Surgery training program responds to pressures on education
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.