Para um vislumbre do mundo de treinamento cirúrgico mais de 100 anos atrás, pode-se olhar para The Agnew Clinic por Thomas Eakins e observe imediatamente as grandes diferenças em relação aos dias de hoje. O anatomista e cirurgião David Hayes Agnew segura ferramentas com as mãos nuas enquanto sua equipe cirúrgica prende um paciente a uma mesa e pressiona seus bisturis contra sua pele. Uma plateia de cavalheiros vestidos de ternos contempla o espetáculo com expressões faciais que vão da diversão ao choque 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. (Se você estiver interessado na carga global de doenças cirúrgicas por país, encorajamos você a ler The Lancet Commission on Global Surgery: https://www.lancetglobalsurgery.org)
Como acontece com a maioria dos países, os programas de treinamento cirúrgico em países de primeiro mundo exigem que os trainees entrem como médicos licenciados antes de completar vários anos de residência. O estágio, período preliminar entre a faculdade de medicina e a residência, não é mais uma fase comum do processo de treinamento, embora ainda seja praticado em sistemas selecionados. A duração do programa de residência varia de acordo com a especialidade, escola e / ou 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 Padrões para currículos e sistemas de avaliação 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.
Uma das maneiras mais eficazes de melhorar o treinamento cirúrgico é padronizar os critérios para capacidades cirúrgicas de alta qualidade e desenvolver ferramentas de avaliação associadas. Ambos devem ser transparentes para estagiários e professores para que cada habilidade possa ser claramente direcionada, alcançada e corrigida, se necessário. As avaliações baseadas em evidências irão influenciar diretamente a qualidade do atendimento ao paciente prestado, portanto, é crucial que os centros de treinamento trabalhem com os conselhos nacionais para desenvolver uma abordagem padronizada para as métricas de avaliação.
Mesmo entre os países bem desenvolvidos, conforme descrito acima, os padrões de treinamento padronizados ainda não foram implementados. As consequências de padrões de treinamento heterogêneos são aparentes quando consideramos o domínio da migração médica no século 21, especialmente entre países de alta renda (HICs) e países de baixa a média renda (LMICs). Este não é um fenômeno pequeno; entre 23-28% de médicos em atividade no Canadá, EUA, Austrália, Reino Unido e Nova Zelândia receberam seu treinamento em outro lugar. A mobilidade entre HICs é apenas uma realocação de indivíduos altamente qualificados, mas a perda de médicos de LMICs para HICs representa uma séria desvantagem em ambas as extremidades.
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 treinamento cirúrgico de alta qualidade. 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.
Conclusão
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.
Referência:
- Singh P, Aggarwal R, Darzi A. Revisão dos currículos cirúrgicos nacionais selecionados: a quantidade não é o único marcador de qualidade. J Surg Educ. Março a abril de 2014; 71 (2): 229-40. doi: 10.1016 / j.jsurg.2013.07.015. https://www.ncbi.nlm.nih.gov/pubmed/24602715
- Hohmann E, Tetsworth K. Exame de saída de bolsa em cirurgia ortopédica nos países da comunidade da Austrália, Reino Unido, África do Sul e Canadá. Eles são comparáveis e equivalentes? Uma perspectiva sobre os requisitos para a migração médica. Med Educ Online. Dezembro 2018; 23 (1): 1537429. doi: 10.1080 / 10872981.2018.1537429. https://www.ncbi.nlm.nih.gov/pubmed/30372402
- Rickard, J. Revisão Sistemática da Educação Cirúrgica de Pós-Graduação em Países de Renda Baixa e Média. 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
- 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 janeiro de 2019 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
- Kakande I, Mkandawire N, Thompson MIW (2011) Uma revisão da capacidade cirúrgica e dos programas de educação cirúrgica na região da COSECSA. East Cent Afr J Surg 16:6–34
- Mittal VK. Padronização Global de Treinamento Cirúrgico. Indian J Surg. 2014;76(5):341–342. doi:10.1007/s12262-014-1189-0 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4571522/
- Kakande I, Mkandawire N, Thompson MIW (2011) Uma revisão da capacidade cirúrgica e dos programas de educação cirúrgica na região da COSECSA. East Cent Afr J Surg 16:6–34
