The Hindu based philosophy of education (Shiksha) and knowledge (Vidya) focused on learning as a value-based exercise – through education, we can attain the skills essential for living and survival but ‘vidya’ (knowledge) is attained for life. Vidya is necessary for growth.
Our professional culture, including that of teaching, has become one of doing and transaction where the task themselves are counted and reported more that their value. Indeed, health care at present does not seem capable of realising the value of any encounter between the patient and a doctor. Similarly, the relationship between the trainer and trainee can be considered strained with the burgeoning service demands. The value, implication and long-time outcome of our interventions are poorly understood, met alone, documentation of supposedly well considered decisions. This is true of the patient but also of the trainee whom we should see as the future independent surgeon practicing what they have learnt from their trainer on their patients. A frequent gripe of the Annual Review of Competence Progression (ARCP) is lack of documentation. Decisions need to include the trainer and trainee voice and it is that relationship and bipartisan commitment to that relationship that is important. Trainee surveys, and those of patients for that matter, show increasing dissatisfaction with transactional nature of training and health care. The way we treat patients and trainees is often transactional – ARCP- a satisfactory-tick-the-box-form to be completed, repeat, and move on to the next task. This completely ignores what we all know and receives more attention – the coffee conversation. This is flawed as it can be saturated with biases and heuristics, sometimes personal dislikes and even vendettas.
The realisation that surgical education was more than the historical and passive osmotic diffusion of knowledge, abridged by the ubiquitous see-one, do-one and teach-one philosophy, brought about the translational age in surgical education. Modernising Medical Careers (MMC) was innovative in that it created structure and evidenced rational thought bringing a welcome end to rather a nebulous process or trial and error which was partly dependent on old school and if your face fitted with the brogues-pants-blazer culture. You cannot forget the club tie.
We progressed further by defining the skills and tasks that required by a surgical trainee to evidence training, but the transactional nature prevails as the trainee clamours to have ‘three-letter’ objectives counted and recorded (WBA, DOPs, CEX). For some trainees, and I have witnessed this, the desire to get signed off to do the exam, eclipses all rational thought about the long-term implications of being unconsciously incompetent on their own career and the safety of their future patients. The quality of this method of assessment has become more translational but much of this must be questioned as we continue to tick the boxes to appease the insatiable appetite of the system – trainee and trainer alike strive to satisfy a system that becomes ever more demanding of one both parties. ‘Satisfactory’ in the colloquial sense is the word and the tick box duties of the trainer and trainee of the day, still prevail.
We are now entering a transformative stage in surgical education and perhaps a beginning of the period of enlightenment in surgical education. Multisource consultant feedback is going to begin to annul the frequent ‘because-there-is-not-time-but-satisfactory’ tick- box that often comes without elucidation and explanation. We are going to make a collective decision and hold each other to account as trainers for our opinions and judgment of trainee capabilities. This is an initiative to be applauded as we consign to history; the egos, and superegos of the ‘club-tie’ era. This is the marking of the extinction of the dinosaur surgical trainer and is welcomed. Furthermore, we are at last going to entrust our trainees in professional activities – the fact they have been doing and leaning and learning by doing for eons is beside the point. At last, we can formally celebrate applaud the skills and abilities of the training surgeon. Personally, I am saddened that this significant step in surgical education is marred by nomenclature – it is called a CIP? This is akin to the brand cleaning product called ‘Flash’ being reduced to ‘CIF’; a shibboleth akin to the Gileadite test word to distinguish from an Ephramite. I hope that we pronounce it properly. The rest of the world is going to call this capability in practice (CIP) an EPA – an entrustable professional activity, where I believe the emphasis is on trust, or should be. To hark back to a quixotic corridor question; ‘would you trust this person to operate on your relative?’ It was powerful emotive question that generated an immediate ‘gut-feeling’, often correct, of negatory response or one the affirmative. Excuse me but I do wonder, pun deliberate, what ‘CIF’? Does the term ‘CIF’ remove that all-important visceral feeling and the meaning of expert intuition conveyed in the word ‘trust’. This is a transformative step in surgical education and heralds an enlightenment in our thinking. Indeed, the service will benefit as we explore high-volume low-cost theatre lists run by trainees with ‘CIF’ accreditation and overseen by the trainer surgeon. The trainee will be able convert competence into experience because the system will afford the volume surgery that is currently and sadly lacking. The trainer will have an umbrella responsibility to enable ‘CIP’ accredited trainees to grow. This takes me back to my training in 1988 when I was on a firm as a senior house officer with a senior registrar (SR or consultant in waiting for the new generation) and two consultants. The colourful consultant Mr B. would walk between the theatres – SR doing a left hemicolectomy in the one theatre and me doing an open cholecystectomy in the other – saying ‘keep cutting my boys!’.
