Earlier this year, I read a transcript of a keynote address from the USA titled: ‘Why Johnny can’t operate’.1 This transcript outlines the challenges faced by surgical trainees in the USA, most of which apply to our own specialty. In this opinion piece I want to consider the current issues around surgical training in obstetrics and gynaecology.
Do we have a problem?
RANZCOG has recently (2013) been re-accredited by the Australian Medical Council (AMC) as the training program for specialist obstetrician and gynaecologists. As part of this process, the College has had to clearly define the attributes of a newly graduated Fellow.2 The FRANZCOG graduate can then register with AHPRA, obtain a Medicare provider number and set up in solo private practice, booking operative procedures and carrying out those procedures unassisted and unsupervised. The prospective patient has no method available to gauge the experience and expertise of the surgeon and relies on the College’s assessment of competency combined with the institutional credentialing process.
Alternatively, those graduates who choose instead to commence specialist practice within the public system, either as a staff specialist or visiting medical officer, are afforded a certain degree of oversight and assistance, either planned or obtainable at short notice. However, skills attrition owing to low caseloads mandated by tight public hospital budgets remain a real risk for the new graduate.
Published surveys3 indicate a majority of these new graduates do not feel confident in their ability to undertake independent surgical practice. So, are we failing to train competent surgeons and, if this is so, why?
If we examine a generational time frame, say 30 years, and look at changes in our specialty’s surgical training, we find a multifactorial causation for a significant problem that has critical implications for the continued delivery of safe care to our patients.
- Do we have a problem?
- Can we blame the trainees?
- Is obstetric and gynaecological surgery becoming more difficult?
- Is it a (Trainee) selection problem? How do we include surgical ‘trainability’ in the selection criteria?
- Is sub-specialisation preventing generalist training in surgery?
- Why train obstetricians (and other ‘non-surgical’ specialists) to operate?
- Training in private settings is, at best, a partial solution.
- Simulation has a role in training surgeons.
- How are other surgical disciplines responding to this issue?
- Does ‘competent’ mean ‘independent’?
- Is operating enough? Why the current public health system is preventing training in holistic surgical care.
Over the remainder of this opinion piece I will examine some of those factors and offer for debate some possible solutions, keeping in mind the unalterable factors such as budgetary limits, gender balance in our specialty and the limitations to the current large pro bono contribution of Fellows to training new specialists.
The evolution of obstetric and gynaecological surgery
A combination of factors is contributing to the challenges of teaching surgery. These include reductions in surgical volume, restricted working hours, medicalisation of gynaecology, obesity in epidemic proportions and additional co-morbidities affecting an ageing gynaecological population. Increasing use of minimally invasive techniques leads to less open surgery, with the remaining (open) cases being complex and less suited to basic surgical training. Robotics means that the teachers are again learners, further reducing training opportunities. Intelligent integration of teaching excellence into the current operative lists is the only option, using published methods4 that maximise the available teaching in every surgical encounter.
You’re in, you’re not – selecting for a surgical specialty
Selection for vocational training is a complex and contentious issue, the only certainty of which is that with an increasing numbers of highly motivated quality candidates the process will become more difficult to get right. Objective measures of future surgical aptitude (‘trainability’) have some limited role in candidate ranking, but do not equate to working alongside the junior doctor in a setting that allows the qualities of a potential specialist to be assessed. Referee reports, CV and interview all have demonstrated failings for identifying those who, even with the best teachers, will retain a ‘two left thumbs’ rating for surgical skill. Obstetrics and gynaecology has the fallback option of the non-surgical career path, but we should not use this default to avoid continued efforts to select Trainees who can also be successfully taught surgery.
Can we blame the Trainees?
‘Rosy retrospection’ is the term for the cognitive bias behind the old adage ‘things were better/tougher/meaner in my day’ frequently quoted by successive generations over time. However, the Gen Y factor is likely to have a very limited role in the challenges facing surgical training today. It is unlikely that we will move far outside the current restrictions on overtime. The gender imbalance in the Trainee workforce (80 per cent female) makes provision for parental leave a constant with which we will have to deal when addressing surgical training. We need to set aside generational criticism and move forward when seeking solutions to training future surgeons.
It’s all the fault of sub-specialisation, right?
Countering the argument mounted by Colyer in the recent MJA Insight5 that subspecialisation was killing generalist training and practice, Leung and colleagues6 have described how the subspecialties (specifically gynaecological oncology) can be actively engaged to enhance both the operative skills and general understanding of the broader surgical journey of specialist FRANZCOG Trainees. In most tertiary centres, Fellows – subspecialty Trainees and overseas graduates on training visas – undertake surgical cases suitable for ‘generalist’ training, such as simple hysterectomy, uncomplicated pelvic floor repairs and primary mid-urethral slings. This reduces the caseload for core and advanced Trainees. Again, innovative and collaborative ways to acknowledge and overcome this seeming impasse are required and will only be achieved with strong leadership from senior clinicians who value and support equitable training opportunities across all groups.
The sensitive issue is the preferential allocation of training opportunities to overseas specialists on training visas, when local Trainees lack adequate surgical exposure. Externally funded overseas Trainees attached to subspecialty units provide assistance and after-hours cover, often to the detriment of local Trainees.
Do obstetricians need to be trained to operate?
