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Principles of surgical education

The balance between didactic teaching and learning in clinical practice will change as the trainee progresses through the training programme, with the former decreasing and the latter increasing.

A number of people from a range of professional groups will be involved in teaching. In accordance with GMC standards, subject areas of the curriculum must be taught by staff with relevant specialist expertise and knowledge. Specialist skills and knowledge are usually taught by consultants and more advanced trainees; whereas the more generic aspects of practice can also be taught by the wider multi-disciplinary team. The Assigned Educational Supervisor (AES) is key as he/she agrees with each trainee how he/she can best achieve his or her learning objectives within a placement.

Establishing a learning partnership creates the professional relationship between the teacher (AES, CS or assessor) and the learner (trainee) that is essential to the success of the teaching and learning programme.

The learning partnership is enhanced in the following situations:

  • When the teacher understands:
    • educational principles, values and practices and has been appropriately trained
    • the role of professional behaviour, judgement, leadership and team-working in the trainee’s learning process
    • the specialty component of the curriculum
    • assessment theory and methods.
  • when the learner:
    • understands how to learn in the clinical practice setting, recognising that everything they see and do is educational
    • recognises that although observation has a key role to play in learning, action (doing) is essential
    • is able to translate theoretical knowledge into surgical practice and link surgical practice with the relevant theoretical context
    • uses reflection to improve and develop practice (see self-directed learning).
  • When there is on-going dialogue in the clinical setting between teacher and the learner
  • When there are adequate resources to provide essential equipment and facilities
  • When there is adequate time for teaching and learning.

Trainee-led learning

The ISCP encourages a learning partnership between the trainee and AES in which learning is trainee-led and trainer-guided. Trainees are expected to take a proactive approach to learning and development and towards working as a member of a multi-professional team. Trainees are responsible for:

  • utilising opportunities for learning throughout their training
  • triggering assessments and appraisal meetings with their trainers, identifying areas for observation and feedback throughout placements
  • maintaining an up to date learning portfolio
  • undertaking self and peer assessment
  • undertaking regular reflective practice.

Learning opportunities

There are many learning opportunities available to trainees to enable them to develop their knowledge, clinical and professional judgement, and technical and operative ability and conduct as a member of the profession of surgery. The opportunities broadly divide into three areas:

Learning from practice

The workplace provides learning opportunities on a daily basis for surgical trainees, based on what they see and what they do. Whilst in the workplace the trainees will be involved in supervised clinical practice, primarily in a hospital environment in wards, clinics or theatre. The trainees’ role in these contexts will determine the nature of the learning experience.

Learning will start with observation of a trainer (not necessarily a doctor) and will progress to assisting a trainer; the trainer assisting/supervising the trainee and then the trainee managing a case independently but with access to expert help. The level of supervision will decrease and the level of complexity of cases will increase as trainees become proficient in the appropriate technical skills and are able to demonstrate satisfactory professional judgement. Continuous systematic feedback, both formal and informal, and reflection on practice are integral to learning from practice, and will be assisted by assessments for learning (formative assessment methods) such as surgical Direct Observation of Procedural Skills in Surgery (DOPS), Procedure Based Assessment (PBA), Clinical Evaluation Exercise (CEX) and Case Based Discussion (CBD), each of which has been developed for the purpose.

Trainees are required to keep a surgical logbook to support the assessment of operative skills, using corresponding supervision levels:

Assisting (A):

The trainer completes the procedure from start to finish

The trainee performs the approach and closure of the wound

The trainer performs the key components of the procedure.

Supervised - trainer scrubbed (S-TS):

The trainee performs key components of the procedure (as defined in the relevant PBA) with the trainer scrubbed.

Supervised - trainer unscrubbed (S-TU):

The trainee completes the procedure from start to finish

The trainer is unscrubbed and is:

- in the operating theatre throughout

- in the operating theatre suite and regularly enters the operating theatre during the procedure (70% of the duration of the procedure).

Performed (P):

The trainee completes the procedure from start to finish

The trainer is present for 70% of the duration of the procedure

The trainer is not in the operating theatre and is:

- scrubbed in the adjacent operating theatre

- not in the operating suite but is in the hospital.

Training more junior trainee (T):

A non-consultant grade surgeon training a junior trainee

Observed (O):

Procedure observed by an unscrubbed trainee

In the workplace – informal

Surgical learning is largely experiential in its nature with any interaction in the workplace having the potential to become a learning episode. The curriculum encourages trainees to manage their learning and to reflect on practice. Trainees are encouraged to take advantage of clinical cases, audit and the opportunities to shadow peers and consultants.

In the workplace - planned and structured

Theatre (training) lists

Training lists on selected patients enable trainees to develop their surgical skills and experience under supervision. The lists can be carried out in a range of settings, including day case theatres, main theatres, endoscopy suites and minor injuries units.

Each surgical procedure can be considered an integrated learning experience and the formative workplace assessments provide feedback to the trainee on all aspects of their performance, from pre-operative planning and preparation, to the procedure itself and subsequent post-operative management.

