Training to Serve – the antidote to the COVID conundrum and the service vs training paradigm

The COVID crisis has removed elective surgery lists and the projected number of people that will be on a waiting list for surgery by the end of the year will approximate to ten million people.  The training authorities are cognisant of the impact that this has had on training. Indeed, the RCSEd webinar on Monday 29 June acknowledged and highlighted the issues. Contemporary data suggested that the cases lost in the context of a six-year training program together with an increased flexibility to the needs to the trainee, will mitigate the long-term impact on training.

But, is this really the solution? The COVID crisis has realised the creativity and ingenuity of the NHS staff.  The NHS has triple-jumped into the digital era - social media and online platforms have replaced meetings and patients have online consultations.  We have proved this to be remarkably effective, if not refreshing, and it is likely it will be embraced and the new way of going forward. However, we still must operate – our remote robotic future is still aspirational.  Surgeons still need to be hands-on and in theatre.  The process will be slower because of the threat of COVID-19 contamination, PPE and theatre cleaning. We will have to slow down. But, is this a bad thing?  We can reclaim time to enable us to teach.

Twenty years of running the Silver Scalpel Award to identify the best surgical trainer of the land, reinforced the principle that good training and good service do go hand in hand.  I recall a metaphor used by one trainer (and only one in fifteen years, mind you).  He said to me that my role was to “drive the wagon and look after the ‘horses’ and his role was to sit on the buckboard next to me and take the reins when the going got tough and I could not manage”.  Yes, you could say he was part of the generation of ‘cowboys’ because he was hard, but he did have ‘True Grit’.  He was very much an old school surgeon and he expected that you sit at the patient’s bedside until the patient was stable.  I do recall him giving me call from ITU to tell me my patient was bleeding – I rushed to ITU and examined the patient and replied that I did not believe that to be the case – the retort was “well then you are in charge” and he left.  The patient settled but the heavy yoke of responsibility was passed (correctly) to me.  Every day is a training day that offers a myriad of technical and non-technical training opportunities.  This is a philosophy and not a paradigm choice of service or training.

COVID presents with an opportunity to look at the training issue from the other end of the telescope.  We do not need to be focussing on trainees, but we do need to be focussing on the system in which we train and the abilities of the trainer.  Does the system and the trainer demonstrate that philosophy?  Sadly not.  Less than one hundred trainers have been shortlisted for the Silver Scalpel Award in twenty years!  The CEO of the Hereford County hospital was cited in the local newspaper that his hospital was now on the map because the 2018 winner worked in his hospital.  Wouldn’t it be amazing if all CEO’s shared that philosophy?  The IST program hiccoughed and recognised the importance of the trainer.  I have always maintained that you can have the most innovative surgical training program you like but it will go nowhere without a good trainer.

It is time that we invest in the development of the trainer.  It is appropriate that we ask that more SPA time is given to training.  It is right to question why the skills of a surgical trainer do not carry the same gravitas as those of an academic surgeon.  The burden of responsibility is just as great if not more because the future of surgery is in their hands.  During my training, another trainer explained to me that it was better for him to do only a hundred and twenty cases a year as opposed to a hundred and fifty because he wanted to ensure that his trainees were properly taught.  Over his career of twenty years he had worked out that he could train twenty cardiac surgeons and they in turn train another twenty surgeons.  He upheld safety and efficacy and instilled this in his trainees.  This is the surgical equivalent of the Avon lady – begat, begat, begat.  I have read about many of our great surgeons and it is not surprising to recognise that ‘stables of pedigree surgeons inspire the next generation of surgeons’.  Trainees currently know which ‘stables’ to go to be inspired and trained – you only have to ask but it is informally acknowledge by all.  I have yet to work out how to examine the impact of the Silver Scalpel award winners, but I have no doubt that same will be true.  It is time to make this explicit.

It all comes back to the philosophy we adopt when considering the trainee and trainer relationship.  I believe that trainers are here to train surgeons to serve.  The most important word in National Health Service is Service – medicine is cited in the Oxford English dictionary as one of the few professions that serve.  Together we serve patients.  It is our duty to ensure that the service we offer today, and tomorrow is safe, effective and offers a good experience for the patient, trainee, and the trainer.  This is the irrefutable value proposition.  COVID is demanding that we slow down, and we are deliberate.  We need to create time and space and attend to details.  The trainee will benefit, and the patient will have time to tell their story and be heard – the latter is for another blog.

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.