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16 March 2021

One of my favourite speakers was Sir Ken Robinson. This YouTube video of his TED talk especially resonated – ‘How to escape education’s death valley’. He talks about the USA’s No Child Left Behind Act of 2001. He asserts that we have an education system that seeks conformity not diversity.

I reflect on Sir Ken’s presentation and the lambasting he gives the education system in general. No child should fail. He highlights that the system is focussed on the lowest common denominator. In other words, education is delivered as command control and one size fits all. He examples this approach as a failure because the dropout rate from schools in the USA is disappointingly high. He contrasts this with Finland who make efforts to tailor the education to the need of the individual and actively seek the talent and potential for growth in the student. Not surprisingly, there is no such thing as a dropout rate in the education system in Finland.

For those of you who have watched the FST webinars ‘Trainees in Need – Touching on Taboos’, I am sure you will join me in saluting the openness and authenticity of the panel. Vicky stated she was told many times that she was not meant for surgery. Yet, despite this she not only prevailed but is succeeding and with a smile. Vicky’s honesty and the YouTube video highlight a similar fixed mindset in the education of surgeons and a mindset that is potentially stifling creativity and ignoring the talent of our trainees.

Our profession is better with inclusion and diversity. We cannot propagate the Surgical Club culture and conformity. I remember a title on the front page of a surgical magazine that proudly stated, “Knife before Wife”. A surgical career was, and still is in some dark corners of the profession, regarded as a sanctimonious decision between cutting or living driven by a command-and-control system. Much of what we have is a system of ‘compliance’ and set hurdles for progression.

We are in the business of attending to people and hopefully allowing them to decide whether to use our skill or not. Our patients are diverse and unique. We need people in the widest sense to enable us to deliver a better service. We need to be inclusive and recognise the talents of all. We need to encourage everyone who share a passion in surgery and not regress to historical stereotypes.

Communities of practice are the current theme of education theory. This theory extols the virtue of legitimate participation. This refers to the trainee. I reflect on Professor Irena Grugulis’ presentation at the FST Conference 2020 – the firefighting crews without trainees were essentially worse off. The trainee brings legitimate experience to the team. They are the fresh pair of eyes described by Professor Sir Bruce Keogh. I reflect on my own surgical practice and lament the fact that the opportunity to learn from others has declined. I have tried hard to establish a culture of consultant regularly helping another consultant but to no avail.

My only at-table learning has to come from the trainee. That, however, has been profound. Eleven years ago, my trainee told me off in no uncertain terms for using bone wax on the sternum. He was quite right- I was guilty of ‘that is the way we had always done that around here’. Together we came up with a tissue care bundle that reduced my all-sternal wound problems to a median of zero. Lord Berkeley Moynihan said that the surgical experience is a posy of other men’s flowers. You learn from seeing different people do the same things in different ways – that is the main benefit of surgical rotations. You must understand the science before you can appreciate the art. The opportunity to see and share different techniques, for many, significantly diminishes on reaching consultant status. That need not be the case. The trainee is the ‘bee’ that is pollinating the flowers. I certainly feel my practice has benefited from trainee pollination.

As Sir Ken says that human beings are naturally different and diverse – trainees and patients alike. It is important to encourage diversity and inclusion. If we do not, we run the risk of becoming a self-serving echo chamber of ‘when I was lad’. Times are moving rapidly, and the demographic of medical school entry has changed significantly – for the better I may add. The challenges for the future require that we inspire and include. One size does not fit all. We need a diverse and inclusive group of people working in our field. It saddens me that the entry criteria to medical school is still dependent on academic achievement in prescribed exams and that entry to medical school is regarded by schools and parents alike as a status achievement. The system is already biased as indicated by Sir Ken Robinson. That dreamer and creative genius in the classroom is already up against it and our system of surgical education propagates a tick box, hurdle-strewn career pathway for trainees.

Future innovation is dependent on creativity and the ability to think outside the box. We need to stimulate curiosity – this is Sir Ken’s engine of achievement. Management theory often talks about ‘letting all the flowers bloom’. Sir Ken Robinson talks about the carpet of flowers in Death Valley – the hottest place on earth that extinguishes life – that ‘magically’ appeared after a fall of rain. The desert was not dead. It was quiescent and all it required to ‘come to life’ was rain. Well, there you have it – when it comes to people, the rain equivalent is inspiration.

In the apparent desert of surgical training, our duty as trainers is to provide the inspiration. As Sir Ken says, we are not here to pass on information – we are here to mentor, coach, stimulate, nurture. Each trainee is different and can add value to your practice. We need to engage and provoke. As Sir Ken says, ‘we may be engaging in the task of teaching but are we stimulating learning?’ You cannot make anyone go through a door, but you certainly can open it and let them in or out! We do not want anyone left behind in surgical training and we need to inspire the next generation of surgeons. We need to help them sculpture their own careers. We need to engage their innate curiosity. I too believe we need to change the conditions of the trainer and trainee to create ‘a climate of possibility’.

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About the author:

David O ReganDavid 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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