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What is the single greatest challenge to training the future generation of surgeons? How can we overcome it?
SURGERY JOURNAL PRIZE-WINNING ESSAY
What is the single greatest challenge to training the future generation of surgeons? How can we overcome it?
The ASiT, Surgery Journal and PLG Foundation Doctors Essay Prize is a national essay competition run by the Association of Surgeons in Training in conjunction with Surgery journal. The Essay Prize is aimed at Foundation Doctors in the UK and Ireland pursuing a career in surgery. For 2014, essays were invited on the topic ‘What is the single greatest challenge to training the future generation of surgeons? How can we overcome it?’. All submitted essays were shortlisted by members of the ASiT Council and the Patient Liaison Group of the Royal College of Surgeons of England selected the three winners from this shortlist. The winners were announced at the ASiT Annual Conference in Glasgow in February 2015. First place went to Jason Yuen, a Foundation Year 2 Doctor from the Oxford Deanery. Jason’s prize was £250 of Elsevier book vouchers and a subscription to Surgery journal. We are delighted to publish the winning essay below. Second place was awarded to Lauramay Davis, a Foundation Year 2 Doctor from the North East Thames Foundation School, who won £150 of Elsevier book vouchers. Third place was awarded to James Blackwell, a Foundation Year 2 Doctor from the Trent Deanery, who won copies of Kirk’s General Surgical Operations book and Quick’s Essential Surgery book.
Jason Yuen
Abstract In this article, we argue that the single greatest challenge to training the future generation of surgeons is the prioritization between trainees’ education and patients’ safety. The key issues include the lack of training time and the lack of exposure to different diseases, due to factors such as the Working Time Directives and subspecialization at major centres. In order to overcome these challenges, it is essential to implement a systematic, competence-based training model, where complex procedures are learnt in small components. With the aid of simulation and new technology, skills can be practised repeatedly before a surgeon is put in front of the operating table. Attachments to hospitals abroad, especially in less developed countries, may also be considered. Targeted courses and seminars would help to increase trainees’ exposure to less common pathologies. Rotation of trainees across centres of different expertise would also minimize discrepancy in training programmes.
mandatory duties such as teaching, research and audit work, less time is available for the education of trainee surgeons.3 This problem spans both the non-technical and technical skills but is certainly more obvious in the latter. To complicate the matter, with the ever-expanding range of diseases that may be treated surgically and the development of new therapies, trainees are expected to learn more in a limited period of time. Although these measures were set to improve patients’ safety, trainees’ opportunity to learn appears to become compromised. This relative lack of training time may lead to a worrying decline in competence. For example, in thyroid surgeries4 and rectal surgeries,5 it was shown that a surgeon’s experience and volume of patients are key factors that determine the postoperative outcome. This has become even more problematic in certain surgical procedures as other non-surgical specialists are now also treating traditional surgical diseases. For example, radiologists are performing more core biopsies and oncologists may perform bone marrow aspiration for staging.6 Considering the mode of assessment using the Miller’s pyramid7 (Figure 1), we can see it is becoming increasingly difficult to assess the ones in the ‘Does’ group, since the number of opportunities in the clinical setting has become markedly reduced. This is verified by a Scottish study8 devised to determine the accuracy of medical staff assessment of trainees’ operative competence. Figure 2 shows the frequency with which consultants evaluated trainees’ competency without personally supervising his/her actual performance. It is shown that a high percentage of assessors provided assessment of procedures which they had not observed, and therefore difficult to make a comprehensive assessment. This is extremely worrying. So, in overall, scheduled training time has certainly reduced and real time assessments have come more difficult. Is there a solution to this? Fortunately, with the adjunct of simulation and virtual reality, we hope to achieve an equally adequate level of surgical
Keywords Patient safety; surgical training; training model
Introduction Ever since the time of Hippocrates, the practice of surgery has constantly been evolving, as our understanding of diseases is changing and innovative techniques are being invented. The art and science of surgical training have attempted to keep up with this evolution but are facing a number of challenges. In this article, we argue that the single greatest challenge is the balance between training opportunities and patients’ safety. To further explore this problem, we will discuss the issues in two aspects e the lack of training time and the lack of exposure to different diseases.
