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Featured Article: Debra A. DaRosa, PhD ACS Presentations RRC Procedures for Granting Duty Hour Exceptions
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Educating surgeons in a 48-hour week: Time to change mindset Educating Surgeons In A 48-Hour Week: Time to Change Mindset In this article the authors report back from a colloquium held at Balliol College, Oxford, last September. The meeting, convened by the Oxford School of Surgery, considered the challenges posed to education by the reduced hours brought in August 2009 by the European Working Time Directive (EWTD). Executive summary The colloquium reached consensus on the following:
A major challenge facing UK surgical education in the 21st century is the introduction in August 2009 of the 48-hour working week as the final phase of compliance with the EWTD.1 This, together with changes in society’s expectations of medical professionals, target-driven government control of healthcare and a general expectation of a reasonable work–life balance, is challenging surgical educators to meet the demands of a ‘high stakes’ educational programme. Patient safety will be at risk if this is not attended to with the utmost care and wisdom. To consider these issues the Oxford School of Surgery invited practicing surgeons with a commitment to surgical education and healthcare educators in higher education from the UK, USA and Australia, to a colloquium at Balliol College, Oxford. The expressed aim of the colloquium was to create a consensus on practical solutions to influence surgical education in the NHS in the light of the EWTD. Background to the EWTD The NHS has for the last 60 years combined service and the education of doctors to create the effective healthcare system that our society currently enjoys. Surgeons now practising in this system gained their expertise through many hours of work at a time in which few if any restraints existed to limit working hours.2 Although few would wish to return to the excessive work hours of the past, the impending 48-hour working week and its implementation is already changing the experience and training of surgeons. Surgeons’ view of the EWTD is generally hostile as it significantly deviates from traditional surgical practice, with the close and interdependent relationship between consultant surgeons and surgeons in training.3 Doctors and administrators have expended considerable energy to achieve compliant rotas to prevent hospital trusts receiving penalties for failure to comply with the directive. There has been scant attention to the quality of education available to train our next generation of consultant surgeons despite an acceptance that this impacts on the quality of patient care.4 A declared purpose of the directive is to ensure safe patient care (http://www.healthcareworkforce.nhs.uk/wtdaboutus.html). Ironically there is growing evidence that the compliant rotas are increasing both doctors’ feelings of fatigue and mistakes in decision-making.5 This is particularly associated with night rotas, which have been introduced despite views from all grades of surgical staff that this does not easily fit complex medical professional (particularly surgical) practice. Additionally, this law’s implementation is seriously compromising sound surgical education due to significantly reduced contact of trainees and trainers. The colloquium Thirty-two delegates attended the colloquium and the Balliol College environment encouraged an open and wide-ranging debate. The participants included trainees, training programme directors, surgical academics, educationalists and representatives from the strategic health authority, deanery and the College. Representatives from the Department of Health and local NHS trusts were invited but were unable to participate. The two-day programme was a mixture of plenary presentations, small group discussions and feedback sessions. There was early agreement in the colloquium that the 48-hour working week could provide a unique opportunity to review how surgical education and training is resourced and delivered. A new approach to clinical and educational programmes could become a reality and ensure the best learning opportunities were made available to surgeons in training. It was recognised that this would require a change of mindset of all involved in surgical education and a need to be visionary, courageous and determined. Range of views on the EWTD The views of the participants on the EWTD are summarised in Table 1 and fall into two categories: benefits and opportunities, or risks and threats. There was a unanimous view that something could and should be done to improve surgical education, using the EWTD as a catalyst. Surgical education must be seen as a priority to preserve and advance surgical expertise and the values of the profession of surgery.
Questions to be addressed Delegates considered a range of questions, which were stimulated through a mixture of plenary sessions, small group discussions followed by feedback and vigorous debate by the entire group. Chatham House rules (http://www.chathamhouse.org.uk/about/chathamhouserule/) encouraged frank discussion, especially from trainees who actively responded to the opportunity to contribute. The key areas of discussion were:
The following summarises the key findings with respect to the responsibilities of the learner to his or her own learning, learning as a group, the responsibilities of
the surgeon educator, faculty responsibilities and the importance of the learning environment. These are summarised below but a more detailed account of the proceedings of the colloquium may be obtained from Tony Jefferis, The learner’s responsibilities There was unanimous agreement that the learners have a key responsibility:
Learners as a community The colloquium agreed that surgeons in training have the potential to influence their own education and training by collaborating with their peers, with their teachers in clinical practice and in the schools of surgery. There was a strong feeling that a cultural shift was required among surgical trainees towards the creation of surgical clubs within schools of surgery, to support self-motivated learning and problem-solving. There is educational validity in this idea.8 Participants believed there was scope to develop a number of groups to lead on education, management, research, audit, leadership, the changing societal needs for surgeons and surgery in the international context. Surgical leaders of the future would emerge as those leading the way in these activities. A return to a ‘firm’ or ‘apprenticeship model’ as recently described in Northwestern University of Chicago, when for up to six weeks at a time the learner becomes ‘apprenticed’ to one of the faculty and completely shares their working life, is an attractive idea.9 It resonated with the delegates as it mimics the surgical practice of the recent past in the UK but appears to avoid the ‘learning by chance’ weakness of the apprenticeship model. The educator’s responsibility The colloquium unanimously endorsed the importance of the relationship between the learner and educator as the building block of safe and sound surgical education. Good teachers were valued for their commitment and prioritisation of teaching, which was both inspiring and highly memorable. Recognising the tension between service and education, teachers should be the learner’s advocate, ensuring they can make the most of learning opportunities. The educational expertise of teachers must be developed through appropriate courses and further opportunities provided for those who wish to become specialists in education. This has is all too often been left to chance. Educating surgeons to become surgical experts requires expert teachers who can nurture the necessary characteristics in surgeons by engaging in sound educational practice. Consultant surgeons should earn the right to have trainee surgeons by demonstrating their proficiency as teachers, clinicians and role models. The role of the surgeon educator should be as important as those with specific specialty surgical skills. Equivalence of merit for clinical excellence awards must apply to teachers as much as clinicians. The faculty of educators In the same way that surgeons in training need to form ‘clubs’ focused on learning and support so it was seen as appropriate for a faculty of surgical educators to develop. Faculty development would need to take place at trust, deanery and national levels. Each should be both the group delivering teaching and also be responsible for developing the vision of surgical education for the future. The need to gain the support of health service providers and employers was seen as pivotal to success. The educational environment The members of this colloquium expressed concern at the changing face of clinical practice and its effect on the education of surgeons and the professionalism of all. The current market-driven healthcare forces were thought to be eroding long-cherished surgical values and professionalism. There was a fear that surgeons might become technicians servicing a market rather than exercising their overall professional expertise in the best interests of individual patients. Summary Creating an environment to nurture good education and training needs a cultural change not only for surgeons but also for the organisations in which they work. The learning culture of NHS institutions is espoused by many but the rhetoric is not always underpinned by action to ensure it. The uneasy tensions between the provision of service and education need continuing debate and development between all interested parties. There are benefits for all but strong resolve will be necessary if the current market-led culture is not to trample on the education of the surgeons of the future. There was strong consensus that patient safety and surgical innovation would falter if champions for the cause were not forthcoming and supported. References
Reprinted with permission from Royal College of Surgeons of England
Online December 1, 2009 |
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