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Surgical training and the European Working Time Directive: The role of informal workplace learning
International Journal of Surgery 8 (2010) 179–180
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.theijs.com
Editorial
Surgical training and the European Working Time Directive: The role of informal workplace learning a b s t r a c t Keywords: Training EWTD Experience Workplace-learning Informal Postgraduate Education
The introduction of European Working Time Directive, limiting doctors’ working hours to 48 per week, has caused recent controversy within the profession. The Royal College of Surgeons of England in particular has been one of the loudest critics of the legislation. One of the main concerns is regarding the negative impact on training hours for those embarking on surgical careers. Simulation technology has been suggested as a method to overcome this reduction in hospital training hours, and research suggests that this is a good substitute for operative training in a theatre. However, modern educational theory emphasises the power of informal workplace learning in postgraduate education, and the essential role of experience in training future surgeons. Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1. Introduction ‘‘Trainees are telling the [Royal College of Surgeons] they cannot gain enough experience to progress on the shortened hours. The choice for the nation is clear – do we want patients of the future to be treated by a group of highly skilled and experienced surgeons; or be passed around a wider group of lower skilled surgeons with less experience. This is a worry for today and tomorrow.’’John Black, President, Royal College of Surgeons of England (2009)1 Surgical training has been in the spotlight in recent years, with the advent of Modernising Medical Careers and the implementation of the European Working Time Directive (EWTD), which limits surgeons’ working weeks to 48-hours. The issue is not limited to the UK; a recent article in the British Medical Journal describes the implications of working time restrictions in the USA.2 In the above quotation, John Black clearly feels strongly that the EWTD is a threat to surgical training. Is the situation as worrying as the President would have us believe? Or can the hours spent working in hospital be substituted by other training methods? I present an argument from an educationalist perspective of the possible effects of limiting surgeons’ hours in the workplace, by analysing the role of experience in the attainment of surgical competencies. 2. The roles of a surgeon The UK’s Intercollegiate Surgical Curriculum Programme (ISCP) identifies the defining characteristics of a fully trained surgeon.3 These are based upon the CanMEDS framework for medical education, developed by the University of Toronto.4 The central role of a surgeon is as a medical (surgical) expert; this encompasses the surgeon’s ability to provide effective care, based on medical knowledge and clinical skills. The ISCP goes on to expand the surgeon’s role to that of a communicator, collaborator, manager, health
advocate, scholar and professional. These roles are key to the clinical tasks a surgeon must perform, which include deciding when to operate, learning relevant anatomy and providing excellent preand post-operative care.2 A trainee must gain competence in all these fields in order complete training; clearly there is more to becoming a surgeon than excelling in the operating theatre. 3. Learning in surgical training 3.1. Gaining operative competence The learning of surgical trainees may be classified into formal and informal. Formal learning may be defined as knowledge and skills that develop as the result of instruction.5 Formal operative experience may be substituted in part by other learning resources such as virtual reality, with regard to surgical skills. A recent RCT compared surgical performance in two groups of trainees, who all had little experience of laparoscopic surgery.6 One group was randomised to laparoscopic simulator training, and the other group underwent standard clinical education. Assessment of technical performance of the simulator-trainees was superior to that of the control group. A recent Cochrane review also concluded that virtual-reality training may improve standard training.7 There appears to be some consensus on the potential benefit of operative simulation; this may have to be implemented further in the future if theatre time is reduced. This advance may provide a source of skills training to surgeons limited to 48-h weeks; however, surgical expertise represents only one strand of the ISCP training outcomes. 3.2. Informal workplace learning ‘‘The likely youth.destined for a medical career.was indentured to some reputable practitioner to whom his service was successively menial, pharmaceutical, and professional.
