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Anaesthetic training: not better, not worse, just different

In their accompanying article [1], Paul et al. present information concerning the number of training opportunities for trainee anaesthetists in their hospital between 1999 and 2009. Their principal conclusion is that for all grades of trainee as a single group, they find no evidence that the European Working Time Directive [2] adversely affected training opportunities in their hospital, in terms of supervised time over this period. It is possible that without the Directive, which has been a Regulation (the EWTR) since its delayed implementation in 2009, trainee service workload might have expanded uncontrolled, to the point that training itself was placed under threat. It is also possible that were it not for the EWTR, their department might now have many more discrete training opportunities than in 1999. Be that as it may, their data do support their conclusions. Of more interest to educationalists, indeed to the public, is the implicit suggestion that the quality of training during these training opportunities is also unchanged. However, Paul et al.’s study did not set out to quantify the quality or efficacy of the training opportunities they documented. There have been numerous developments in postgraduate medical education since 1999 [3]. There has been an increasing emphasis on the documentation of performance, the provision of effective feedback, the creation of Schools in Deaneries and the approval of posts and programmes against General Medical Council (GMC) standards [4]. What has been the effect of these developments? There have been many opportunities created for quality improvement and increased efficiency in the delivery of training, both in the working environment and away from it. Examples of this are the involvement of trainees and trainers from all crafts in the local architecture of their training environment; something of a tradition for UK anaesthesia [5–7]. Other developments such as trainee ⁄ trainer surveys, an emphasis on faculty development, and the recognition of the potential offered by simulated practice, have all created the prospect of improved educational governance [8]. The proposal that these changes may have offset, and possibly more than compensated for, any negative impact of the EWTR (if there has been a negative impact) has sufficient face validity that it merits further academic enquiry. Patient safety is the first domain in the GMC’s standards for training which are described in their 2011 document The Trainee Doctor [4]. The GMC requires that the ‘‘...supervision of trainees must be consistent with the delivery of highquality, safe patient care’’. The impact of non-technical skills and human factors on the curriculum for anaesthesia training in the UK is already measurable [9, 10]. The effect of the World Health Organization’s Surgical Safety Checklist in the UK is becoming more tangible as providers of surgical services implement the detail of these guidelines, for example, team briefing at the start of lists and marking the site of regional blockade [11, 12]. These developments are becoming a daily part of the experience of UK anaesthetists in training. Building the principles that underlie these initiatives into the development of medical professionalism in anaesthetists in training is likely to lead to improved patient care [9, 13]. And what of experience? The ubiquitous proposal that ‘experience’ is a fundamental component of achieving proficient practice has compelling face validity, but is it true? Byrne’s recent editorial [14] in this journal has eruditely drawn attention to the academic basis of what surgeons have been asserting for some time [15]. Byrne argues that apprentiship training enhanced by appropriately designed and assessed simulated practice is valuable. With reference to cognitive psychology, he proposes that, ‘‘... the function of an expert in any field is largely dependent on [the development of] schemata’’, which are internal Anaesthesia 2012, 67, 937–950