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Three Part Question

What are [surgical trainees] attitudes towards [approaches to operative training]and what are the implications for [operative learning]

Clinical Scenario

To guide learning and training the Intercollegiate Surgical Curriculum Project implemented workplace based assessments promoting supervised observation, self assessment, reflection and feedback and emphasising a trainee focused and centred approach to surgical training.

The underlying driving force of this review is to address training and education to gain an insight into what underpins effective learning for the surgical trainee in the operative environment.

The most objective and meaningful assessment of good training is an assessment of the learning achieved, however as Iwaszkiewicz underlines such’ measures of learning are seldom available’. A significant trend amongst researchers in medical education and particularly surgical education is to canvass and analyse learner opinions of training so providing a window into evaluating teaching effectiveness and infer on how effective learning can be achieved.

Search Strategy

Medline/Pubmed, Embase,CINAHL and ERIC databases through the national library for health website
Search terms used for the review (title and abstract), medical AND education; doctors AND training; attitude of health personnel; (train* OR educat* OR learn*) AND (surg* OR operat*) AND (attitude* OR prefer* OR view* OR perspective*).

Search Outcome

An initial 5010 search results were reduced to 147 by combining the search terms. The abstracts for each of these papers were screened to identify those of maximum relevance to the research question.Mandatory components of any paper selected were an account of and research specifically of trainee attitudes to training and trainers.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Leong S.C.L.; Waghorn A.J. October 2006 England	122 SHO’s in Mersey BST programme from yrs 1-4 of training	Survey: Ascertain level of competency of SHO’s in performing minor surgical procedures. Incision & Drainage of perianal abscess chosen as the standard.		35% had no senior surgeon present when they performed their first I&D of perianal abscess.	Poor response rate 29% so difficult to claim representative. Unclear as to criteria for selection of those questionnaire distributed to.
Ker J.S.; Williams B.; Reid M.; Dunkley P.; Steele R.J.C. August 2003 Scotland	12 trainer/trainee pairs(Cons&SpR) for interview All General Surgery Consultants in Scotland	Survey: Identify attributes perceived as good by surgical trainers and level of consensus of these attributed amongst Scottish general surgeons		Trainers regarded operative & clinical competence, interest in trainee, treating juniors with respect and knowing own limitations as most important (>85% consensus).	Data from trainees in interview not presented. Potential bias of interview as unclear whether the trainee/trainer pair were interviewed together or separately with trainee less likely to speak about poor training.
Brown J; de Cossart L; Wiltshire C September 2002 England	115 SHO’s on Mersey Basic Surgical Training Scheme	Survey: Determine reasons for choosing a surgical career, career intentions and their opinions on gauging their own performance.		Self appraisal of own skills and aptitudes, job experience and particular teachers most influential factors in career choice.	12 respondents not accounted for from data presented. Free text responses not presented and analysed for reader to draw conclusions.
Drew P.J.; Cule N.; Gough M.; Heer K.; Monson J.R.T.; Lee P.W.R.; Kerin M.J.; Duthie February 1999 Scotland	52 Basic Surgical Trainees (28 from a Teaching hospital and District General) (28 from training courses)	Survey: Investigate preferred learning style of basic surgical trainees		The majority of surgical trainees optimal learning techniques include problem solving and hands on experience.	Unclear as to how trainees selected (recruitment bias). Results not presented sufficiently for reader to fully draw conclusions. Validity of conclusion that trainees are a self selecting group entering as it matches their learning style unclear from this study.
Steele RJ; Logie JR; Munro A December 1989 Scotland	222 general surgical trainees aim to recruit all general surgical trainees in Scotland. 179 responses, 8 not evaluated as not in operative surgery posts	Survey: Investigate technical training of general surgical trainees and identify areas of weakness.		Trainees felt that amount of time assisting at operations was too much. Large proportion of trainees felt they sometimes operated beyond their capabilities in emergency procedure (325 district general and 15% teaching hospital). Trainee supervised operations comprised only 10% of operative cases.	Aims require greater specificity Unclear as to validation of questionnaire.
Musselman L.J.; MacRae H.M.; Reznick R.K.; Lingard L.A. September 2005 Canada	22 faculty and 14 residents from 2 academic centres in Toronto	Focus Group/Narrative: Document and compare how teachers (staff surgeons) and learners (surgical residents) define intimidation and harassment. Examine and compare teachers’ and learners’ perceptions of the impact of intimidating and harassing behaviours on the learning environment		Current surgeon definitions of intimidation and harassment are ambiguous.Participants viewed intimidation and harassment as both dysfunctional and functional.	Voluntary participation open to responder bias Results do not detail negative impact of ‘good intimidation’ for reader to draw conclusions. Sample size will not sustain demographic comparisons for gender/age/specialty.
Evans A W, McKenna C, Oliver M April 2005 England	6 trainees and postgraduate students in Oral surgery	Narrative: Compare trainees perceptions of self assessment of their performance with the assessors’ judgements and student attitudes to this approach and related approaches including peer assessment.		Self assessment clearly perceived by the participants as benefiting their learning and their performance. Trainees generally prefer and expect to be assessed by experts.Trainees interviewed did not receive any feedback on the operations they performed.	Impact of methods on data collection not fully considered Small sample size and using single procedure means unable to apply in wider setting. Potential bias on data collecting of self assessment as preponderance to be more positive.
Foley PJ; Roses RE; Kelz RR; Resnick AS; Williams NN; Mullen JL; Kaiser LR; Morris Nov/Dec 2008 USA	All general surgery residents in programme in 40 US states. 997 surveyed. 14% response rate but state proportion of each demographic matched to that of total no of residents.	Survey: Characterise current resident perspectives on the important issues that face the profession of surgery and surgical training today.		Residents believed that they will be prepared to enter clinical practice at the end of their training (86%) and that they are exposed to sufficient case volume and complexity (84%). Few believe work hour restrictions improve training and patient care (46%)	Low response rate raising doubts over inferring results as view of sampled cohort. Global perception obtained but questionnaire did not allow for more detailed enquiry into the various satisfactions expressed by residents.
Iwaszkiewicz M.; DaRosa D.A.; Risucci D.A. Nov/Dec 2008 USA	All general surgery residents enrolled in a Midwestern university based residency program over 1 year ( n = 63).	Survey: Identify the learning needs of faculty members who are not perceived by residents as outstanding teachers in the operating room.		Strongest resident perceptions of what makes an outstanding teacher in the operating room include a positive attitude toward teaching, remaining calm and courteous and providing a ‘hands on’ experience.	Single residency program. Although anonymised bias towards favourable evaluation as only asked to evaluate those trainers residents had spent considerable time with. Few trainers received poor overall rating so difficult to conclude on behaviours related to poor rating as teachers.