1743-9191/$ – see front matter Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2010.01.011
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Editorial / International Journal of Surgery 8 (2010) 179–180
He ran his master’s errands washed the bottles, mixed the drugs, spread the plasters, and finally, as the stipulated term drew towards its close, actually took part in the daily practice of his preceptor – bleeding his patients, pulling their teeth, and obeying a hurried summons in the night.’’Abraham Flexner, Medical Education in America (1910) 8 More informal, implicit learning also occurs in the workplace; when this occurs, the trainee acquires knowledge and skills unconsciously, and without explicitly recognising what has been learned.9,10 An example of this is working with other healthcare professionals. This requires trainees to communicate effectively, collaborate with others and manage the healthcare team, as the ISCP requires.3 During this time, the trainee will unconsciously be learning from experience, reflecting on their skills and perhaps receiving feedback. A review of the impact of working hour restrictions in the USA reported that reduction in surgical training hours had worsened the quality of patient handovers and communication between healthcare professionals.11 Informal learning opportunities help trainee development by social and collaborative engagement within the team.12 I would propose that it is for this process that there can be no substitute for experience. In fact, this may be said of many of the ISCP objectives. The recent article in the British Medical Journal by Jackson and Tarpley2 suggests that the challenging aspect of working time restriction may not be the absolute number of hours. They argue that the important factor may be ‘‘whether a trainee can assimilate the necessary experiences’’. This would seem to further emphasise the importance of workplace learning. 4. Impact of the European working time directive on training ‘‘Surgeons in training should have a contract defined by their training needs and not by hours worked.’’John Black, President, Royal College of Surgeons of England (2009)13 The European Working Time Directive (EWTD) is a piece of legislation developed by the Council of Europe that seeks to regulate working hours in order to protect the health and safety of workers. It stipulates minimum requirements in relation to working hours, rest periods, annual leave and conditions for night workers. The EWTD was first implemented in the UK in 1998, with a special twelve-year extension negotiated for medical training. In 2003, junior doctors’ working hours were limited by contract to 56 h per week. In August 2009, this limit was further reduced to 48 h. Through the necessity of complying with legislation, surgical rotas have been adjusted and may not now take account of the requirements of trainees’ development.14 Concerns have been raised about the impact a 48-h week will have on surgical training: will surgical trainees be able to achieve the competencies of the ISCP when workplace training is limited? The EWTD will limit the powerful effect of informal workplace learning in surgical training. A combination of reduced hours and a different pattern of workplace experience (shift working) conspire to limit experiential development. Trainees report the EWTD has resulted in increasing rigid rotas and reduced time in a traditional firm, which mean workplace training is becoming more difficult.13,14
5. Conclusion Recent concern over the effect of the EWTD on the restriction of training time is a problem facing surgical trainees. Recent studies have suggested that there may be a substitute for actual operative experience for the acquisition of medical knowledge and clinical skills. However, the importance of informal learning in the workplace must not be underestimated when considering the full requirements of surgical training. If surgeons of the future are to become effective managers, collaborators and communicators, as well as skilled operators, then workplace experience is imperative. Restrictions imposed by the EWTD may harm this experiential learning to the detriment of surgical training: there really is no substitute for experience.
Conflicts of interest None declared.
References 1. Royal College of Surgeons of England. Surgeons call for solution on patient safety and future training as doctors hours are slashed. Available from: http://www. rcseng.ac.uk/news/surgeons-call-for-solution-on-patient-safety-and-futuretraining-as-doctors-hours-are-slashed; 2009 [accessed 16.09.09]. 2. Jackson GP, Tarpley JL. How long does it take to train a surgeon? BMJ 2009;339: b4260. 3. ISCP. The intercollegiate surgical curriculum. London: Intercollegiate Surgical Curriculum Programme; 2007. 4. University of Toronto. CanMEDS. 2006. Available from: http://www. deptmedicine.utoronto.ca/CanMEDS.htm [accessed 04.06.09]. 5. Resnick L. Learning in and out of school. Educational Researcher 1987;16(9): 13–20. 6. Larsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T, Schouenborg L, Ottosen C, et al. Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ 2009;338:b1802. 7. Gurusamy KS, Aggarwal R, Palanivelu L, Davidson BR. Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database of Systematic Reviews. Available from: http://www.mrw.interscience.wiley.com/cochrane/ clsysrev/articles/CD006575/frame.html, 2009;1 [accessed 16.09.09]. 8. Flexner A. Medical education in America. The Atlantic; 1910. 9. Reber A. Implicit learning and tacit knowledge: an essay on the cognitive unconscious. Oxford: Oxford University Press; 1993. 10. Swanwick T. Informal learning in postgraduate medical education: from cognitivism to ‘culturism’. Med Educ 2005;39(8):859–65. 11. Curet MJ. Resident work hour restrictions: where are we now? J Am Coll Surg 2008;207(5):767–76. 12. Shah P, Dexter H, Dornan T, Snowden N. Can acquisition of expertise be supported by technology? Available from: http://repository.alt.ac.uk/635; 2009 [accessed 21.09.09]. 13. Black J. EWTD: maintaining the pressure. Ann R Coll Surg Engl (Suppl) 2009;91: 258–9. 14. Wade RG, Henderson J. Perceived impact of EWTD on UK doctors. Ann R Coll Surg Engl (Suppl) 2009;91:132–4.