Lack of training time Although it was not until the late 19th century that William Halstead formalized the surgical apprenticeship system in America,1 surgery has traditionally been learnt by a ‘see one, do one, teach one’ approach for a long time. Working time directives2 have been introduced to improve the safety of both doctors and patients. However, compounded with increasing administrative load, demand for documentation and other
Jason Yuen MSci MA (Cantab) BM BCh (Oxon) MRCS (Eng) is a Foundation Year 2 Doctor in Thames Valley (Oxford Deanery), UK. Conflict of interests: none declared.
SURGERY 33:6
290
Ó 2015 Elsevier Ltd. All rights reserved.
SURGERY JOURNAL PRIZE-WINNING ESSAY
Figure 1
by Bridges and Diamond10 estimated that the inexperience of their general surgical trainees and expensive theatre time had cost the USA $53 million a year. Simulation, by virtue of simulators and training stations, offers an opportunity to break down complex procedures into components, which may be familiarized with repetition. This helps trainees to acquire familiarity with instruments, improve dexterity and become knowledgeable about surgical management, techniques, and potential complications before they actually participate in the procedures. In fact, these developments have been validated by an increasing amount of data demonstrating application of these skills to the operations.11,12 For example, a study at Yale13 showed that concentrated didactic training in laparoscopy improved skills in
competence. This follows the example of the aviation industry, which has employed similar techniques to train their staff and reduce ‘human factor’ errors. Competence e both surgical (knowledge-based and technical) and professional (interaction with patients) e can be taught and adapted by simulation.9 The first advantage it provides is a highly reproducible method to train and objectively assess the clinical skills in a structured manner, since the simulators and actors are often reused for each candidate. Trainees may also practise skills that may be more sparsely used in their daily practice. Then, in surgery, as with playing the piano, ‘practice makes perfect’. However, teaching basic surgical skills in the operating theatre is not efficient and carries high costs. A study in the 1990s
Figure 2
SURGERY 33:6
291
Ó 2015 Elsevier Ltd. All rights reserved.
SURGERY JOURNAL PRIZE-WINNING ESSAY
Conclusion
both residents and established surgeons. Competence-based advancement, rather than time-served one, is becoming the standard in surgical training.14 Although simulation seems to be a neat solution, the current UK system faces a resource-related problem.15 In a recent survey of UK surgical trainees, only 41.2% had access to simulators and fewer (16.3%) had access out of hours.16 Therefore the importance of simulation must be emphasized nationwide in order to meet the trainees’ needs. Another solution we propose is to allow trainees to take time out to train in developing countries as part of a formalized teaching/exchange programme with the local hospitals. Globalization of surgical training is made easier by high-speed communication and convenient air transport. For example, The College of Surgeons of East, Central and Southern Africa (COSECSA)17 has formal links with institutions in developed world such as the Royal Colleges in the UK. There are many developing countries with a high patient load but a low supply of competent surgeons. Giving trainees a formal opportunity to train abroad for a period of time can not only give them an opportunity to put their skills into practice but it also helps to train the local medical staff. Since teaching skills are an important trait of a surgeon, this would offer extra benefit to the trainees. It must be noted that there are ethical issues involved in operating in foreign developing countries18 but they can be overcome by strict ethical considerations and close supervision. Therefore a formalized programme is mandatory.