The German philosopher Hans Georg Gadamer (1900 - 2002) maintained that we are losing our vital instincts for authenticity, language, and conversation; reflective consciousness; and self-understanding. He describes this as a societal disequilibrium, and I believe this is reflected in the trainer – trainee relationship. The current system undervalues the importance of the trainer - trainee relationship. The amyotrophy of the connection by the system undermines the potential of mutual growth that fails to realise the important transcendental nature of the trainer – trainee relationship. We are failing to invest time in our job plans and space in our hospitals to nurture this relationship. For the trainer-trainee relationship to grow these are necessary ingredients and are at the heart of a successful trainer – trainee relationship. This is the value chain, described in my last blog, that benefits all parties especially the patient, today and tomorrow. We need to ensure that space, time, and means for reflective practice are inculcated into our organisations, leadership, and work environments. Edgar Schein, the guru on organisational culture at MIT in Boston, wrote time and space were the two of the five ingredients necessary for a health culture. This is the ‘Vidya’ of Hindu philosophy.
The ‘stables’ of surgical excellence and education that are seen throughout history are as a result of the great teachers who commanded, and demanded, status for the trainer. I have spoken to many people during my tenure as Director of the Faculty of Surgical Trainers (FST)– we all agree the Professors of departments today are measured by transactional means – success is defined by how many papers are produced by the department, the higher the impact value the better, and how much money the individual can attract in research grants. The professor of yesteryear is emeritus as the system has discharged them from the duties of education. My questions are ‘Who is taking charge of growing and educating the people in the unit of today?’ Who is taking charge of creating value though education? This is why it is vital an education equivalent of an academic professor is present in every speciality in every hospital. Someone needs to be appointed to look after the next generation – education is the mortar that holds the bricks of an organisation together, ensures succession and secures the future. Good education is an attractor. This applies not only to the surgical trainee but the whole team.
Gadamer believes that intentional raising of consciousness, engagement in dialogue, and arriving at new understandings require us to ethically assume responsibility for these – this is particularly important when we consider the sublime qualities required of a surgeon – communication, empathy, compassion, humility, and fallibility. This embodies ‘vidya’ and defines an educator. The educator is more than a trainer of skills, and a teacher of knowledge. A good educator heralds the last and most important transcendental step. We learn best within a safe and supportive social context – think of parenting and all that entails. Healthy communities of learning arise when clinicians who practice together form what is known as a community of learning and support an education strategy. Educators reinforce that successful knowledge-sharing that depends on human networks and relationships. To nurture and sustain a healthy community of learning, the system needs to recognise the imperative of a safe learning environment that is described by Amy Edmondson (Professor at Harvard Business school and author on psychological safety) as reflective. It cultivates trust, is open to possibilities, and deliberately honours vulnerability.
The operative word I note in the twenty-one years of reading Silver Scalpel Award citations is ‘nurture’. Whatever is derived from the trainees’ experience, training, environment, values and upbring deserves respect of that the individual. The ‘trainers’ duty is to role model and their function is much more holistic if not ethereal. The more authentic we can be as trainers, the healthier the relationship with trainee and the healthier our departments will be. As educators, and as parents, we have a duty to open the door to the possible. Learning itself is not something that occurs inside an individual; it grows within a community and flourishes in the relationships between its members; especially the trainer and the trainee. It is a journey, a gradual process of becoming. It is growing. Letting someone be. This is described by Peter Senge as ‘love’.
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