James A. Giles* The University of Manchester, AV Hill Building, Manchester M13 9PT, United Kingdom * Tel.: þ07985 532 186. E-mail address: [email protected] Available online 6 February 2010
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.theijs.com
Editorial
Surgical training and the European Working Time Directive: The role of informal workplace learning a b s t r a c t Keywords: Training EWTD Experience Workplace-learning Informal Postgraduate Education
The introduction of European Working Time Directive, limiting doctors’ working hours to 48 per week, has caused recent controversy within the profession. The Royal College of Surgeons of England in particular has been one of the loudest critics of the legislation. One of the main concerns is regarding the negative impact on training hours for those embarking on surgical careers. Simulation technology has been suggested as a method to overcome this reduction in hospital training hours, and research suggests that this is a good substitute for operative training in a theatre. However, modern educational theory emphasises the power of informal workplace learning in postgraduate education, and the essential role of experience in training future surgeons. Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1. Introduction ‘‘Trainees are telling the [Royal College of Surgeons] they cannot gain enough experience to progress on the shortened hours. The choice for the nation is clear – do we want patients of the future to be treated by a group of highly skilled and experienced surgeons; or be passed around a wider group of lower skilled surgeons with less experience. This is a worry for today and tomorrow.’’John Black, President, Royal College of Surgeons of England (2009)1 Surgical training has been in the spotlight in recent years, with the advent of Modernising Medical Careers and the implementation of the European Working Time Directive (EWTD), which limits surgeons’ working weeks to 48-hours. The issue is not limited to the UK; a recent article in the British Medical Journal describes the implications of working time restrictions in the USA.2 In the above quotation, John Black clearly feels strongly that the EWTD is a threat to surgical training. Is the situation as worrying as the President would have us believe? Or can the hours spent working in hospital be substituted by other training methods? I present an argument from an educationalist perspective of the possible effects of limiting surgeons’ hours in the workplace, by analysing the role of experience in the attainment of surgical competencies. 2. The roles of a surgeon The UK’s Intercollegiate Surgical Curriculum Programme (ISCP) identifies the defining characteristics of a fully trained surgeon.3 These are based upon the CanMEDS framework for medical education, developed by the University of Toronto.4 The central role of a surgeon is as a medical (surgical) expert; this encompasses the surgeon’s ability to provide effective care, based on medical knowledge and clinical skills. The ISCP goes on to expand the surgeon’s role to that of a communicator, collaborator, manager, health
advocate, scholar and professional. These roles are key to the clinical tasks a surgeon must perform, which include deciding when to operate, learning relevant anatomy and providing excellent preand post-operative care.2 A trainee must gain competence in all these fields in order complete training; clearly there is more to becoming a surgeon than excelling in the operating theatre. 3. Learning in surgical training 3.1. Gaining operative competence The learning of surgical trainees may be classified into formal and informal. Formal learning may be defined as knowledge and skills that develop as the result of instruction.5 Formal operative experience may be substituted in part by other learning resources such as virtual reality, with regard to surgical skills. A recent RCT compared surgical performance in two groups of trainees, who all had little experience of laparoscopic surgery.6 One group was randomised to laparoscopic simulator training, and the other group underwent standard clinical education. Assessment of technical performance of the simulator-trainees was superior to that of the control group. A recent Cochrane review also concluded that virtual-reality training may improve standard training.7 There appears to be some consensus on the potential benefit of operative simulation; this may have to be implemented further in the future if theatre time is reduced. This advance may provide a source of skills training to surgeons limited to 48-h weeks; however, surgical expertise represents only one strand of the ISCP training outcomes. 3.2. Informal workplace learning ‘‘The likely youth.destined for a medical career.was indentured to some reputable practitioner to whom his service was successively menial, pharmaceutical, and professional.