Balancing between trainees’ education and patients’ safety is currently the greatest challenge to surgical training. This is manifested in the lack of training time and exposure to different diseases. Although one may argue a well-trained future surgeon would benefit many coming patients, with an unprecedented emphasis on patients’ safety and best interest, there is no doubt learning naturally takes second place to patients’ needs.21 Suffering from the lack of training time and exposure, in order to achieve the same competence in our future surgeons, we must shift the paradigm from the traditional Halstedian model of apprenticeship to a new systematic, competence-based model, where learning of complex procedures are broken down into small components. These are then learnt and assessed individually, with the aid of simulation and new technology before the surgeon may attempt to complete the procedure himself/herself. This also ensures all core aspects of surgical training are delivered uniformly.22 Although assessment in the operating room remains the ‘gold standard’, this change is nonetheless essential in the learning of surgery given the modern circumstances. In addition, in this article we have explored the option of formally introducing surgeons to train abroad for a period of time in order to acquire new skills, as well as training the local staff. With regards to the problem with lack of exposure to certain cases due to subspecialization of trainees and centres, we believe courses and seminars tailored to individual groups of trainees as well as short attachments may consolidate a trainee’s experience and ensure patients’ safety. A
Lack of exposure In order to improve the efficiency of the system and to improve patients’ outcome,19 the National Health Service has been promoting subspecialization of services and centralization of resources. For example, there are approximately 338 paediatric surgeons concentrated at 29 centres across the UK.20 Such centres often have their own subspecialties. As a result, trainees in certain centres may be deprived of exposure to particular cases. Sometimes they may have never seen a case of a rarer pathology that is not treated at their centre before they complete their training. While it helps to improve patients’ outcome after surgery, the breadth of training in managing general conditions is reduced. Patients may be misdiagnosed and therefore mistreated for the wrong diseases, and it may lead to inappropriate use of resources. To educate trainees who do not have regular exposure to rarer conditions, professional bodies such as the Royal Colleges should organize series of courses and seminars tailored to different groups of trainees, regarding the management of these diseases. This should also be reflected in their regular assessment. In addition, this may again be supplemented by the use of simulation. It is not the intention to force the trainees to learn about all the management protocols and become so-called ‘protocol monkeys’ but to give them the ability to recognize dangerous pathologies and refer appropriately. Then, it is important to encourage trainees to rotate around different centres. We understand it is extremely difficult due to staffing issues, continuation of care and trainees’ family circumstances. However, more short attachments should be made available as an option and facilitated by the training directors.
SURGERY 33:6
REFERENCES 1 Grillo HC. To impart this art: the development of graduate surgical education in the United States. Surgery 1999; 125: 1e14. 2 Safe shift working for surgeons in training: Revised policy statement from the Working Time Directive working party. London: The Royal College of Surgeons of England, 2007. 3 Bell RH. Surgical council on resident education: a new organization devoted to graduate surgical education. J Am Coll Surg 2007; 204: 341e6. 4 Sosa JA, Bowman HM, Tielsch JM, et al. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 1998; 228: 320e30. 5 Porter GA, Soskolne CL, Yakimets WW, Newman SC. Surgeon-related factors and outcome in rectal cancer. Ann Surg 1998; 227: 157e67. 6 Braun S, Pantel K, Muller P, et al. Cytokeratin-positive cells in the bone marrow and survival of patients with stage I, II, or III breast cancer. N Engl J Med 2000; 342: 525e33. 7 Lincoln Memorial University. Available from:http://www.lmunet.edu/ tomec/files/assessment_and_feedback_for_residents_and_students. pdf. (Accessed on 01 Nov 14). 8 Paisley AM, Baldwin PJ, Paterson-Brown S. Accuracy of medical staff assessment of trainees’ operative performance. Med Teach 2005; 27: 634e8. 9 Peracchia A. Surgical education in the third millennium. Ann Surg 2001; 234: 709e12. 10 Bridges M, Diamond D. The financial impact of teaching surgical residents in the operating room. Am J Surg 1999; 177: 28e32.
292
Ó 2015 Elsevier Ltd. All rights reserved.
