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Surgery

May 6, 2019

Heterogeneity in Surgical Training

For a glimpse into the world of surgical training over 100 years ago, one can look at The Agnew Clinic by Thomas Eakins and immediately observe the vast differences compared to today. Anatomist and surgeon David Hayes Agnew holds tools in his bare hands while his surgical team pins a patient down to a table and press their scalpels into his skin. An audience of suit-clad gentleman gaze at the spectacle with facial expressions ranging from amusement to utter shock.

Observation and senior supervision are still part of surgical training - though they thankfully no longer involves throngs of the mass public staring over the surgeon’s shoulder as a means for afternoon entertainment. The didactic piece is still highly valuable for new residents or interns during early procedural exposure, but the overall training experience is becoming much more robust.

In an ideal world, surgical training would be standardized in accordance with a collaborative global council. Training would be flexible enough to change with the times while stable enough to promote high-quality and accessible clinical care. Unfortunately, some surgical institutions are so behind in their adaptive capacities that patient needs go unmet and disparities in global health become exacerbated. Such heterogeneity seems destructive and even counterintuitive to the essence of medicine: If we know how to effectively prepare our surgical providers, why can’t every cohort of health professionals receive equal training opportunities?

A systematic review of each country’s surgical training centers would span pages; global surgery is a specialty in itself. Instead, we will look at heterogeneity in surgical education, barriers and enablers to standardization, and the future of surgical training.  (If you are interested in the global burden of surgical disease by country, we encourage you to read The Lancet Commission on Global Surgery: https://www.lancetglobalsurgery.org)

As with most countries, surgical training programs in first-world countries require trainees to enter as licensed physicians before completing several years in residency. The internship, a preliminary period between medical school and residency, is no longer a common phase of the training process although still practiced in select systems. The length of time in a residency program varies by specialty, school, and/or country.

Traditional training followed the linear route of higher case volumes and longer residency durations as a means to surgeon readiness. While still important, solely equating quantity with quality is just too simplified in the context of modern medicine. To this effect, a systematic review of general surgery residency training was performed across Australia, Canada, the United States, Hong Kong, and the United Kingdom. Each country’s surgical curriculum was evaluated against the General Medical Council’s Standards for Curricula and Assessment Systems which included Competency, Supervision, Assessment, Feedback, and Documentation. Findings revealed high similarity across the curriculum standards and trainee preparedness; it was the assessment systems that had the greatest differences. For instance, Canada emphasized competence over case volume but lacked explicit means for communicating the expected index procedures and their assessment metrics to trainees. By contrast, the US hadn’t fully transitioned into a competency-based design but they were receiving well-structured and explicit guidance from the Milestones Project. Hong Kong and the UK were committed to online documentation accessibility though Australia was the most transparent in matching its expectations to specific deadlines.

One of the most effective ways to improve surgical training is to standardize the criteria for high-quality surgical capabilities and develop accompanying assessment tools. Both must be transparent to trainees and teachers so that each skill can be clearly targeted, achieved, and remediated if necessary. Evidence-based evaluations will directly influence the quality of patient care being delivered, thus it is crucial for training centers to work with national councils to develop a standardized approach to assessment metrics.

Even among well-developed countries, as described above, standardized training standards have yet to be implemented. The consequences of heterogeneous training standards are apparent when we consider the dominance of medical migration in the 21st century, especially between high-income countries (HICs) and low-to-middle-income countries (LMICs). This is no small phenomena; between 23-28% of practicing physicians in Canada, US, Australia, UK, and New Zealand received their training elsewhere. Mobility between HICs is just a relocation of highly skilled individuals, but the loss of physicians from LMICs to HICs poses a serious disadvantage on both ends.

A recent study examined surgical education across 34 LMICs and reported 2 billion people lack access to quality surgical care. These countries have fewer surgeons serving significantly larger populations, as well as inconsistent training standards or availability. Learning expectations vary widely and the evaluation processes rarely encompass all three elements of written, oral, and practical exams. For example, Zambia’s population of 16 million is served by only 100 surgeons. The 8 local surgical training centers all had different case volumes and workload hours, only two centers were equipped with research labs, and opportunities for mentorship were limited. If a local surgeon leaves to practice elsewhere, s/he impedes the delivery of high-quality medical care in Zambia. However, the receiving institution (presumably in a middle or high-income country) will also experience the effects of heterogeneous training standards as time and financial support will have to be invested into skill upgrading.