The syllabus is designed to ensure that teaching is systematic and based on progression. The level of supervision will decrease and the level of complexity of cases will increase as trainees become proficient in the appropriate technical skills and are able to demonstrate satisfactory professional judgement. By certification time trainees will have acquired the skills and judgement necessary to provide holistic care for patients normally presenting to their specialty and referral to other specialists as appropriate. Feedback on progress is facilitated by the DOPS and PBA.

Clinics (outpatients)

Trainees build on clinical examination skills developed during the Foundation Programme. There is a progression from observing expert clinical practice in clinics to assessing patients themselves, under direct observation initially and then independently, and presenting their findings to the trainer. Trainees will assess new patients and will review/follow up existing patients.

Feedback on performance will be obtained primarily from the CEX and CBD workplace assessments together with informal feedback from trainers and reflective practice.

Ward Rounds (inpatient)

As in the other areas, trainees will have the opportunity to take responsibility for the care of in-patients appropriate to their level of training and need for supervision. The objective is to develop surgeons as effective communicators both with patients and with other members of the team. This will involve taking consent, adhering to protocols, preoperative planning and preparation and postoperative management.

Progress will be assessed by MSF, CBD, CEX, DOPS and PBA.

Learning from formal situations

Work-based practice is supplemented by an educational programme of courses, local postgraduate teaching sessions arranged by the Specialty Training Committees (STCs) or schools of surgery and regional, national and international meetings. Courses have a role at all levels — for example, basic surgical skills courses using skills centres and specialty skills programmes. These focus on developing specific skills using models, tissue in skills labs and deceased donors as appropriate, and are delivered by the colleges, specialty associations and locally by deaneries/LETBs.

It is recognised that there is a clear and increasingly prominent role for off-the-job learning through specific intensive courses to meet specific learning goals. Trainees must show evidence that they have gained competence in the management of trauma through a valid certificate of the Advanced Trauma Life Support (ATLS®), Advanced Paediatric Life Support (APLS) or equivalent, at the completion of core training. In the following specialties, trainees need to show that this certificate of competence is being maintained up to certification:

  • Neurosurgery
  • Oral and Maxillofacial Surgery
  • Paediatric Surgery (APLS)
  • Plastic Surgery
  • Trauma and Orthopaedic Surgery.

Learning from simulation

Simulation in this context means any reproduction or approximation of a real event, process, or set of conditions or problems e.g. taking a history in clinic, performing a procedure or managing postoperative care. Trainees have the opportunity of learning in the same way as they would in the real situation but in a patient-safe environment. Simulation can be used for the development of both individuals and teams.

Simulation training is often classified as either high or low fidelity. The fidelity of simulation refers to how accurately or closely the simulation resembles the situation being reproduced. The realism of the simulation may reflect the environment in which simulation takes place, the instruments used or the emotional and behavioural features of the real situation. Simulation training does not necessarily depend on the use of expensive equipment or complex environments, e.g. it may only require a suturing aid or a role play.

Simulation training has several purposes:

  • supporting learning and keeping up to date
  • addressing specific learning needs
  • situational awareness of human factors which can influence people and their behaviour
  • enabling the refining or exploration of practice in a patient-safe environment
  • promoting the development of excellence
  • improving patient care.

The use of simulation in surgical training should be regarded as part of a blended approach to managing teaching and learning concurrent with supervised clinical practice. The use of simulation on its own cannot replace supervised clinical practice and experience or authorise a doctor to practice unsupervised.

Provision of feedback and performance debriefing are integral and essential parts of simulation-based training. Feedback can be assisted by Workplace Based Assessments and recorded in the learning portfolio. Simulation training should broadly follow the same pattern of learning opportunities offering insight into the development of technical skills, team-working, leadership, judgement and professionalism.

Self-directed learning

Self-directed learning is encouraged. Trainees are encouraged to establish study groups, journal clubs and conduct peer review; there will be opportunities for trainees to learn with peers at a local level through postgraduate teaching and discussion sessions, and nationally with examination preparation courses. Trainees are expected to undertake personal study in addition to formal and informal teaching. This will include using study materials and publications and reflective practice. Trainees are expected to use the developmental feedback they get from their trainers in appraisal meetings and from assessments to focus further research and practice.

Reflective practice is a very important part of self-directed learning and is a vital component of continuing professional development. It is an educational exercise that enables trainees to explore with rigour the complexities and underpinning elements of their actions in surgical practice in order to refine and improve them.

Reflection in the oral form is very much an activity that surgeons engage in already and find it useful and developmental. Writing reflectively adds more to the oral process by deepening the understanding of surgeons about their practice. Written reflection offers different benefits to oral reflection which include: a record for later review, a reference point to demonstrate development and a starting point for shared discussion.

Some of this time will be taken as study leave. In addition there are the web-based learning resources which are on the ISCP website and specialty association websites.

Academy of Medical Royal Colleges (AoMRC) guidance on entering information onto ePortfolios can be found here.