SURGERY JOURNAL PRIZE-WINNING ESSAY
11 Sachdeva AK. The changing paradigm of residency education in surgery: a perspective from the American College of Surgeons. Am J Surg 2007; 73: 120e9. 12 Grantcharov T, Kristiansen VB, Bendix J, et al. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 2004; 91: 146e50. 13 Rosser JC, Rosser LE, Savalgi RS. Objective evaluation of a laparoscopic surgical skill program for residents and senior surgeons. Arch Surg 1998; 133: 657e61. 14 Polavarapu HV, Kulaylat AN, Sun S, et al. 100 years of surgical education: the past, present, and future. Bull Am Coll Surg 2013; 98: 22e7. 15 Kordowicz AG, Gough MJ. The challenges of implementing a simulationbased surgical training curriculum. Br J Surg 2014; 101: 441e3. 16 Milburn J, Khera G, Hornby ST, et al. Introduction, availability and role of simulation in surgical education and training: review of current evidence and recommendations from the Association of Surgeons in Training. Int J Surg 2012; 10: 393e8.
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17 The College of Surgeons of East, Central and southern africa. http:// www.cosecsa.org/. (Accessed on 01 Nov 14). 18 Howe KL, Malomo AO, Bernstein MA. Ethical challenges in international surgical education, for visitors and hosts. World Neurosurg 2013; 80: 751e8. 19 Ihse I. Surgical challenges in the twenty-first century. Ann Acad Medicae Bialostoc 2004; 49: 7e9. 20 The Surgical Specialties: 4 e Paediatric Surgery. London: Royal College of Surgeons of England. Available from: https://www. rcseng.ac.uk/media/media-background-briefings-and-statistics/thesurgical-specialties-4-2013-paediatric-surgery. (Accessed on 01 Nov 14). 21 Gawande AA. Creating the educated surgeon in the 21st century. Am J Surg 2001; 181: 551e6. 22 Pugh CM, Sippel RS. Success in Academic Surgery: Developing a Career in Surgical Education. London: Springer Science & Business Media, 2013.
293
Ó 2015 Elsevier Ltd. All rights reserved.
What is the single greatest challenge to training the future generation of surgeons? How can we overcome it?
The ASiT, Surgery Journal and PLG Foundation Doctors Essay Prize is a national essay competition run by the Association of Surgeons in Training in conjunction with Surgery journal. The Essay Prize is aimed at Foundation Doctors in the UK and Ireland pursuing a career in surgery. For 2014, essays were invited on the topic ‘What is the single greatest challenge to training the future generation of surgeons? How can we overcome it?’. All submitted essays were shortlisted by members of the ASiT Council and the Patient Liaison Group of the Royal College of Surgeons of England selected the three winners from this shortlist. The winners were announced at the ASiT Annual Conference in Glasgow in February 2015. First place went to Jason Yuen, a Foundation Year 2 Doctor from the Oxford Deanery. Jason’s prize was £250 of Elsevier book vouchers and a subscription to Surgery journal. We are delighted to publish the winning essay below. Second place was awarded to Lauramay Davis, a Foundation Year 2 Doctor from the North East Thames Foundation School, who won £150 of Elsevier book vouchers. Third place was awarded to James Blackwell, a Foundation Year 2 Doctor from the Trent Deanery, who won copies of Kirk’s General Surgical Operations book and Quick’s Essential Surgery book.
Jason Yuen
Abstract In this article, we argue that the single greatest challenge to training the future generation of surgeons is the prioritization between trainees’ education and patients’ safety. The key issues include the lack of training time and the lack of exposure to different diseases, due to factors such as the Working Time Directives and subspecialization at major centres. In order to overcome these challenges, it is essential to implement a systematic, competence-based training model, where complex procedures are learnt in small components. With the aid of simulation and new technology, skills can be practised repeatedly before a surgeon is put in front of the operating table. Attachments to hospitals abroad, especially in less developed countries, may also be considered. Targeted courses and seminars would help to increase trainees’ exposure to less common pathologies. Rotation of trainees across centres of different expertise would also minimize discrepancy in training programmes.
