{'fraction_non_alphanumeric': 0.01712707182320442, 'fraction_numerical': 0.003130755064456722, 'mean_word_length': 5.5512665862484925, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
DOES TEACHING AFFECT OUTCOME WITH MAJOR OPEN SURGERY?

The Royal Australasian College of Surgeons has introduced surgical education and training (SET) with the aim of streamlining and thus reducing the duration of surgical training.1 As a consequence, it is possible that trainees will enter specialist training at an earlier stage in their career with limited experience and exposure to all aspects of surgery and with less time to acquire technical surgical skills. Current operative teaching is a combination of a modular curriculum and an apprenticeship model whereby mentors teach skills to help the trainee’s gain competency in all components of core operative procedures. Effective training requires not only observation and assistance during surgery but also the opportunity to be actively involved. Appropriate supervision must be available to ensure no compromise to patient safety. Furthermore, operative outcomes have become subject to increasingly rigorous scrutiny and public expectation that may potentially influence training opportunities. Wide-ranging resources are now available as adjuncts to surgical training outside of the operating theatre. These include animal and cadaver workshops, inanimate bench models, computer-based learning and most recently virtual reality stimulators.2 An ongoing challenge is to match the appropriate resource to a particular skill being taught. These resources need to serve training needs and should occur within a sound educational framework.3 Although these resources have an evolving role, they cannot replace direct ‘hands on’ experience, which accommodates the numerous anatomical and pathological variations that exist in surgical practice. Operative competence implies the ability to carry out the operation in its entirety. Successful surgery incorporates both technical and cognitive abilities. Early identification of strengths and weaknesses in an individual trainee provides efficiency in training by maintaining a positively accelerating trajectory in acquiring competency.4 Mentor and trainee fatigue can both compromise surgical training. Focusing on all components of a procedure within a teaching environment can be difficult, particularly in the later stages of an operation and may prolong operating time. Most complex important surgical procedures may be defined by several steps, all of which are critical to the success of the operation. Published work in surgical education supports acquiring surgical expertise through deliberate practice, whereby the trainee focuses on a defined task rather than undirected time spent within the operating theatre.5 Improvements in performance occur when clear objectives and focused practice on defined tasks are combined with immediate correction and feedback.6 Urological surgery, like most other surgical specialties, requires a diverse set of skills, including endoscopic, laparoscopic and open techniques. As a consequence of this evolving diversity, the acquisition of operative skills in particular is becoming increasingly difficult to achieve within current training programmes. To address these issues, we developed a structured modular operative teaching programme for radical retropubic prostatectomy (RRP) similar to a model by Stolzenburg et al.7,8 (Table 1). By carrying out selected components of the operation, each module establishes a clearly defined objective for the trainee. The number of components an individual trainee carries out per procedure is variable and depends on the trainee’s experience and progress throughout his/her rotation in a particular post. Because of anatomical and time considerations, not all components are always carried out by the trainee in consecutive order of degree of difficulty or by operation sequence. When the trainee carries out more advanced components, particularly when these are in the later stages of an operation, the consultant surgeon carries out components of lesser difficulty. Thus, the trainee is not distracted or fatigued by preliminary steps, providing them with the best opportunity to meet the specific objectives of the task. In our experience, a first-year advanced trainee (SET three equivalent) carries out four components per operation not exceeding difficulty grade 3. A second-year advanced trainee carries out nine components of all grades with the consultant surgeon completing lower degree of difficulty components to maintain operative momentum. Our modular teaching programme for RRP has now been incorporated into training in a private practice setting. In all specialties, many important procedures because of their elective nature are more commonly carried out within the private sector compared with public hospitals, which are overburdened by trauma and emergency surgery. Eighty per cent of RRP are carried out within private hospitals.9 Using trainees in this setting provides an opportunity to enhance trainee exposure and experience in both RRP and open surgery. To evaluate any compromise in patient or economic needs, after 12 months of follow up, we have independently and prospectively collected and compared 75 consecutive RRP carried out by a single consultant urologist and the remaining 63 RRP carried out involving a urological trainee following a modular operative framework. Preoperatively, patients are counselled regarding the K. Gray MB BS; P. HeathcoteMB BS, FRACS (Urol); D. Nicol MB BS, FRACS (Urol).