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Surgical training and assessment: 2013

In 2009, a full edition of ANZ Journal of Surgery was devoted to education, covering trainee selection, training, examination and continuing medical education. Recognizing our College commitment to the education of trainees, this edition includes a series of papers providing updated information. In a preliminary report, Oldfield et al. look at the correlation between trainee selection scores and their performance during Surgical Education and Training (SET) years 1–3. The trainees’ curriculum vitae scores appear to have poor correlation with subsequent performance during the first years of surgical training. With the progressive reduction in hours worked, the emphasis on a rapid surgical journey for patients and altered patient and community expectations, surgical training is under considerable pressure. While surgeons strongly support the apprenticeship model, it is recognized that some technical and non-technical surgical skills can be acquired more rapidly through varying forms of simulation. Perry and Oldfield provide an update on progress in this area of surgical education. Crebbin, Beasley and Watters expand upon the concepts of slow and fast thinking, and how an understanding of this information processing can explain differences between experienced surgeons and trainees in the accuracy and speed of clinical decision making. While both processes are complementary, the experienced surgeon more often utilizes fast thinking, an intuitive subconscious process relying largely upon pattern recognition, to quickly reach a decision. In contrast, the trainee with limited experience is dependent upon slow thinking, a more analytical conscious process where the numerous separate items of information available are considered. Campbell and Watters further develop this theory and, highlighting the importance of situational awareness, explore decision making in the setting of emergency surgery. Given that there is often limited and incomplete clinical and investigative information available, the experienced surgeon is more comfortable accepting uncertainty while commencing intervention. The trainee surgeon lacking apparently important items of information is at risk of being overcome with anxiety and thereby failing to commence the necessary timely care. Watters and Truskett consider errors arising in emergency surgery as being those of omission, commission or inition. While we all acknowledge the occurrence of errors of omission (reflecting failure as a consequence of a lack of knowledge, clinical information or interpretation) and errors of commission (reflecting failure because of inappropriate intervention for the specific clinical situation), we are much less likely to admit to and discuss errors of inition (failure to intervene where our or other interests are placed ahead of those of the patient). Distractors are highlighted as significant background influences upon appropriate decision making, particularly in emergency surgery provision, and good situational awareness can help to mitigate the risk of errors. Surgical training underwent significant change with the introduction of the SET programme 4 years ago, so it is timely that Beasley and Hardware discuss the influence of these changes on the final examination. The development of explicit curricula for each of the nine specialties has provided a framework upon which the examination is now based. This has helped to ensure that the final fellowship examination covers the breadth of the curriculum. In addition, Bloom’s taxonomy has been utilized (with knowledge recall being at the lower end, and complex evaluation of knowledge at the higher end) to better consider the level of cognitive function required in setting the examination. The final fellowship examination represents a significant summative assessment of each surgical trainee prior to their commencement of independent surgical practice. Consequently, it is essential that this is based upon the breadth of knowledge and at sufficient depth to ensure each candidate will be able to provide high-quality safe surgical care. While in the past, this examination lacked consistency across the seven segments, whereby candidates could experience significantly different assessments, there has been progressive standardization. Beasley et al. describe the increased examiner training provided to promote greater consistency between examiners in their approach and decision making. Examination marking has long been based on the close marking system to arrive at a pass/fail decision. While it has been relatively easy to distinguish candidates at the each end of the scale, decision making in respect to the borderline candidate has often been difficult. In an attempt to improve the reliability and validity of the examination and to provide better information about both the candidate and the examination, there has been considerable work undertaken developing an expanded version of the close marking system. Beasley, Wannan and Hardware provide detail of this modification and report on findings of trials of its use. This series of articles provides fellows, trainees and those with an interest in surgical education with considerable information in respect to the College’s progressive approach to the education of our junior colleagues. There is also much for each of us to understand about our own thinking and with this knowledge better assist the trainees with whom we work each day.