To look to the future, we must understand our past – and the history of surgical education presents milestones highlighting an important evolution.
In the middle of the 16th century, the training of medical apprentices began around 13 years under a single mentor. This process involved direct observation and imitation of skills in a clinical environment for 5 to 7 years, which was followed by independent practice. There was no regulations on the required skills, the training structure or surveillance after an independent practice.
Over time, the development of the Halstedian pyramidal, the model of graduate autonomy and the training of medical advice provided a structure necessary for surgical training. The evolution of standardization between hospitals and the residence review committees and the transition to skills based on skills have propelled us into the modern era.1
So where are we going from here? The future of surgical education depends on surgeon leaders recognizing the challenges inherent in the acquisition of a massive quantity of knowledge and skills required in an accelerated training time.
Rather than a linear model “See one, do one, teach one”, trainees should evolve in several areas simultaneously to become well -balanced medical surgeons (see Figure 1). Surgical educators will have to plan the acquisition of technical skills and medical knowledge to highlight the value of self-reflection and current comments, increase specialized certification and encourage the development of non-technical skills.
We will see another major change in the training model, moving from the assessment of the adequacy of the training according to time and cases, towards a complete holistic examination of the way in which the trainee works at all basic skills within the framework of the largest health system.
Develop technical skills
As the modern world has evolved with the growing integration of technology in daily life, medicine, surgery and surgical education also. The previous acquisition of skills has been relegated to “present” with learning models or even a simulation practice.
The future integration of technology will allow us to “train our past” by doing resources to record, analyze and examine procedures universally. Indeed, current multimedia training applications have proven to considerably improve the surgical performance of scholarship holders and students' education.2
These systems will become transparently integrated into the training and will offer a variety of advantages. Video and audio recordings can be obtained for whole cases, and publishing software can be used to condense these protruding videos which focus on the key aspects of a procedure.
Trainees will generally have immediate access to data that will facilitate self-reflection with longitudinal records to monitor their progression. In addition, these videos will allow feedback and coaching mechanisms of surgical educators, regardless of time or space and will allow the trainee to develop higher level skills targeted on certification and, ultimately, an improvement in quality.
Technology in the operating room (gold) has also been applied to surgical security with the creation of the golden black box. The term “black box” comes from the aviation industry where technology is used to collect full flight data and real -time monitoring. Based on this information, the risk can be attenuated and accidents can be examined to develop strategies to identify and avoid future events.
Our current model of operating rooms safety is based on subjective factors such as retrospective examination and self -depressed morbidities and mortalities. In the future, the identification of its objective measures can be standardized with the collection of data from wall cameras, microphones and video flows from laparoscopic instruments for cases of general surgery. The first studies revealed on average 20 errors per case, generally during the dissection and reconstruction of cases, and an average of 138 hearing distractions.3
Future surgical trainees will have to control their technical skills using clinical and simulated training, supplemented by a video review, in order to assess their performance while identifying the fields of improvement. Current obstacles to develop this larger process include the cost of integrating this technology and the acceptance of a continuous surgical training coaching model.
Technical skills assessment
As the number of technical skills increases, learning procedures must also and for the verification of these skills. Although the fundamental principles of laparoscopic surgery (FL) and the fundamental principles of endoscopic surgery programs (FE) are now necessary for the qualification examination of general surgery, there is no normalization for the end of these certifications or a consensus concerning the required surgical simulation program.4
In addition, comfort in a simulation environment can predict improved performance but do not guarantee control of the operating environment for laparoscopic, endoscopic or robotic procedures.
Indeed, there are subtle technical shades which are only acquired thanks to an operating exhibition supervised in real time with a more time resident autonomy. To facilitate this learning curve, programs can look into an early introduction of FLS and FES programs, which makes it possible to master more time for advanced skills during the remaining years of residence and by increased levels of comfort of teachers concerning resident autonomy.
Simulation in surgical education must parallel to the growth of variety and sophistication of surgical technology over time.
Laparoscopic surgery dominated procedures in private and university centers; However, since its introduction in 2004, the FLS program has not been adapted for parallel this increasing complexity. Recent evidence of a highly raised rate of FLS 96% denies the need for study programs to correspond to the growing complexity of exposure to laparoscopic cases of trainees and the required skills of a resident of graduate general surgery.5
The development or alteration of new modules, however, should carefully consider their value instead of the clinical responsibilities of a trainee, financial charges and mental well-being. The certifications added without appropriate educational value will undoubtedly have a negative impact.
Importance of general skills
The current transition to health care centered on the patient will lead to the future reorientation of surgical education and the creation of an ideal “professional” surgeon. It is increasingly aware that these effective surgeons must have non -technical skills (NTSS) or general skills to engage with patients and colleagues, and undergo formal training and evaluation of the NTSS.
The NTS have been defined in various ways, most often as “the cognitive and social skills that characterize very efficient individuals and teams”.6 These skills are frequently organized in three distinct categories: cognitive (for example, decision -making, awareness of the situation); Interpersonal / Social (for example, communication, teamwork, leadership); And staff (for example, overcome professional exhaustion, manage fatigue).
Over the past decade, the importance of the NTSS for patient care has been widely demonstrated, studies showing that the majority of surgical complications results from deficiencies in the NTSS (for example, a break in communication) rather than technical errors.7
The formalized training and validated NTSS validated assessment tools for surgeons and surgical trainees have also been studied. The most studied and validated tool is the system of non -technical skills for surgeons (NOSS). A modified version of this framework, the note-USS, has been studied as an assessment of trainees in the United States.8
Nots and note systems focus on four areas: awareness of the situation, decision-making, communication and teamwork and leadership. Each of these categories is still broken down into specific elements (for example, exchanging information, facing pressure).
A qualified assessor uses this tool to assign the trainee a note for each relevant competence, after which feedback and discussion should identify the areas to be improved. While note focuses on a surgeon in the operating room, other modified assessment tools have been developed to assess the surgical team as a whole (surgeon, anesthesiologist and nurses) or a surgeon in the resuscitation environment in trauma.
In the studies of trainees, the notsss-US proved to be in correlation with the third cycle year.9 This suggests that, similar to technical skills, there should be an expected graduated improvement of the NTSS and a formal incorporation in the training. In the current framework, the NTSS is of the individual skills of professionalism and the interpersonal communication stages that residents should target before obtaining the diploma. While the transition to a more holistic training based on skills occurs, the NTSS will be integrated into formalized training as a fundamental part of surgical training during the next decade.
Paradigm shift in evaluation
Our trainees should now control open, laparoscopic, endoscopic and robotic surgery. In addition, they should acquire a knowledge base in constant expansion and demonstrate the skills in leadership and communication. It is no longer possible to rely only on time in training or the number of cases to assess the preparation of a trainee for independent practice.
So how are we going to assess this “future surgeon” who is responsible for mastering knowledge, technical skills and general skills? This evaluation will probably occur while the profession is involved in the new paradigm of Professional Configuration Activities (EPAS).
The EPAs were initially developed in the Netherlands so that doctors better determine their gaps in skills. The executive of the EPA will be launched in addition to the established stages of the accreditation council for graduate medical education.
In 2020, five general surgery EPA were controlled: evaluation and management of a patient with an inguinal hernia; Evaluation and management of a patient with pain in the lower right quadrant; evaluation and management of a patient with a gallbladder disease; Initial assessment and management of a patient with blunt or penetrating trauma; and provide general surgical consultation to other health care providers.
From July 2025, these five EPAs and 13 others will be launched in general surgery programs (see table). Together, these 18 EPAs aim to assess basic skills (knowledge, technical skills and general skills) in a standard holistic manner.