The future of standardized surgical training is cautiously optimistic. Enrolment figures in LMICs are slowly growing and capacity-building partnerships with HICs are assisting with curricular development and bilateral exchange programs. Malawi, Uganda, Zambia, Zimbabwe and Rwanda have all fully recognized COSECSA as a specialist qualification and this has had direct impact on surgical trainee enrolment and with the adoption of higher training standards. Ethiopia’s Black Lion Hospital has signed several memoranda of agreement with North American partners and is joining the ranks of well-established, high-quality surgical training programs. For example, the University of Toronto’s Department of Surgery annually supports an Ethiopian surgical fellow in his/her training and all have returned home to make sustainable changes in the country’s surgical training programs.

India’s surgical system was established in the 1950s and has not changed much since, despite peer feedback voting largely in favour of reform. The Fulbright Commission proposal ‘Global Surgical Education and Uniformity’ was born out of observation that many surgical trainees in India were leaving to complete their education in the United States due to the more comprehensive quality of training. The proposal listed several excellent suggestions for reducing the heterogeneity between the two countries’ training and we believe that they are relevant to any institution wishing to follow suit. First and foremost, the establishment of a national council similar to the American Board of surgery is needed to organize centralized examinations and a standardized certification process. The suggestions also elective programs and global partnerships to facilitate bilateral research exchanges. It was recommended that guidelines surrounding duty hours, case loads, OR participation, and remediation protocols undergo revision in accordance with a surgical board and to ensure their strict adherence. Lastly, it called for skill upgrading through the adoption of robotics and laparoscopic training.


Conclusion

Surgical training is dynamic in that it reflects innovative technologies and techniques, population health trends, as well as the government sanctions that can directly limit or enable a hospital’s infrastructure and activities. The uneven skill sets between surgeons in high and low-income countries are powerful testament to the urgent need for standardized surgical training through a mechanism that will have an impact to patients while addressing the government barriers that stand in the way of doing so. When examining the 14 countries within the College of Surgeons of East, Central, and South Africa, we see that these countries’ GDP health expenditures are very low compared to their high population densities. If the government does not invest in surgical training, it is unlikely that officials would be willing to go one step further and ascribe to national boards or accreditation councils. Thus, a cycle of nonuniform surgical training is perpetuated and countries fail to thrive equally.

The excellence of surgeons is only as good as their training opportunities allow. While a natural degree of variance is expected between training centers, it is within institutional and government interest to adopt standardized approaches for educational delivery. Evidence-based teaching and evaluation guidelines will facilitate this effort, as well as commitment from educational organizations, program directors, ministries of health and national surgical boards. Reduced heterogeneity simply means that all surgeons are united in their efforts to promote best practices and reduce adverse clinical outcomes. There are several paved roads in these educational pathways in both HIC’s and LMIC’. There are, however, several which are not. Working with members that want to help develop and enhance the current infrastructure is a social responsibility that is important to us.  Like many hoping to make a difference, we also share your enthusiasm and see how the technological advances we have reached help to realize the above. A change is certainly on the horizon and it may come sooner than we think.


Reference:

  1. Singh P, Aggarwal R, Darzi A. Review of selected national surgical curricula: quantity is not the sole marker of quality. J Surg Educ. 2014 Mar-Apr;71(2):229-40. doi: 10.1016/j.jsurg.2013.07.015. https://www.ncbi.nlm.nih.gov/pubmed/24602715
  1. Hohmann E, Tetsworth K. Fellowship exit examination in orthopaedic surgery in the commonwealth countries of Australia, UK, South Africa and Canada. Are they comparable and equivalent? A perspective on the requirements for medical migration. Med Educ Online. 2018 Dec;23(1):1537429. doi: 10.1080/10872981.2018.1537429. https://www.ncbi.nlm.nih.gov/pubmed/30372402
  2. Rickard, J. Systematic Review of Postgraduate Surgical Education in Low- and Middle-Income Countries. World J Surg (2016) 40: 1324. https://doi.org/10.1007/s00268-016-3445-x https://link.springer.com/article/10.1007/s00268-016-3445-x#citeas
  3. Wang DE, Sultan D, Ismail H, Robinson E, Zulu R, et al. Understanding surgical education needs in Zambian residency programs from a Resident's perspective. Am J Surg. 2019 Jan 4. pii: S0002-9610(18)30723-2. doi: 10.1016/j.amjsurg.2018.12.073. [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/30654918
  4. Kakande I, Mkandawire N, Thompson MIW (2011) A review of surgical capacity and surgical education programmes in the COSECSA region. East Cent Afr J Surg 16:6–34
  5. Mittal VK. Global Standardization of Surgical Training. Indian J Surg. 2014;76(5):341–342. doi:10.1007/s12262-014-1189-0 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4571522/
  6. Kakande I, Mkandawire N, Thompson MIW (2011) A review of surgical capacity and surgical education programmes in the COSECSA region. East Cent Afr J Surg 16:6–34
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