1743-9191/$ – see front matter Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2010.01.011
180
Editorial / International Journal of Surgery 8 (2010) 179–180
He ran his master’s errands washed the bottles, mixed the drugs, spread the plasters, and finally, as the stipulated term drew towards its close, actually took part in the daily practice of his preceptor – bleeding his patients, pulling their teeth, and obeying a hurried summons in the night.’’Abraham Flexner, Medical Education in America (1910) 8 More informal, implicit learning also occurs in the workplace; when this occurs, the trainee acquires knowledge and skills unconsciously, and without explicitly recognising what has been learned.9,10 An example of this is working with other healthcare professionals. This requires trainees to communicate effectively, collaborate with others and manage the healthcare team, as the ISCP requires.3 During this time, the trainee will unconsciously be learning from experience, reflecting on their skills and perhaps receiving feedback. A review of the impact of working hour restrictions in the USA reported that reduction in surgical training hours had worsened the quality of patient handovers and communication between healthcare professionals.11 Informal learning opportunities help trainee development by social and collaborative engagement within the team.12 I would propose that it is for this process that there can be no substitute for experience. In fact, this may be said of many of the ISCP objectives. The recent article in the British Medical Journal by Jackson and Tarpley2 suggests that the challenging aspect of working time restriction may not be the absolute number of hours. They argue that the important factor may be ‘‘whether a trainee can assimilate the necessary experiences’’. This would seem to further emphasise the importance of workplace learning. 4. Impact of the European working time directive on training ‘‘Surgeons in training should have a contract defined by their training needs and not by hours worked.’’John Black, President, Royal College of Surgeons of England (2009)13 The European Working Time Directive (EWTD) is a piece of legislation developed by the Council of Europe that seeks to regulate working hours in order to protect the health and safety of workers. It stipulates minimum requirements in relation to working hours, rest periods, annual leave and conditions for night workers. The EWTD was first implemented in the UK in 1998, with a special twelve-year extension negotiated for medical training. In 2003, junior doctors’ working hours were limited by contract to 56 h per week. In August 2009, this limit was further reduced to 48 h. Through the necessity of complying with legislation, surgical rotas have been adjusted and may not now take account of the requirements of trainees’ development.14 Concerns have been raised about the impact a 48-h week will have on surgical training: will surgical trainees be able to achieve the competencies of the ISCP when workplace training is limited? The EWTD will limit the powerful effect of informal workplace learning in surgical training. A combination of reduced hours and a different pattern of workplace experience (shift working) conspire to limit experiential development. Trainees report the EWTD has resulted in increasing rigid rotas and reduced time in a traditional firm, which mean workplace training is becoming more difficult.13,14
5. Conclusion Recent concern over the effect of the EWTD on the restriction of training time is a problem facing surgical trainees. Recent studies have suggested that there may be a substitute for actual operative experience for the acquisition of medical knowledge and clinical skills. However, the importance of informal learning in the workplace must not be underestimated when considering the full requirements of surgical training. If surgeons of the future are to become effective managers, collaborators and communicators, as well as skilled operators, then workplace experience is imperative. Restrictions imposed by the EWTD may harm this experiential learning to the detriment of surgical training: there really is no substitute for experience.
Conflicts of interest None declared.
References 1. Royal College of Surgeons of England. Surgeons call for solution on patient safety and future training as doctors hours are slashed. Available from: http://www. rcseng.ac.uk/news/surgeons-call-for-solution-on-patient-safety-and-futuretraining-as-doctors-hours-are-slashed; 2009 [accessed 16.09.09]. 2. Jackson GP, Tarpley JL. How long does it take to train a surgeon? BMJ 2009;339: b4260. 3. ISCP. The intercollegiate surgical curriculum. London: Intercollegiate Surgical Curriculum Programme; 2007. 4. University of Toronto. CanMEDS. 2006. Available from: http://www. deptmedicine.utoronto.ca/CanMEDS.htm [accessed 04.06.09]. 5. Resnick L. Learning in and out of school. Educational Researcher 1987;16(9): 13–20. 6. Larsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T, Schouenborg L, Ottosen C, et al. Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ 2009;338:b1802. 7. Gurusamy KS, Aggarwal R, Palanivelu L, Davidson BR. Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database of Systematic Reviews. Available from: http://www.mrw.interscience.wiley.com/cochrane/ clsysrev/articles/CD006575/frame.html, 2009;1 [accessed 16.09.09]. 8. Flexner A. Medical education in America. The Atlantic; 1910. 9. Reber A. Implicit learning and tacit knowledge: an essay on the cognitive unconscious. Oxford: Oxford University Press; 1993. 10. Swanwick T. Informal learning in postgraduate medical education: from cognitivism to ‘culturism’. Med Educ 2005;39(8):859–65. 11. Curet MJ. Resident work hour restrictions: where are we now? J Am Coll Surg 2008;207(5):767–76. 12. Shah P, Dexter H, Dornan T, Snowden N. Can acquisition of expertise be supported by technology? Available from: http://repository.alt.ac.uk/635; 2009 [accessed 21.09.09]. 13. Black J. EWTD: maintaining the pressure. Ann R Coll Surg Engl (Suppl) 2009;91: 258–9. 14. Wade RG, Henderson J. Perceived impact of EWTD on UK doctors. Ann R Coll Surg Engl (Suppl) 2009;91:132–4.
James A. Giles* The University of Manchester, AV Hill Building, Manchester M13 9PT, United Kingdom * Tel.: þ07985 532 186. E-mail address: [email protected] Available online 6 February 2010