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Maintaining adequate surgical training in a time of doctor shortages and working time restriction

The announcement by the Australian government to finance and create new training places for general practitioners and specialists over a 10-year period is very welcome not only to address the escalating demand for medical services, motivated by chronic doctor shortages in rural areas, an increasingly ageing and numbering Australian population, but also in order to replace the significant number of practicing doctors close to retirement. Besides the difficult task to accommodate such a large number of new trainees in a very short period of time, this proposal is expected to create an even bigger challenge for institutions such as the Royal Australasian College of Surgeons (RACS) in the era of ‘working time restriction’. Why? The RACS has a duty to maintain the highest standards for the education of surgical trainees. This is important if we want to continue offering quality treatment in both public and private hospitals. Reducing the training time is therefore not an acceptable way to accommodate workforce shortages. It will only create more specialists with limited exposure to a wide range of medical conditions, and as a result, their degree of knowledge and surgical expertise will be limited and suboptimal. In other words, ‘dilution’ of the current surgical workload in our institutions will necessarily imply favouring ‘quantity’ of trained surgeons over ‘quality’. This is unacceptable, not only for the safety of our patients but also in a world of increasing medico-legal implications and litigation. At present, under the new safe working hours policy, a general surgical trainee will be very lucky to include 130 major cases in his logbook over a 6-month term as compared to 10 years ago where this number was easily doubled. This is not to say that we should challenge those new guidelines and recommendations. On the contrary, safety and well being of our surgical trainees always remains a priority. As recently stated by the president of the Royal College of Surgeons of England, Mr John Black, ‘surgeons in training should have a contract defined by their training needs and not by hours worked’. In other words, the challenge of work time legislation is to know whether the surgical trainee can still assimilate the necessary clinical experience in a reduced time frame. Traditionally, a consultant surgeon would have had around 20 000 h of training, working, on an average, 80 h a week over a period of 5 years. Reducing this amount to 56 h a week would bring this total down to 13 440. What could be done about it? If we really want to increase the number of our surgical trainees without impacting on the quality of their education, several changes need to be made. We know that one of the main reasons for extended waiting times for elective surgery is the underfunding and lack of resources in public hospitals. This also includes chronic shortage of nursing staff. Due to lack of vital resources, it is becoming more and more common to see surgical lists being limited in an all-day list and/or patients having their procedure cancelled because of time constraint or theatre overrun. This, undoubtedly, contributes to spiralling of waiting lists. It is therefore imperative that theatre times allocated to consultant surgeons be adequately staffed and fully utilized. We cannot treat new patients if we do not have the nursing staff to look after them! I therefore suggest that priority be made on recruitment of new nurses. This invariably means not only listening to their current needs such as reducing ongoing pressure from their current extra responsibilities, workload and shift work but also improving their salaries and benefits such as subvention for their training. There are many ex-nurses who, I am sure, would consider going back to their previous job if real changes happened. Improving the workload of our hospitals within safe hour conditions is also the key to offering and maintaining a high-quality education experience for our trainees. This can only remain by implementing an effective hospital-specific training curriculum. If it does not happen, the only solution to maintain adequate standard is by extending the current length of surgical training such as in Norway or Germany. We should not compromise or lower our standards under any circumstances. As a supervisor of surgical training, I also believe that it is our duty to resist political pressure to accommodate more trainees in our programs with potentially insufficient selection criteria. Despite an increasing government oversight, we, as professionals, must continue to supervise and regulate selection of new candidates ourselves. There is no doubt that the level of competency and experience of our young surgeons has gradually decreased. An attempt to correct it has been made by allowing surgical trainees to assist in private hospitals with their consultant surgeon. Although I welcome this initiative, my impression is that this is not good enough to try solving the problem. Surgical trainees should be capable of obtaining a proper experience in public hospitals only, where continuity of care of elective or emergency patients is a critical part of training. The principle of ‘see one, do one, teach one’ is also not really applicable and should remind us, consultants, of our duty to adequately supervise and train these surgeons. Unfortunately, taking a trainee through a difficult procedure needs time. This means, once again, more appropriate theatre time in order to, first, properly train our registrars and, second, avoid cancellation of cases. If we progressively lower our expectations, we will allow more and more of those trainees to progress through the course of their curriculum without proper assessment. I do understand that this may PERSPECTIVES