- Email: [email protected]
International consensus statement on surgical education and training in an era of reduced working hours
t h e s u r g e o n 9 ( 2 0 1 1 ) S 3 eS 5
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Review
International consensus statement on surgical education and training in an era of reduced working hours John P. Collins Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
article info
abstract
Article history:
An international consensus statement has been developed as a reference on the key
Received 22 October 2010
principles to be considered during discussions on surgical education and training and the
Accepted 3 November 2010
delivery of surgical care in an era of restricted hours. ª 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction
Participants
The aims of surgical education and training programmes are to produce surgeons with the required proficiency for safe unsupervised practice, able to function independently or as part of a multidisciplinary team and competent to provide elective and emergency care in a range of practice settings. While the time required to reach this level of proficiency varies between individuals, mastery in surgery can only be attained through extensive and repeated practice accompanied by appropriate feedback. This requires substantial time. Working time or work hour restrictions vary from country to country and the impact on surgical training and the delivery of surgical care is the subject of ongoing international debate. Working time is defined as “any time during which (the worker) is working at his employer’s disposal and carrying out his activity or duties”.
Two hundred and fifty delegates from 22 countries attending an international conference participated in the development of this consensus statement. These included representatives from a wide spectrum of international surgical colleges and or equivalent surgical educational institutions.
Aims To develop an international consensus statement on the key foundation principles necessary for discussion on surgical education and training and the delivery of surgical care in an era of reduced working hours.
Consensus process Following a review of the literature, a small writing group developed a draft statement which was given to each delegate attending the 2nd International Conference on Surgical Education and Training held at the Royal College of Surgeons in Ireland on May 2010. The first plenary session of the conference focused on global perspectives of the impact of reduced working time on surgical training. These included presentations by surgical leaders from North America, Europe, the United Kingdom, Ireland, Australia and New Zealand and was followed by presentations by leaders of trainee (residents) associations from Australia and Ireland, and a panel discussion. A number of these presentations are included in this number and volume of the Surgeon.
E-mail address: [email protected]. 1479-666X/$ e see front matter ª 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2010.11.008
S4
t h e s u r g e o n 9 ( 2 0 1 1 ) S 3 eS 5
A second draft statement was produced based on the written and verbal feedback received following the first plenary session. This was circulated to delegates at the end of first day of the conference and discussed the following afternoon at the conference consensus development workshop. A third draft was constructed following this discussion and emailed to each delegate with timelines for feedback. The final Consensus Statement was then completed taking into account the feedback received.
Areas of controversy One of the most contentious issues amongst conference delegates surrounded flexibility or the need for trainees to have the freedom to avail of educational opportunities which fall outside their normal restored working hours. There is no greater learning experience for surgeons than accompanying one of their patients back to the operating theatre following a complication. Denying a surgeon in training this uncommon but unique voluntary learning opportunity on the basis that it conflicts with the maximum number of working hours allowed is short-sighted. The second major controversy related to working schedules which restrict a trainee’s exposure to the natural course of a disease and its response to treatment e both critical to learning. While it is acknowledged that individual surgeons cannot provide continuity of care in modern day surgical practice and a move to team-based care with formal hand-over procedures is essential, restrictions on working hours must avoid surgical trainees becoming little more than transient acquaintances during a patient’s illness.
International consensus statement e Key principles Background Safe care of the surgical patient and the effective functioning of a nation’s health care system are dependent on the quality of education received by its future surgeons. This is a shared responsibility between government, health care providers, surgeons and educational institutions. Delivery of future high-quality surgical care is reliant on the calibre of surgical trainees selected, the quality of their educational experience and supervision, their exposure to high-quality patient care and their aspiration to excellence. Lack of a consistent correlation between the number of hours worked and surgical performance may be a reflection of the complex interaction between the many other factors involved rather than the absence of a genuine relationship. Working hours which lead to fatigue may affect the capacity of surgeons, including those in training, to consistently deliver high-quality patient care and may
have negative consequences on their health, social life and family responsibilities.
