Value Based Training

An article by Mr David J O'Regan, Director of the Faculty of Surgical Trainers (FST)

David J O'Regan, 2021 

I was particularly struck by the book written by Michael Porter on value-based health care when studying for my MBA. He is an esteemed advisor to the NHS. What is Value-Based Health Care? Value in healthcare is realised when we achieve the best possible healthcare outcomes for our population with the resources that we have, and these outcomes should be comparable with the best in the world. I believe the same applies for our training. Value based training is realised when we see the new generation of surgeons delivering the best possible outcomes for their patients and the best teaching for their students. 

The patient is at the centre of the Trainer/Trainee relationship – everything we do, say and practice will have a direct effect on the patient. They will remember the encounter and the experience for the rest of their lives and may indeed have a scar to prompt their thinking. It is what matters to the patient and how you made them feel that counts.  Sadly, at present we have very crude metrics to measure patient outcome. It is often limited to death-count-easy-data with little attention to quality of life or long-term outcome.  Moreover, do we ask if our intervention was worth it? I offered new and follow up patient satisfaction questionnaires to all my patients. I collected morbidity at follow up, usually six to eight weeks, and asked them if the intervention i.e. heart surgery was worth it. The vast majority replied in the affirmative but a few, especially those who had protracted stays and post-operative clinical events, disagreed and one or two regretted the decision and wondered why they bothered.  This framed my thinking and I find myself exploring the needs of the patient more diligently at  the first consultation, and in the elderly I find myself saying, ‘if in doubt please do not go ahead or please go away and think about it’. 

I recall, as a registrar, clerking a man in for surgery on a Sunday evening, the night before, wondering why he was distracted. It transpired that his son was on a ventilator at another hospital in London and the ‘experts’ had declared that he was going to die. When I asked why he was here, he replied he did not want to be cancelled. I believe we still encourage disease conveyor belts and often disregard the value to the patient. We do not have the systems or data to collect this nuance, but we have it in ourselves as doctors.

I use the trainee in clinic to see all the new patients and for them to present the history and examine the patient with me present.  I always get a better history when I would say to the patient with a smile, ‘I am here to interrogate the trainee and cross examine you’. The play back enabled better communication for all parties and real time feedback on judgment and clinical decision skills of the trainee. I felt it was an enriching and enhancing experience for all parties. The patient was delighted as they saw two doctors for the price of one and the trainee was honing their clinical skills on a one-to-one basis in the protected time of outpatients. Sadly, the staffing of outpatients when there are rota groups is regarded as the lowest of priorities when compared to the theatre, ITU or the ward.  However, the ward could be run by other staff freeing up the necessary training time to develop clinical skills in outpatients thereby satisfying the NHS prime directive which, I believe, is to serve. We are all irked by queues and when we are made to wait for a service, so why do we tolerate that in our clinics?

Training and teaching is a privilege and a joy. I have gotten enormous pleasure seeing trainees succeed and taking the perceived ‘failing’ trainee and turning them around. I delighted in recent years employing my trainees as consultant colleagues.  I want to see them become better than me. Their ability, and growing capability engenders a holistic competency.  This cycle satisfies my soul, and I am blessed to have attained a reputation through recommendation. These are self-fulfilling cycles of growth over the years – begat, begat, begat. The time taken to better a trainee means that they in turn will take time to better their trainees and ensure the patients of tomorrow have a better service and experience.

There is no magic. It is a simple philosophy. As trainers we are here to serve our patient and our trainees through education and by creating value. The glue that holds all this together is confidence. It is ok to err as we all have in our careers. We need to be able to instil confidence in our patients and our trainees. The words that abound the citations submitted for the Silver Scalpel Award are pastoral and nurture. Perhaps we need to train more with the heart than the head. Trainees and patients will respond more to a philosophy of caring above anything else. No matter what pedagogy we know or employ or how many degrees or diplomas we have, unless our trainees and patients know that we care, we will not have value-based training.

"When you are unsure about the future, keep doing what is in front of you with all your heart and with love, and what is meant for you will find you."

Gurumayi Chidvilasananda

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