mandatory duties such as teaching, research and audit work, less time is available for the education of trainee surgeons.3 This problem spans both the non-technical and technical skills but is certainly more obvious in the latter. To complicate the matter, with the ever-expanding range of diseases that may be treated surgically and the development of new therapies, trainees are expected to learn more in a limited period of time. Although these measures were set to improve patients’ safety, trainees’ opportunity to learn appears to become compromised. This relative lack of training time may lead to a worrying decline in competence. For example, in thyroid surgeries4 and rectal surgeries,5 it was shown that a surgeon’s experience and volume of patients are key factors that determine the postoperative outcome. This has become even more problematic in certain surgical procedures as other non-surgical specialists are now also treating traditional surgical diseases. For example, radiologists are performing more core biopsies and oncologists may perform bone marrow aspiration for staging.6 Considering the mode of assessment using the Miller’s pyramid7 (Figure 1), we can see it is becoming increasingly difficult to assess the ones in the ‘Does’ group, since the number of opportunities in the clinical setting has become markedly reduced. This is verified by a Scottish study8 devised to determine the accuracy of medical staff assessment of trainees’ operative competence. Figure 2 shows the frequency with which consultants evaluated trainees’ competency without personally supervising his/her actual performance. It is shown that a high percentage of assessors provided assessment of procedures which they had not observed, and therefore difficult to make a comprehensive assessment. This is extremely worrying. So, in overall, scheduled training time has certainly reduced and real time assessments have come more difficult. Is there a solution to this? Fortunately, with the adjunct of simulation and virtual reality, we hope to achieve an equally adequate level of surgical
Keywords Patient safety; surgical training; training model
Introduction Ever since the time of Hippocrates, the practice of surgery has constantly been evolving, as our understanding of diseases is changing and innovative techniques are being invented. The art and science of surgical training have attempted to keep up with this evolution but are facing a number of challenges. In this article, we argue that the single greatest challenge is the balance between training opportunities and patients’ safety. To further explore this problem, we will discuss the issues in two aspects e the lack of training time and the lack of exposure to different diseases.
Lack of training time Although it was not until the late 19th century that William Halstead formalized the surgical apprenticeship system in America,1 surgery has traditionally been learnt by a ‘see one, do one, teach one’ approach for a long time. Working time directives2 have been introduced to improve the safety of both doctors and patients. However, compounded with increasing administrative load, demand for documentation and other
Jason Yuen MSci MA (Cantab) BM BCh (Oxon) MRCS (Eng) is a Foundation Year 2 Doctor in Thames Valley (Oxford Deanery), UK. Conflict of interests: none declared.
SURGERY 33:6
290
Ó 2015 Elsevier Ltd. All rights reserved.
SURGERY JOURNAL PRIZE-WINNING ESSAY
Figure 1
by Bridges and Diamond10 estimated that the inexperience of their general surgical trainees and expensive theatre time had cost the USA $53 million a year. Simulation, by virtue of simulators and training stations, offers an opportunity to break down complex procedures into components, which may be familiarized with repetition. This helps trainees to acquire familiarity with instruments, improve dexterity and become knowledgeable about surgical management, techniques, and potential complications before they actually participate in the procedures. In fact, these developments have been validated by an increasing amount of data demonstrating application of these skills to the operations.11,12 For example, a study at Yale13 showed that concentrated didactic training in laparoscopy improved skills in
competence. This follows the example of the aviation industry, which has employed similar techniques to train their staff and reduce ‘human factor’ errors. Competence e both surgical (knowledge-based and technical) and professional (interaction with patients) e can be taught and adapted by simulation.9 The first advantage it provides is a highly reproducible method to train and objectively assess the clinical skills in a structured manner, since the simulators and actors are often reused for each candidate. Trainees may also practise skills that may be more sparsely used in their daily practice. Then, in surgery, as with playing the piano, ‘practice makes perfect’. However, teaching basic surgical skills in the operating theatre is not efficient and carries high costs. A study in the 1990s
Figure 2
SURGERY 33:6
291
Ó 2015 Elsevier Ltd. All rights reserved.