Regulations on safe working practices Notwithstanding the variability across jurisdictions, the need to comply with local laws or regulations on fatigue management as it relates to surgical trainees is acknowledged. Regulations on the number of hours and patterns of safe working in surgery are a reality, and require the reconfiguration of surgical practice and innovative educational programmes and rostering. Because the level of fatigue and its consequent effect on safety and work performance is the product of a range of factors, it is not possible to meaningfully recommend limits on rest periods such as the maximum length of a safe period of working or the respite required between episodes of work.
Education and training Surgical trainees and their respective healthcare and educational institutions must use every opportunity in the workplace and outside the workplace to facilitate the training of competent surgeons in a reasonable time. Voluntary learning should be supported and must not be considered part of measured working hours. Surgical training must be focused and efficient, recognising all interactions with patients as potential learning opportunities and where possible employ innovative approaches to learning such as simulator training and web-based education. A structured curriculum with standards and matched assessments is essential to facilitate learning. Competency-based rather than time-based training should be norm. Surgical training programmes and posts should be regularly accredited against clearly defined standards and criteria. Clinical rotations should be aligned to the career aspirations of the trainee and organised to ensure that trainees cover all of the requirements of the curriculum.
Faculty development and role modelling Exemplary role modelling by surgeons is necessary during undergraduate medical education and postgraduate surgical training programmes. Faculty development must include regular training and accreditation/approval of surgical trainers in the skills required to deliver a modern surgical education programme. Those who deliver the programmes should receive appropriate reward and support from employers and recognition by surgical education bodies and trainees.
Service delivery Safety and efficiency in modern day surgical practice requires a change from individual responsibility for continuity
t h e s u r g e o n 9 ( 2 0 1 1 ) S 3 eS 5
of care to a personal commitment to team-based care with clear formal hand-over procedures. To ensure patient safety and continuity of care, standards for regular hand-over must be in place and include a structured verbal and documented transfer of an informative and practical dataset. Separation of elective and emergency surgical services e where possible - is beneficial for the preservation of training opportunities in both elective and emergency surgery.
S5
Acknowledgements The author wishes to acknowledge the enthusiastic contributions made by the conference convenors and all delegates to the development of this consensus statement.
Conflict of interest None declared.
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Review
International consensus statement on surgical education and training in an era of reduced working hours John P. Collins Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
article info
abstract
Article history:
An international consensus statement has been developed as a reference on the key
Received 22 October 2010
principles to be considered during discussions on surgical education and training and the
Accepted 3 November 2010
delivery of surgical care in an era of restricted hours. ª 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction
Participants
The aims of surgical education and training programmes are to produce surgeons with the required proficiency for safe unsupervised practice, able to function independently or as part of a multidisciplinary team and competent to provide elective and emergency care in a range of practice settings. While the time required to reach this level of proficiency varies between individuals, mastery in surgery can only be attained through extensive and repeated practice accompanied by appropriate feedback. This requires substantial time. Working time or work hour restrictions vary from country to country and the impact on surgical training and the delivery of surgical care is the subject of ongoing international debate. Working time is defined as “any time during which (the worker) is working at his employer’s disposal and carrying out his activity or duties”.
Two hundred and fifty delegates from 22 countries attending an international conference participated in the development of this consensus statement. These included representatives from a wide spectrum of international surgical colleges and or equivalent surgical educational institutions.
Aims To develop an international consensus statement on the key foundation principles necessary for discussion on surgical education and training and the delivery of surgical care in an era of reduced working hours.
Consensus process Following a review of the literature, a small writing group developed a draft statement which was given to each delegate attending the 2nd International Conference on Surgical Education and Training held at the Royal College of Surgeons in Ireland on May 2010. The first plenary session of the conference focused on global perspectives of the impact of reduced working time on surgical training. These included presentations by surgical leaders from North America, Europe, the United Kingdom, Ireland, Australia and New Zealand and was followed by presentations by leaders of trainee (residents) associations from Australia and Ireland, and a panel discussion. A number of these presentations are included in this number and volume of the Surgeon.
