Surgical Training
06
Mayo
Cirugía

Heterogeneidad en la formación quirúrgica

Publicado en por Brian Bubser

Para echar un vistazo al mundo de entrenamiento quirúrgico hace más de 100 años, uno puede mirar La Clínica Agnew por Thomas Eakins e inmediatamente observe las grandes diferencias en comparación con la actualidad. El anatomista y cirujano David Hayes Agnew sostiene herramientas en sus manos desnudas mientras su equipo quirúrgico sujeta a un paciente a una mesa y presiona sus bisturíes en su piel. Una audiencia de caballeros vestidos con traje contempla el espectáculo con expresiones faciales que van desde la diversión hasta la conmoción total.

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.  (Si está interesado en la carga global de enfermedades quirúrgicas por país, le recomendamos que lea The Lancet Commission on Global Surgery: https://www.lancetglobalsurgery.org)

Como ocurre con la mayoría de los países, los programas de formación quirúrgica en los países del primer mundo requieren que los aprendices ingresen como médicos con licencia antes de completar varios años de residencia. La pasantía, un período preliminar entre la escuela de medicina y la residencia, ya no es una fase común del proceso de formación, aunque todavía se practica en sistemas selectos. La duración de un programa de residencia varía según la especialidad, la escuela y / o el país.

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 Estándares para planes de estudios y sistemas de evaluación 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.

Una de las formas más efectivas de mejorar la formación quirúrgica es estandarizar los criterios para las capacidades quirúrgicas de alta calidad y desarrollar herramientas de evaluación complementarias. Ambos deben ser transparentes para los alumnos y los profesores, de modo que cada habilidad pueda ser claramente enfocada, lograda y remediada si es necesario. Las evaluaciones basadas en evidencia influirán directamente en la calidad de la atención al paciente que se brinda, por lo que es crucial que los centros de capacitación trabajen con los consejos nacionales para desarrollar un enfoque estandarizado para las métricas de evaluación.

Incluso entre los países bien desarrollados, como se describió anteriormente, los estándares de capacitación estandarizados aún no se han implementado. Las consecuencias de estándares de formación heterogéneos son evidentes cuando consideramos el predominio de la migración médica en el siglo XXI, especialmente entre países de ingresos altos (PIA) y países de ingresos bajos a medianos (PIBM). Este no es un fenómeno pequeño; entre 23-28% de médicos en ejercicio en Canadá, EE. UU., Australia, Reino Unido y Nueva Zelanda recibieron su capacitación en otros lugares. La movilidad entre HIC es solo una reubicación de personas altamente calificadas, pero la pérdida de médicos de LMIC a HIC plantea una seria desventaja en ambos extremos.

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, programas de formación quirúrgica de alta calidad. 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.

Conclusión

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.

Referencia:

  1. Singh P, Aggarwal R, Darzi A. Revisión de programas de estudios quirúrgicos nacionales seleccionados: la cantidad no es el único indicador de la calidad. J Surg Educ. 2014 marzo-abril; 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. Examen de salida de la beca en cirugía ortopédica en los países de la Commonwealth de Australia, Reino Unido, Sudáfrica y Canadá. ¿Son comparables y equivalentes? Una perspectiva sobre los requisitos para la migración médica. Med Educ Online. Diciembre de 2018; 23 (1): 1537429. doi: 10.1080 / 10872981.2018.1537429. https://www.ncbi.nlm.nih.gov/pubmed/30372402
  2. Rickard, J. Revisión sistemática de la educación quirúrgica de posgrado en países de ingresos bajos y medios. 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. 4 de enero de 2019 pii: S0002-9610 (18) 30723-2. doi: 10.1016 / j.amjsurg.2018.12.073. [Publicación electrónica antes de la impresión] https://www.ncbi.nlm.nih.gov/pubmed/30654918
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