SURGERY JOURNAL PRIZE-WINNING ESSAY
Conclusion
both residents and established surgeons. Competence-based advancement, rather than time-served one, is becoming the standard in surgical training.14 Although simulation seems to be a neat solution, the current UK system faces a resource-related problem.15 In a recent survey of UK surgical trainees, only 41.2% had access to simulators and fewer (16.3%) had access out of hours.16 Therefore the importance of simulation must be emphasized nationwide in order to meet the trainees’ needs. Another solution we propose is to allow trainees to take time out to train in developing countries as part of a formalized teaching/exchange programme with the local hospitals. Globalization of surgical training is made easier by high-speed communication and convenient air transport. For example, The College of Surgeons of East, Central and Southern Africa (COSECSA)17 has formal links with institutions in developed world such as the Royal Colleges in the UK. There are many developing countries with a high patient load but a low supply of competent surgeons. Giving trainees a formal opportunity to train abroad for a period of time can not only give them an opportunity to put their skills into practice but it also helps to train the local medical staff. Since teaching skills are an important trait of a surgeon, this would offer extra benefit to the trainees. It must be noted that there are ethical issues involved in operating in foreign developing countries18 but they can be overcome by strict ethical considerations and close supervision. Therefore a formalized programme is mandatory.
Balancing between trainees’ education and patients’ safety is currently the greatest challenge to surgical training. This is manifested in the lack of training time and exposure to different diseases. Although one may argue a well-trained future surgeon would benefit many coming patients, with an unprecedented emphasis on patients’ safety and best interest, there is no doubt learning naturally takes second place to patients’ needs.21 Suffering from the lack of training time and exposure, in order to achieve the same competence in our future surgeons, we must shift the paradigm from the traditional Halstedian model of apprenticeship to a new systematic, competence-based model, where learning of complex procedures are broken down into small components. These are then learnt and assessed individually, with the aid of simulation and new technology before the surgeon may attempt to complete the procedure himself/herself. This also ensures all core aspects of surgical training are delivered uniformly.22 Although assessment in the operating room remains the ‘gold standard’, this change is nonetheless essential in the learning of surgery given the modern circumstances. In addition, in this article we have explored the option of formally introducing surgeons to train abroad for a period of time in order to acquire new skills, as well as training the local staff. With regards to the problem with lack of exposure to certain cases due to subspecialization of trainees and centres, we believe courses and seminars tailored to individual groups of trainees as well as short attachments may consolidate a trainee’s experience and ensure patients’ safety. A
Lack of exposure In order to improve the efficiency of the system and to improve patients’ outcome,19 the National Health Service has been promoting subspecialization of services and centralization of resources. For example, there are approximately 338 paediatric surgeons concentrated at 29 centres across the UK.20 Such centres often have their own subspecialties. As a result, trainees in certain centres may be deprived of exposure to particular cases. Sometimes they may have never seen a case of a rarer pathology that is not treated at their centre before they complete their training. While it helps to improve patients’ outcome after surgery, the breadth of training in managing general conditions is reduced. Patients may be misdiagnosed and therefore mistreated for the wrong diseases, and it may lead to inappropriate use of resources. To educate trainees who do not have regular exposure to rarer conditions, professional bodies such as the Royal Colleges should organize series of courses and seminars tailored to different groups of trainees, regarding the management of these diseases. This should also be reflected in their regular assessment. In addition, this may again be supplemented by the use of simulation. It is not the intention to force the trainees to learn about all the management protocols and become so-called ‘protocol monkeys’ but to give them the ability to recognize dangerous pathologies and refer appropriately. Then, it is important to encourage trainees to rotate around different centres. We understand it is extremely difficult due to staffing issues, continuation of care and trainees’ family circumstances. However, more short attachments should be made available as an option and facilitated by the training directors.
