Surgery train­ing pro­gram re­sponds to pres­sures on ed­u­ca­tion

The Weekend Australian - Travel - - Health - JOHN COLLINS

A NEW, im­proved pro­gram to train sur­geons in Aus­tralia and New Zealand will be­gin in Jan­uary, 2008. Start­ing with a sin­gle, mer­it­based se­lec­tion process, would-be sur­geons will com­mence train­ing in the sur­gi­cal spe­cialty of their choice, pos­si­bly in their third year af­ter grad­u­a­tion.

The cur­ricu­lum and as­sess­ment will be based on the com­pe­ten­cies re­quired to ful­fil the many roles so­ci­ety ex­pects of its sur­geons, and the length of train­ing will evolve from its his­tor­i­cal time-based process to be­come com­pe­tency-based, and will de­pend upon the speed at which in­di­vid­ual trainees be­come pro­fi­cient in th­ese com­pe­ten­cies.

The pro­gram is evo­lu­tion­ary, builds on the proven suc­cesses of the past, and has been dis­cussed in nu­mer­ous meet­ings of all stake­hold­ers across both coun­tries for two years.

How­ever, this pro­gram is not with­out its crit­ics, and ques­tions have been raised as to why change is nec­es­sary, and what im­pact th­ese changes will have on trainees, their teach­ers and the hos­pi­tals.

So why the changes? There have been many pres­sures on med­i­cal ed­u­ca­tion, and sur­gi­cal train­ing in par­tic­u­lar. The Royal Aus­tralasian Col­lege of Sur­geons re­sponded by rec­om­mend­ing a new pro­gram be de­vel­oped through an ed­u­ca­tional part­ner­ship be­tween the col­lege, its sur­geons and trainees, and hos­pi­tals.

Sur­gi­cal ed­u­ca­tion is at a cross­roads and must face up to many new ex­ter­nal fac­tors. To­day’s med­i­cal grad­u­ates are older, more ma­ture, more likely to be fe­male and fre­quently carry sig­nif­i­cant debt. They are also more cer­tain of their long-term ca­reer choice. Re­cruit­ment of the best grad­u­ates into surgery is be­com­ing more dif­fi­cult world­wide, due in par­tic­u­lar to the in­creas­ing im­por­tance of con­trol­lable lifestyle fac­tors to grad­u­ates, cou­pled with the more at­trac­tive life­styles of­fered by al­ter­na­tive med­i­cal ca­reers.

Length of sur­gi­cal train­ing is said to be daunt­ing for some, and the per­cep­tion that many years are wasted in hospi­tal ser­vice with­out much ed­u­ca­tion be­ing pro­vided is an­other dis­in­cen­tive.

Sig­nif­i­cant change has oc­curred in the meth­ods used to teach and learn surgery. The ap­pren­tice­ship model of ed­u­ca­tion is no longer sus­tain­able in busy hos­pi­tals and clin­ics, where an un­easy ten­sion ex­ists be­tween ser­vice de­liv­ery and pro­tected time for ed­u­ca­tion.

The learn­ing en­vi­ron­ment has also changed be­cause of the growth of am­bu­la­tory care, shorter hospi­tal stays, altered pa­tient mix due to the in­creas­ing shift of elec­tive surgery to the private sec­tor, and the nec­es­sary im­ple­men­ta­tion of safer work­ing hours.

New meth­ods of learn­ing us­ing skills lab­o­ra­to­ries are now avail­able and en­able trainees to ac­quire sur­gi­cal and other skills be­fore pro­gress­ing to the su­per­vised man­age- ment of pa­tients. More re­li­able meth­ods for as­sess­ing and mon­i­tor­ing the progress of trainees are avail­able and must be in­tro­duced.

The aim of a qual­ity sur­gi­cal train­ing pro­gram is to pro­duce fully-fledged sur­geons as quickly and ef­fi­ciently as pos­si­ble, but this is pred­i­cated on some cer­tainty over pro­gres­sion for the trainees in­volved. The pre­vi­ous pro­gram was di­vided into ba­sic and ad­vanced sur­gi­cal train­ing with sep­a­rate se­lec­tion for each stage.

Large num­bers of med­i­cal grad­u­ates em­barked on the pro­gram each year with a call from the hos­pi­tals for an an­nual in­crease to help de­liver ser­vices. Un­for­tu­nately, no cor­re­spond­ing in­crease in hospi­tal po­si­tions for ad­vanced trainees was made by the states, re­sult­ing in a train­ing bot­tle­neck. Only half of those who had com­pleted the first part of their train­ing were suc­cess­ful each year in ob­tain­ing a po­si­tion in ad­vanced train­ing, and many of the re­main­der or the so-called ‘‘ lost tribe’’ re­mained shut out, with sig­nif­i­cant ca­reer, per­sonal and fi­nan­cial con­se­quences for them­selves and their fam­i­lies.

What, then, is the re­sponse to this pro­gram by those who as­pire to be sur­geons, those who teach them and those who em­ploy them? Med­i­cal stu­dents and those who have re­cently grad­u­ated from med­i­cal school sup­port the new pro­gram mainly be­cause it in­volves one se­lec­tion di­rectly into the spe­cialty of choice, and gives greater cer­tainty of com­ple­tion. Fail­ure to be se­lected will oc­cur at the start of the pro­gram and those who are un­suc­cess­ful can em­bark on other ca­reers.

The main point of con­tro­versy sur­rounds the el­i­gi­bil­ity re­quire­ments for se­lec­tion by some spe­cial­ties, and th­ese are be­ing re­viewed. The 700 ba­sic sur­gi­cal trainees cur­rently in the first part of the pro­gram are con­cerned they may be forgotten dur­ing this pe­riod of tran­si­tion to a new pro­gram, but th­ese fears have been al­layed.

An is­sue for many sur­geons or teach­ers is whether it will be pos­si­ble to se­lect trainees so very early in their post­grad­u­ate ca­reers, and how to man­age those re­jected and who lack the in­sight to change to an­other ca­reer.

Some hos­pi­tals are con­cerned the pro­gram is be­ing im­ple­mented too quickly, and per­ceive the changes will leave them short of ju­nior doc­tors.

It was con­sid­ered im­por­tant to im­ple­ment the re­vised pro­gram as quickly as fea­si­ble, oth­er­wise in each year of de­lay an­other group of around 250 ba­sic trainees would en­ter an out­dated pro­gram. Med­i­cal grad­u­ates in­ter­ested in a sur­gi­cal ca­reer will con­tinue to ap­ply for hospi­tal po­si­tions and ac­quire the knowl­edge and skills nec­es­sary to ap­ply for sur­gi­cal train­ing. No short­age is ex­pected.

What will be dif­fer­ent is se­lected trainees will only be ap­pointed to hospi­tal posts which pro­vide the re­quired learn­ing ex­pe­ri­ences. This is, af­ter all, the ba­sis of all ed­u­ca­tion. Many hos­pi­tals have em­braced the new pro­gram and worked in co-oper­a­tive part­ner­ships for its suc­cess­ful im­ple­men­ta­tion. Oth­ers have been slower to be­come in­volved. John Collins is as­so­ci­ate pro­fes­sor in surgery and med­i­cal ed­u­ca­tion at the Univer­sity of Melbourne, and dean of ed­u­ca­tion at the Royal Aus­tralasian Col­lege of Sur­geons.

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