Every time the surgical training debate is aired, the call is made to separate obstetrics and gynaecology at an early stage of the program, freeing up the gynaecological surgery training opportunities for the latter. The revised training program (with the inclusion of ‘special interest’ Advanced Training Modules [ATMs]) has recognised that the FRANZCOG qualification can no longer signify ‘is able to do everything’. It has also re-enforced the fact that obstetrics remains a surgical discipline and certain generic skills must be attained during training to ensure safe practice as a consultant. The increasing complexity of caesarean section surgery alone (obesity, abnormal placentation, other co-morbidities in an older population) dictates that division of the specialty into ‘surgical’ and ‘non-surgical’ is neither practical nor safe. The exceptions may include special interest groups such as sexual health physicians, office gynaecologists and the imaging subspecialty (COGU).
Training in private settings
RANZCOG has used the private sector for training since the Federal Department of Health initiative in 2006 (Extended Specialist Training Program) funded positions in the private sector. This continues, with some excellent opportunities provided by experienced training supervisors working with senior and mid-level Trainees within the private sector. With limited funding and competition among all the specialist colleges for the available support, this training pathway will remain a complementary rather than core part of RANZCOG surgical training.
Mentoring and group practice
Many FRANZCOG graduates will have limitations with respect to surgical expertise and scope of practice. The rewards of private practice will continue to encourage new graduates into either full-time private business or a combination of private and public work. It is timely to address the issue of mentorship and the benefits of group practice. RANZCOG has a statement on mentoring under development. The surgical personality has long encouraged a ‘coping, or being seen to be coping’ mentality, not always to the advantage of our patients. Does competent mean independent? The answer is, definitely, no. We need to encourage recent graduates to seek advice and assistance in their formative years of practice. This is particularly important when the initial years of specialist practice are undertaken part-time and there is a very real risk of rapid skills attrition.
Who is training the teachers?
Those who have taken a Trainee through his or her first (or even tenth) major surgical procedure know the anxiety that accompanies handing over control of a complex fine motor exercise to a relative novice. Loss of the correct surgical plane, poor clamp placement, poor knots and other variations from the teacher’s well-established procedural steps can cause supervisor and Trainee distress and loss of confidence for both. Some good surgical teachers are born, but others have to learn these skills. To counter this, a structured approach to each operating room encounter designed to maximise the benefit of teacher-Trainee interaction is crucial. Each Trainee will have differing needs for the same operation, the junior wanting to confidently enter the anterior peritoneal space (without cystotomy) at vaginal hysterectomy, and the senior Trainee keen to master the debulking myomectomy of the large uterus with inaccessible pedicles. This structured approach should become an integral part of every major surgical procedure undertaken by Trainees. Leung et al4 have published a validated template for the surgical encounter that maximises the learning opportunity of each operation. Surgeons responsible for teaching need to actively seek out those ‘trained teachers’ who can guide them towards becoming that elusive boss with whom everyone on the training program wants to work.
There’s more to surgery than operating
Good surgical results start in the consulting room, not the operating theatre. Knowing when not to operate is far harder than knowing when to operate, and the teaching of those skills requires a similar investment of time and resources to that required in the theatre. Managing a bad outcome requires far more skill than managing a success. The RANZCOG curriculum covers communication, peri-operative assessment and the difficult patient. However, the Trainee’s first contact with the patient may be the holding bay or anaesthetic room of the theatre. Many factors outside the control of the surgeon and Trainee mitigate against continuity of care for the surgical case, with some hospitals outsourcing outpatient services, and enforcing rosters so restrictive in hours it is pure chance if a Trainee sees a patient through from admission to discharge. Specialisation should not preclude holistic care of patient and family.
Don’t bring me problems, bring me solutions
Problems in obstetric and gynaecology surgical training are neither new nor immediately solvable. Strategies to address the issue include:
- Reducing the intake of accredited trainees from 2016 onwards.
- Expanding the current ‘teach the teachers’ programs to focus on surgical training.
- Prioritising the College e-Logbook project to allow real-time access to Trainee procedure numbers.
- Expanding the role of simulation in our training.
- Supporting mentorship and group practice for new graduates.
- Restricting overseas specialists using training positions that could be allocated to local Trainees.
- Including core Trainees in the subspecialty operations, using parts of complex procedures to teach general skills (for example, the mid-urethral sling that is part of a complex pelvic floor repair, the hysterectomy that is part of a complex gynaecological oncology case and so on).
- Working in active collaboration with the other surgical colleges to find solutions to a shared problem.
In conclusion, I believe we should actively engage all stakeholders across the surgical disciplines to seek immediate and sustainable solutions to the problems besetting surgical training. This is the role of the specialist medical colleges – to act as leaders and facilitators in curricula writing, standard setting and assessment to ensure that the graduates meet community needs and expectations in holistic surgical care.
- Professor Richard Bell Surgery 2009; 146:533-42 (Presented in an abridged version at the 66th Annual Meeting of the Central Surgical Society, Sarasota, Florida, March 5-7, 2009).
- RANZCOG Statements – C-Gen 19: Attributes of a RANZCOG Fellow www.ranzcog.edu.au/college-statements-guidelines.html#general .
- Obermair A, Tang A, Charters D, Weaver E, Hammond I. Survey of surgical skills of RANZCOG trainees. ANZJOG. 2009;49(1):84-92.
- Leung Y, Salfinger S, Tan JJ, Frazer A. The introduction and the validation of a surgical encounter template to facilitate surgical coaching of gynaecologists at a metropolitan tertiary obstetrics and gynaecology hospital. ANZJOG. 2013;53:477-83.
- Colyer S. Subspecialists hold back generalists. Available from: https://mjainsight.com.au/insight/2014/26/subspecialties-hold-back-generalists .
- Leung et al. 2014. Subspecialty training programs and the specialist Trainee. (Personal communication – Submitted for publication).