SURGERY 33:6
REFERENCES 1 Grillo HC. To impart this art: the development of graduate surgical education in the United States. Surgery 1999; 125: 1e14. 2 Safe shift working for surgeons in training: Revised policy statement from the Working Time Directive working party. London: The Royal College of Surgeons of England, 2007. 3 Bell RH. Surgical council on resident education: a new organization devoted to graduate surgical education. J Am Coll Surg 2007; 204: 341e6. 4 Sosa JA, Bowman HM, Tielsch JM, et al. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 1998; 228: 320e30. 5 Porter GA, Soskolne CL, Yakimets WW, Newman SC. Surgeon-related factors and outcome in rectal cancer. Ann Surg 1998; 227: 157e67. 6 Braun S, Pantel K, Muller P, et al. Cytokeratin-positive cells in the bone marrow and survival of patients with stage I, II, or III breast cancer. N Engl J Med 2000; 342: 525e33. 7 Lincoln Memorial University. Available from:http://www.lmunet.edu/ tomec/files/assessment_and_feedback_for_residents_and_students. pdf. (Accessed on 01 Nov 14). 8 Paisley AM, Baldwin PJ, Paterson-Brown S. Accuracy of medical staff assessment of trainees’ operative performance. Med Teach 2005; 27: 634e8. 9 Peracchia A. Surgical education in the third millennium. Ann Surg 2001; 234: 709e12. 10 Bridges M, Diamond D. The financial impact of teaching surgical residents in the operating room. Am J Surg 1999; 177: 28e32.
292
Ó 2015 Elsevier Ltd. All rights reserved.
SURGERY JOURNAL PRIZE-WINNING ESSAY
11 Sachdeva AK. The changing paradigm of residency education in surgery: a perspective from the American College of Surgeons. Am J Surg 2007; 73: 120e9. 12 Grantcharov T, Kristiansen VB, Bendix J, et al. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 2004; 91: 146e50. 13 Rosser JC, Rosser LE, Savalgi RS. Objective evaluation of a laparoscopic surgical skill program for residents and senior surgeons. Arch Surg 1998; 133: 657e61. 14 Polavarapu HV, Kulaylat AN, Sun S, et al. 100 years of surgical education: the past, present, and future. Bull Am Coll Surg 2013; 98: 22e7. 15 Kordowicz AG, Gough MJ. The challenges of implementing a simulationbased surgical training curriculum. Br J Surg 2014; 101: 441e3. 16 Milburn J, Khera G, Hornby ST, et al. Introduction, availability and role of simulation in surgical education and training: review of current evidence and recommendations from the Association of Surgeons in Training. Int J Surg 2012; 10: 393e8.
SURGERY 33:6
17 The College of Surgeons of East, Central and southern africa. http:// www.cosecsa.org/. (Accessed on 01 Nov 14). 18 Howe KL, Malomo AO, Bernstein MA. Ethical challenges in international surgical education, for visitors and hosts. World Neurosurg 2013; 80: 751e8. 19 Ihse I. Surgical challenges in the twenty-first century. Ann Acad Medicae Bialostoc 2004; 49: 7e9. 20 The Surgical Specialties: 4 e Paediatric Surgery. London: Royal College of Surgeons of England. Available from: https://www. rcseng.ac.uk/media/media-background-briefings-and-statistics/thesurgical-specialties-4-2013-paediatric-surgery. (Accessed on 01 Nov 14). 21 Gawande AA. Creating the educated surgeon in the 21st century. Am J Surg 2001; 181: 551e6. 22 Pugh CM, Sippel RS. Success in Academic Surgery: Developing a Career in Surgical Education. London: Springer Science & Business Media, 2013.
293
Ó 2015 Elsevier Ltd. All rights reserved.