relevance of surgical education will increase the proportion of training expectations outside direct patient responsibilities, with a concomitant decrease in amount—but increase in quality—of time spent with real patients. Such restructuring could also be amenable for other much-needed modifications for career preparation. Many surgeons will ultimately have multiple responsibilities in addition to patient care, such as conducting research, administrative duties, policy work, teaching, and, most important, family.

Starting families should be a viable option for those who desire it, and flexible part-time training options for starting a family, pursuing research, and engaging in other professional interests should be developed in the U.S., particularly considering part-time training is already becoming a reality in other countries.7 Additionally, the methods through which countries like the U.K. reduce errors when average clinical hours decreased to only 43 per week should be explored for adaptation in the U.S.8 One possible schedule to address these issues could be a continuous four “on,” four “other” cycle for trainees and attendings alike, in which four days of patient duties alternate with four days for doing intensive educational activities, research, or time with family.

We have a duty to our patients to minimize risk and to provide them with physicians capable of handling their concerns, without solely entrusting delivery of surgical knowledge to an unreliable human memory. We have a duty to the general public to use training time and resources judiciously, and to avoid developing irrelevant competencies. We have a duty to the future of surgery to become balanced, well-rounded, “cosmopolite” professionals with diverse interests and commitments, especially to family, which are necessary for further innovation and for producing new generations of productive individuals.9

We now have the opportunity to enhance the future of surgery by developing new models of training and practice—focused on eventual careers, forged on an unprecedented partnership between clinicians and information technology, and based on simulation and remote curriculum modules—so that the educational benefits of direct clinical management can be coupled with the elimination of inefficiency and risk to patients. With these models, standards of quality could be raised, research accelerated, and innovation catalyzed. The benefits could be manifold, and perhaps these changes are only the beginning.


References

  1. Olsen L, Aisner D, McGinnis JM, eds. The Learning Healthcare System: Workshop Summary (IOM Roundtable on Evidence-Based Medicine). Washington, DC: National Academies Press; 2007.
  2. Johnson J. Designing with the Mind in Mind, Second Edition: Simple Guide to Understanding User Interface Design Guidelines. Amsterdam; Boston: Morgan Kaufmann; 2014.
  3. Kohn LT, Corrigan JM, Donaldson MS (eds). To Err Is Human: Building A Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000.
  4. Friedell ML, Vandermeer TJ, Cheatham ML, et al. Perceptions of graduating general surgery chief residents: Are they confident in their training? J Am Coll Surg. 2014;218(4):695-703.
  5. Eberlein TJ. A new paradigm in surgical training. J Am Coll Surg. 2014;218(4):511-518.
  6. Williams TE Jr, Ellison EC. Population analysis predicts a future critical shortage of general surgeons. Surgery. 2008;144(4):548-554; discussion 554-556.
  7. Royal Australasian College of Surgeons. Institution Women in Surgery Section, Flexible Surgical Training in Australia: It’s Time for Change (white paper). WIS Executive Committee. Available at: https://www.surgeons.org/media/18744675/ppr_2012-01-04_flexible_surgical_training.pdf. Accessed August 30, 2014.
  8. Cappuccio FP, Bakewell A, Taggart FM, et al. Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients’ safety: Assessor-blind pilot comparison. QJM. 2009;102(4):271-282.
  9. Rogers EM. Diffusion of Innovations, 5th Edition. New York, NY: Free Press; 2003.

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