Comment(s)

There is a real paucity of evidence amongst UK trainees on opinions on effective operative training and is an area of educational research that requires further enquiry. This is necessary to further advise on the models necessary for effective operative learning in this current NHS workplace.

Clinical Bottom Line

The studies are clear in the trend that all trainees uphold certain attributes and learning behaviours as most popular and effective for their learning. Within the operative arena supervision and effective feedback are regarded very highly and mirror the recommendations and training framework and assessment tools set by ISCP. Trainee opinion also quite strongly promotes successful learning when trainers have a clear enthusiasm to teach the trainee and when this occurs in an environment of mutual respect.

References

1. Leong S.C.L.; Waghorn A.J. A survey of competency-based training of senior house officers in performing minor surgical procedures Annals of the Royal College of Surgeons of England October 2006 88/6(576-578)
2. Ker J.S.; Williams B.; Reid M.; Dunkley P.; Steele R.J.C. Attributes of trainers for postgraduate training in general surgery - A national consensus Surgeon August 2003 1/4(215-220)
3. Brown J; de Cossart L; Wiltshire C Exploring the views of basic surgical trainees (senior house officers) on a basic surgical training scheme. Medical Teacher September 2002 24/5(559-61)
4. Drew P.J.; Cule N.; Gough M.; Heer K.; Monson J.R.T.; Lee P.W.R.; Kerin M.J.; Duthie Optimal education techniques for basic surgical trainees: Lessons from education theory Journal of the Royal College of Surgeons of Edinburgh February 1999 44/1(55-56)
5. Steele RJ; Logie JR; Munro A Technical training in surgery: the trainee's view. British Journal of Surgery December 1989 76/12(1291-3)
6. Musselman L.J.; MacRae H.M.; Reznick R.K.; Lingard L.A. 'You learn better under the gun': Intimidation and harassment in surgical education Medical Education September 2005 39/9(926-934),
7. Evans A W, McKenna C, Oliver M Trainees’ perspectives on the assessment and self-assessment of surgical skills Assessment & Evaluation in Higher Education April 2005 vol 30, no 2(163-174),
8. Foley PJ; Roses RE; Kelz RR; Resnick AS; Williams NN; Mullen JL; Kaiser LR; Morris The State of General Surgery Training: A Different Perspective Journal of Surgical Education Nov/Dec 2008 Vol 65,No 6: pg 494-498
9. Iwaszkiewicz M.; DaRosa D.A.; Risucci D.A. Efforts to Enhance Operating Room Teaching Journal of Surgical Education Nov/Dec 2008 Vol 65,No 6: pg 436-440