Surgical training

When this journal first went to press, surgical trainees followed an apprenticeship model propagated by William Halsted at the John Hopkins University School of Medicine. His ‘see one, do one, teach one’ method of teaching has been a surgical training mantra for generations. However, over the past decade the subject of surgical training has enjoyed greater exposure and there has been a change in attitude towards it. There is evidence that the quality of surgical training can affect patient outcomes1. Surgical training has evolved into an academic discipline, with a growing body of evidence for potential improvements. Drivers for this change include pressures of time, innovation and introduction of new technology, and increasing awareness of patient safety requirements. Moreover, surgical trainees themselves have changed. This article discusses how surgical training has evolved, and explores potential advances and challenges to surgical training in the future. Training a surgeon while simultaneously providing a high-volume and high-standard patient service is a challenging task. The current political focus of financial incentives for service delivery can act inadvertently as a barrier to training. The introduction of the European Working Time Directive has contributed to a reduction in volume of operative procedures for trainees. In addition, Birkmeyer and colleagues' seminal work2 examining the volume–outcome relationship of surgeons and hospitals has transformed the geographical distribution of surgical procedures. As a result, the past decade has seen a dramatic increase in subspecialization both of surgeons and, more importantly for training, of hospitals. For example, centralization of vascular procedures and upper gastrointestinal cancer resections largely restricts trainee exposure in these specialties to teaching hospitals. Consequently structured and targeted training is now crucial, as time alone will no longer ensure sufficient exposure to the breadth of training required to produce a competent surgeon.