Abstract
The surgeon apprentice
Surgical training has always involved an apprenticeship between trainer and trainee. The concept of a learning curve in the ‘craft specialities’ and the relationship between the number of cases performed and surgical complications are well known. 1 Historically, a transition from assistant through supervised operating to independent operator was made on the simple basis of case volume and attendance in theatre. Yet, the advent of laparoscopy has provided an opportunity to evolve traditional training techniques, which have been primarily based on quantity over quality, and perhaps redefine the roles of trainer and trainee.
Laparoscopic surgery has many benefits in terms of patient outcomes. 2 But in addition to these, there are the advantages for surgical training as laparoscopy lends itself for use as a remote teaching tool.3,4 There have been many studies investigating the optimal methods of training to minimise the learning curve, 5 but what has rarely been addressed is the changing relationship between trainer and trainee.
Surgical training can be categorised into two distinct components: (1) acquisition of dexterity; and (2) pattern recognition and decision-making. While the first of these requires physical practice, the latter can be part-learnt outside the operating theatre to some extent. For example, reviewing recorded laparoscopic procedures in an analytical manner as part of surgical training allows for the conscious increase in pattern recognition and therefore operative decision-making. Surgical decision-making can be further divided into intuitive or analytical, depending on the context of the procedure. 6 However, both processes rely on experience and pattern recognition. Intimate analysis of different operative scenarios between trainer and trainee can therefore contribute to shortening the learning curve.
The ‘surgical coach’
If a trainer has successful methods and invests time and effort into their trainee, they are more likely to succeed. Compare this to the world of professional sport. Modern training tools used by professional sports coaches and their dedication to improvement play an enormous part in the success of athletes. The detailed monitoring of performance helps identify areas of strength and weakness allowing for tailored programmes to be developed. Individual sports such as tennis and golf have a more intimate player–coach relationship akin to a consultant and registrar. In many cases, it is the nature of this relationship which is most often what underpins success in both sport and surgical training.
Without trivialising the stakes involved in operating on a patient, surgery as a discipline has many similarities to professional sport. In addition to the years of dedication and sacrifice required to master the technical skills demanded of surgery, the training methods of a surgeon are comparable to the training of an elite athlete. And just as sport has adopted modern training tools, in particular the use of video-based analysis to improve the minutest of technical details, so too does laparoscopy lend itself to such methods.
The ‘surgical replay’
Video-based analysis of surgery is not an entirely new concept, 7 but laparoscopy provides the ideal situation to exploit this. The use of videos to scout opponents, develop skill and perfect specific techniques is ubiquitous to all sports. The coach identifying areas of improvement and translating that to the player(s) through the use of edited videos is a powerful tool. However, surgery has one major advantage over professional sports in this respect as sports coaches tend to be ex-players at best, while surgical trainers are commonly practising surgeons at the peak of their careers. The experience and training tips they can offer are those which they use every day and are therefore closer to reality for the trainee – the credentials of the surgical trainer can be directly assessed by the trainee.
The role of the trainer must therefore evolve with the technology on offer. The teaching methods of open surgery may not be optimal for laparoscopy, and video-based analysis should become the norm. Trainees are able to find vast resources online to become familiar with specific laparoscopic procedures before attempting the actual surgery. But beyond this, it is the role of the trainer to sit with the trainee and go through videos of procedures being taught to familiarise the trainee with the techniques required. Furthermore, focus on individual steps of the procedure in a variety of situations furnishes the trainee with a ‘toolbox of tricks’ to manage a spectrum of patients. Using an example specific to colorectal surgery, the trainee can be shown ligation of a colonic vessel in a number of different clinical scenarios using different techniques to ensure they are equipped to deal most eventualities. It is the concept of breaking the whole operation down into a series of steps which can be marginally improved one bit at a time leading to an overall significant increase in proficiency. David Brailsford, the successful Team GB cycling coach, explained their success as follows: The whole principle came from the idea that if you broke down everything you could think of that goes into riding a bike, and then improved it by 1%, you will get a significant increase when you put them all together.
In our experience, watching example videos of the procedure to be undertaken helps focus the trainee and allows pattern recognition to be fresh in the mind. The de-brief means the positive and negative aspects of the case can be discussed in detail using the video of the case to punctuate the feedback. Hu et al. 9 performed an interesting study using a video-based coaching technique to provide feedback for trainees. The study showed that using such a method is instructive to trainees of any level and provides a practical approach to continuous professional development.
Conclusion
Surgery already takes lessons from the airline industry and can take similar lessons from professional sport with regards to training. The relationship of a coach and elite sportsman is similar in many respects to that of trainer and trainee. As surgical technology advances, so must the teaching tools and strategies to train the next generation of surgeon.