We are seeing increasing reports of the lack of engagement and recruitment of new graduates to the surgical disciplines. There is a dearth of training courses available for aspiring surgical trainees. It may take up to three years for newly qualified doctors and aspiring surgeon to get to theatre and actually handle surgical instruments. This is perhaps too late to realise that surgery may not be for you or frustrating that you have not been able to handle instruments before being expected to perform in theatre. Trainees are getting less and less time in the operating theatre to learn basic surgical skills. Wetlabs and simulators are not widely available and paradoxically, according to the literature, the most high fidelity labs are under lock and key and under used. We need a system of training and practice that can be achieved under supervision but carried out at home.
The profession would further benefit from identifying and encouraging surgeons early in their careers: many medical schools have Surgical Societies and many aspiring surgeons were drawn to the profession at school. It is never too early to start: looking at the age most our champion sports men and women started to acquire their skills.
Many consultants of today learnt their skills by volume by ‘practicing’ on patients. Basic Surgical Skills were acquired and rarely taught. Many a trainer, when asked how they executed a specific task will not be able to deconstruct the actions into set up, posture, instrument handling, angles etc. They will when it is explained i.e. the tacit is made explicit. Surgery is a motor skill that has to be learnt through practice. The acquisition of motor skills and the principles are well documented especially in sport. The theory and practice of coaching all athletes at every level involves an understanding of the fundamentals of movement and ergonomics.
The handling of instruments and the passage of the needle through the tissue can be explained in a similar way – this theory has been published and the success of this teaching is realised over sixteen years delivering critically acclaimed courses – PAR Excellence and PAR Aorta courses. The feedback from trainees includes “I wish I was taught this earlier!” and “why hasn’t anyone explained this to me before!”
The time it takes an expert surgeon and a trainee to deliver a needle through the tissue is the same for a single pass “systole”– but the difference between the expert and the trainees becomes obvious when examining the time it takes to set up to take the second stitch “diastole”. The diastolic time is reliant on the ergonomics of the setup, posture, positioning and handling of the instruments – these skills are tacit for the expert surgeon and have been honed by volume and time. For the trainee, this aspect can be explained and taught in educational terms as largely due to ‘Negative Passive behaviours’ of ‘not doing what should be done’. Have you ever wondered why a good operation appears as smooth; it because the diastolic period is minimized and the surgeon makes it look easy because they have attended to the setup, their posture, address to the table and angles i.e. all the negative-passive behaviours. These are poorly explained, taught or realised by the trainee or trainer alike but can be understood and more importantly practiced and rehearsed on low fidelity systems at home.
You will observe that most skills workshops have trainees seated on fixed chairs operating at tables – this is not optimising the functional anatomy of the upper limb and cannot be further from the movements and understanding of the ergonomics required to effect a smooth action at the operating table where we are standing. Those disciplines that do sit to operate undoubtedly have a stool that is on wheels and goes up and down. The stools can move through three dimensions. It is not fixed. We are training our surgeons incorrectly. Moreover, we do not offer a framework of understanding or provide models for deliberate practice.
The practice of surgery like all sports requires the application of the same principles. It is important to deconstruct the movements and explain ergonomics required to achieve the action. It is this understanding and rehearsal or these movements that will cultivate and reinforce a motor memory resulting in a reduction in the diastolic time of an operation and a smooth transition between actions.
The 10 000 hours needed to become an expert can be helped in the early stages of training with deliberate practice and observation by a skilled trainer.
These simple principles have been employed in the instruction of the martial arts for thousands of years. The power and flow is achieved with an attention to the practice of the deconstructed movements; the first skill is to master correctness.
This proposal is based on the observations and interviews of sixteen years of Silver Scalpel Award Winners and the learning achieved through the critically acclaimed PAR Excellence and PAR Aortic courses. We have demonstrated remarkable improvements in basic skills teaching over 190 students on potatoes, bananas and poached eggs! The video evidence of improving skills is compelling.
Laparoscopic surgery has an advantage as most the movements and be captured digitally for analysis – there are a plethora of models a available for practice but this luxury has not been afford the simple skills of
- Knife and scissor skills
- Knot tying skills
- Non dominant hand skills
- Assisting skills
With advise from educationalists, we have come up with a technique based assessment of these skills. The skills are analysed in three domains
Negative passive Behaviours
Each of the five skills is deconstructed. The focus is on the ergonomics of the action.
The theory and the models have been scrutinised by educational academics. The models meet the requirements for deliberately feedback and can be used at home. The result of practice has been be captured, coded and scored digitally. They are reproducible.
Mastery comes through practice
“The more I practice the luckier I get”
This has been successfully introduced to local and national level in Surgical Student societies and as well as foundation years. It has even been met with enthusiasm at a school careers fare.
The art of surgery starts with an understanding of the instruments, soft hands, respect of the tissues and coordinated movement. Deliberately practice requires models that offer feedback: the low fidelity model we use fulfill this need.
The learning needs to be overseen by an expert. Progression is dependent on mastering the basic steps and understanding the ‘Why’ of what we are doing. This is realizing the tacit knowledge of the expert surgeon and making it explicit.
Surgeons are very goal orientated and respond accordingly especially if there is a perceived reward.
The acquisition of these skills has been from the format used in martial arts. The progress and mastery of the basic movement will result in improved flow and accuracy. The first skill to master is correctness.
The concept of the Black Belt Academy of Surgical Skills is offered.Â This addresses many surgical concerns. The concept of diastolic learning focuses on basic techniques for the early surgeon:
- The tacit is now explicit and can be taught
- The practice is deliberate
- The models are available all the time at home
- It offers a clear syllabus
- It is not a one off
The benefits are clear. The training surgeon has a framework to practice and understand their skills. There are assessed at regular intervals and progression is documented. The aspiring surgeon and their trainers, as well as the patient, will see and feel the benefit of honed skills when they eventually get to theatre.
This offers the surgical profession an opportunity to instill enthusiasm and pride in the skills of surgery are very early age. There is no reason why it should not open to A level and medical students: many surgeons knew the wanted a career in surgery at an early age. We will able to identify the rising stars.
We can make this fun and a powerful attractor for our profession. The aspiring surgeon registers their intent to improve their skills and over a minimum of eighteen months attend skills workshops and grades. The registration and management is set up on a smart phone app.
A registration fee £50 entitles the trainee to a eighteen months tuition and a basic set of instruments with which high to practice
This Academy is to run as a franchise. It can be set up with minimal expense in any room by an enthusiastic trainer anywhere in the country.
I am inviting any consultant surgeon who sees this as an opportunity to shape the future of surgical training to contact me via twitter, LinkedIn or Facebook or email firstname.lastname@example.org.
I will be delighted to discuss this further.
David J. O’Regan
MBA (Distinction) MD BM FRCSEd (C-Th) FFSTEd
First Dan in Wado Ryu Shotokan Karate