E-mail address: [email protected]. 1479-666X/$ e see front matter ª 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2010.11.008
S4
t h e s u r g e o n 9 ( 2 0 1 1 ) S 3 eS 5
A second draft statement was produced based on the written and verbal feedback received following the first plenary session. This was circulated to delegates at the end of first day of the conference and discussed the following afternoon at the conference consensus development workshop. A third draft was constructed following this discussion and emailed to each delegate with timelines for feedback. The final Consensus Statement was then completed taking into account the feedback received.
Areas of controversy One of the most contentious issues amongst conference delegates surrounded flexibility or the need for trainees to have the freedom to avail of educational opportunities which fall outside their normal restored working hours. There is no greater learning experience for surgeons than accompanying one of their patients back to the operating theatre following a complication. Denying a surgeon in training this uncommon but unique voluntary learning opportunity on the basis that it conflicts with the maximum number of working hours allowed is short-sighted. The second major controversy related to working schedules which restrict a trainee’s exposure to the natural course of a disease and its response to treatment e both critical to learning. While it is acknowledged that individual surgeons cannot provide continuity of care in modern day surgical practice and a move to team-based care with formal hand-over procedures is essential, restrictions on working hours must avoid surgical trainees becoming little more than transient acquaintances during a patient’s illness.
International consensus statement e Key principles Background Safe care of the surgical patient and the effective functioning of a nation’s health care system are dependent on the quality of education received by its future surgeons. This is a shared responsibility between government, health care providers, surgeons and educational institutions. Delivery of future high-quality surgical care is reliant on the calibre of surgical trainees selected, the quality of their educational experience and supervision, their exposure to high-quality patient care and their aspiration to excellence. Lack of a consistent correlation between the number of hours worked and surgical performance may be a reflection of the complex interaction between the many other factors involved rather than the absence of a genuine relationship. Working hours which lead to fatigue may affect the capacity of surgeons, including those in training, to consistently deliver high-quality patient care and may
have negative consequences on their health, social life and family responsibilities.
Regulations on safe working practices Notwithstanding the variability across jurisdictions, the need to comply with local laws or regulations on fatigue management as it relates to surgical trainees is acknowledged. Regulations on the number of hours and patterns of safe working in surgery are a reality, and require the reconfiguration of surgical practice and innovative educational programmes and rostering. Because the level of fatigue and its consequent effect on safety and work performance is the product of a range of factors, it is not possible to meaningfully recommend limits on rest periods such as the maximum length of a safe period of working or the respite required between episodes of work.
Education and training Surgical trainees and their respective healthcare and educational institutions must use every opportunity in the workplace and outside the workplace to facilitate the training of competent surgeons in a reasonable time. Voluntary learning should be supported and must not be considered part of measured working hours. Surgical training must be focused and efficient, recognising all interactions with patients as potential learning opportunities and where possible employ innovative approaches to learning such as simulator training and web-based education. A structured curriculum with standards and matched assessments is essential to facilitate learning. Competency-based rather than time-based training should be norm. Surgical training programmes and posts should be regularly accredited against clearly defined standards and criteria. Clinical rotations should be aligned to the career aspirations of the trainee and organised to ensure that trainees cover all of the requirements of the curriculum.
Faculty development and role modelling Exemplary role modelling by surgeons is necessary during undergraduate medical education and postgraduate surgical training programmes. Faculty development must include regular training and accreditation/approval of surgical trainers in the skills required to deliver a modern surgical education programme. Those who deliver the programmes should receive appropriate reward and support from employers and recognition by surgical education bodies and trainees.
Service delivery Safety and efficiency in modern day surgical practice requires a change from individual responsibility for continuity
t h e s u r g e o n 9 ( 2 0 1 1 ) S 3 eS 5
of care to a personal commitment to team-based care with clear formal hand-over procedures. To ensure patient safety and continuity of care, standards for regular hand-over must be in place and include a structured verbal and documented transfer of an informative and practical dataset. Separation of elective and emergency surgical services e where possible - is beneficial for the preservation of training opportunities in both elective and emergency surgery.
S5
Acknowledgements The author wishes to acknowledge the enthusiastic contributions made by the conference convenors and all delegates to the development of this consensus statement.
Conflict of interest None declared.