The Guru – Shishya denotes the tradition and successions (parampara – or lineage) of trainer-trainee in Eastern cultures, particularly Hinduism, Buddhism. This relationship is extolled in Sanskrit teachings. The Guru denotes the teacher, the source of knowledge and instruction and the Shishya – or Chela the disciple or pupil. Knowledge and instruction were imparted in a growing relationship founded on respect and trust. It depended on the ‘genuineness’ of the guru and was without prejudice; not based on age or looks. Mastery and knowledge were transferred from the guru to the chela through commitment and obedience. The Isha foundation in India runs educational facilities founded on the same principles and many lessons are conducted under the trees. This is not based on rote learning - they teach you how to think and you are encouraged to ask questions.
This evolved into the teacher-apprenticeship model that can be seen in modern ages – good craftsmen set up guilds. Their skills and knowledge were highly desired to the extent many would demand payment for their teachings. The hours were long and arduous, and few progressed beyond the menial tasks. A retired colleague remembered his early day as a trainee in India in the 1950’s in Vellore – junior doctors paid the hospital for instruction and the best teachers were highly sought after.
Since 1000 AD, barber surgeons were employed to deal with everything that required the use of sharp implements such as bloodletting, amputation, leeching and even pulling teeth. More often they attended to the less wealthy. The upper classes had physicians who thought it beneath themselves to indulge in such ‘dirty practices’ although they were more educated in the sciences and arts. The barber surgeons were not accredited by universities and formed into guilds of craftsmen. They became adept at treating all diseases, local infections, dealing with trauma, setting fractures and births. The more skilled indulged in trepanation to release pressure on the brain. The apprenticeship model of training flourished. Barbers were also found in monasteries where they attended to the shaving of the monks’ heads and since monasteries become refuges for the ill and thus hospitals, the barber surgeon evolved into a clinical and surgical role. Thirteen century France passed a law forbidding physicians from practicing surgery but the need to provide care in town and villages meant the role of the ‘barber surgeon’ increased with time. In 1308 the barber attained a guild status and in 1375 this separated into two groups – those who did surgery and those who cut hair. War and conflict required the barber surgeon to become more adept at treating trauma. In 1505, the Incorporation of Surgeons and Barbers, became the foundations of what is now known as The Royal College of Surgeons of Edinburgh. A Seal of Cause conferred privilege but also mandated a knowledge of anatomy and surgical procedures.
The model of surgical training has always been based on the apprenticeship model. Stables of good surgical instruction, not unlike the parampara, can easily be identified. Great surgeons like Lord Moynihan worked with McGill and Mayo-Robson and encourage Archibald McIndoe to move to the UK. He then worked with Sir Harold Gillies. The lineage is clear – guru-chela, begat and begat. The student eventually masters the knowledge the guru embodies.
The current training system is designed to assess competency and consistency, with a combination of formative and summative assessment throughout a trainee’s tenure. Numerical scores denote pass or fail. This goes a long way to dehumanising the individual and ignoring their needs. I fear that we may be complicit in systemising the individual and blunting their performance.
The process itself is reinforced by a tick box approach to learning where ‘satisfactory’ will do. This is very much a transactional relationship. It is very unilateral and requires the trainee to fulfil those conditions to earn the trust of the trainer and the system. The fulfilment of this transaction condescends the right of passage to the next step.
The guru-chela relationship is initiated in a ceremony whereby the guru accepts responsibility for the spiritual wellbeing and progress of the shishya. Their relationship is founded on trust, respecting character, and extending compassion. The relationship is transformative and is no longer learned but it is generative. This places demands on both the trainer and trainee as it becomes restorative and empowering.
Today we all can recognise centres or ‘stables’ of good surgical teaching but these are sadly few and far between. Why doesn’t the system recognise the profound responsibility of preparing the next generation of surgeons? Are we equipping them with the right skills? Are we teaching surgeons to think? Are we allowing our trainee ‘to be’? Letting someone be, according to Peter Senge, is the definition of love. In that respect, leading, parenting and teaching are the same. We are stewards of people’s lives and everyone has potential and deserves respect. The FST aims to go beyond the transactional to the transformative, and transcend current training dogma.
About the author:
David O'Regan is the Director of the Faculty of Surgical Trainers. He has been a Consultant adult Cardiac Surgeon in Leeds since 2001.
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