Surgery is considered a ‘craft’ specialty, demanding a combination of theoretical knowledge, manual dexterity, and wisdom/experience. The barber surgeons of old learned these skills by serving as apprentices: learning from the master and eventually acquiring the skills to work autonomously. Those days are of course long gone and surgical training continues to evolve; sometimes, it has to be said, taking a wrong turn.
In the UK, the European working time directive (EWTD) sent shock waves through the existing model of training. The existence of surgical ‘firms’ (where a core team worked together providing continuity of care, continuity of training, with many of the benefits of apprenticeship) was immediately threatened. The 48-hour working week meant fixed shift patterns, compulsory ‘zero days’ to avoid breaching the hours limit, and the surgical firm was made extinct. Continuity of care, beneath consultant level, was significantly undermined – as was training.
Whilst the drive to reduce hours had laudable motivations (improving patient safety, improving surgeon safety, decreasing burnout), arguably the baby was thrown out with the bath water. Indeed, fixed rotas with nights intermixed with standard days, long days, late days etc can feel as bad (sometimes worse) than prior models of 24-hour on calls. Almost inevitably, training suffered. The NHS combines service delivery with training and the delivery of service has, and always will be, under some strain. In the post EWTD era, surgical trainees found themselves spending almost all of their time performing service delivery tasks – and missing out on key learning opportunities like elective operating lists and clinics.
The issue is now being tackled and the Improving Surgical Training (IST) programme is the result. The IST is working to redress the balance between service delivery and training, improving access to elective training opportunities. It is also working to bring back some of the important essence of the surgical firm/apprenticeship model. Training posts last at least a year to allow relationships between trainee and trainer to be better informed. Simulation is also integrated into the curriculum, with every trainee have their own take-home simulator. These changes have only happened due to significant efforts from motivated trainers combined with additional funding from the Scottish government. At eoSurgical, we are pleased to play a small role by providing take-home simulators and curricula, and we are delighted to be working with the current cohort of IST trainees to help to optimise their training.
Clinical Lecturer in Neurosurgery, University of Edinburgh