Educating Orthopaedic Surgeons

The Walter Mercer Lecture of the Royal College of Surgeons of Edinburgh commemorates the most outstanding general surgeon of his generation. His clinical reputation was based on his skills as a superb technical operator across the whole field of surgery. This was reflected in his typical operating lists; which might include partial gastrectomies, osteotomies, a meniscectomy or two, as well as cardiac surgery, such as ligation of a patent ductus arteriosus. Orthopaedic surgery had always been his major interest and he made some pioneering contributions to this field, notably in the early attempts to achieve spinal fusion by an anterior approach. However, he did not confine his work solely to orthopaedics until after his appointment in 1948, as the first George Harrison Law Professor of Orthopaedic Surgery in the University of Edinburgh. He received many Honours and Awards in his lifetime, but it is surprising that although elected a Fellow of the British Orthopaedic Association (BOA) in 1925, he never became its President.

In recognising Mercer's outstanding abilities in the operating theatre (Figure 1) it is easy to forget his talent as a surgical educator and it is this aspect of his life that forms the theme for this lecture. Like many trainees of my generation I used his well-established textbook as my guide to orthopaedic knowledge. The first edition was published in 1932 in response to the request of his trainees and Fellowship candidates who had benefited from the material which he used for his teaching course on Orthopaedics and Fractures in Edinburgh Royal Infirmary. In addition to his writing, he had a reputation as an outstanding clinical teacher, both at the bedside and in the outpatient clinic. This interest in surgical education was extended when he became President of the Royal College of Surgeons of Edinburgh in 1952. He introduced a number of new ideas to the College, including structured postgraduate surgical training and teaching in the basic sciences.

Figure 1: Sir Walter Mercer in theatre dress (reproduced with the permission of the Editor of the British Volume of the Journal of Bone and Joint Surgery)

The question posed by the title of the Lecture is one I have often asked myself in the past 30 years when faced with the frequent changes in curriculum, regulations, and programmes, which frustrate our attempts to produce a co-ordinated training scheme for the speciality. My original ideas on the 'Education of an Orthopaedic Surgeon' had been to build these around Shakespeare's “Seven Ages of Man”, but on reflection seven seemed a little too many. The answer to my problem came from this picture (Figure 2) which is on display in the National Gallery in London. It is a painting by Valentin- de Boulogne, entitled “The Four Ages of Man”'. The four figures which it depicts allowed me to divide orthopaedic education into four phases; the Undergraduate Student, the Pre-Fellowship Surgical Trainee, the Specialist Registrar and, finally, the Orthopaedic Consultant.

Figure 2: The Four Ages of Man. From a Painting by Valentin De Boulogne (reproduced with the permission of the National Gallery, London)

The first figure depicted at the front of the painting is that of a young boy with a look of incomprehension on his face. The reason for his puzzlement is that the bird trap he is holding has an open lid - the bird has flown! Our undergraduate students frequently display the same emotions when they lose their motivation to comprehend what we are trying to teach them. Why is it that so many of these very bright and highly articulate entrants to Medical School become so disillusioned by the time they reach the end of their clinical years? We need to understand what must be done to influence them at this early stage, as this is our first opportunity to attract them to a future career in surgery.

A number of factors are working against us at a time when Medical Schools are changing from their traditional curriculum to follow GMC guidelines for a more student-centred course, and surgery is increasingly regarded as a superfluous postgraduate subject. Faced with these pressures for change we must define what essential core surgical knowledge should be taught to all students. Early in the undergraduate course the students clearly need to have instruction to equip them with the basic tools of history taking and physical examination of the musculo-skeletal system, a task which can be shared with our colleagues in rheumatology. Students should be encouraged to use these skills as part of their general examination of all patients throughout their training. The other essential topic is a basic knowledge of the principles of trauma management, which can be combined with instruction in first aid.

Another limiting factor is the change in clinical practice that has resulted in shorter inpatient stays and limited bedside teaching. Pre-admission screening may save money, but does not facilitate teaching of students or junior medical staff. The increasing use of the Day Surgery Unit means that the clinical material available in the ward is more complex and less appropriate for student teaching. There is a need to counter the political and media pressure, which encourages patients to ‘opt-out’ and not be used for ward and clinic teaching. Patients need to be reminded that they still expect their junior doctors to be totally clinically competent on the first day after qualification.

All this seems a far cry from my own experience as a student in the 1950s, when you were given the somewhat grandiose title of 'dresser' on surgical firms. You were expected to assist the nurses at dressing wounds and removing stitches, as well as carrying out the preoperative skin preparation and shaving of all male patients on the morning of their operation. Heaven help you if you slept in!

Traditional lectures and tutorials produce boredom and disinterest and should be replaced by collaborative teaching with the basic sciences, particularly anatomy. Both subjects can be brought to life once students are shown that surgical treatment requires a working knowledge of anatomical structures and their relationships. Details of surgical techniques are inappropriate for undergraduates, unless they form part of structured clinical teaching on a complete patient care episode. Surgical teaching can be enhanced by the development of video-links to theatres, allowing students the opportunity for verbal interaction. When surgical topics are linked to other clinical and basic science subjects as Special Study Modules they can be very successful.

Lastly, those of us who are fortunate enough to teach students should be aware of the example that we set them as role models. If they perceive us as disinterested in the patient as a whole and too pre-occupied with our role as surgical technicians they will probably seek alternative careers.

The young man in the left of the picture, dressed in fine clothes and playing a lute is clearly wrestling with the dilemma of choosing between an easy life or the harsh regime of a surgical career. If starting his Basic Surgical Training (BST) he would have every reason to be apprehensive as it is the one part of surgical education that we have never succeeded in getting quite right. Walter Mercer, and the Edinburgh College, held the view that to be a good specialist one must always be a good general surgeon. This concept, which has always been a feature of surgical training in the United Kingdom, has never been seriously challenged, even though in North America and parts of Europe direct entry to specialist training is the norm.

Now may be the time to question the role of BST in orthopaedic education. Why do we need it? If we do need it, how long should it last, and what should be its content?

For many years the Colleges required two years experience in designated posts in general surgery before allowing trainees to sit the Fellowship Examination having passed the Primary. The latter often required a period of basic science training, usually as an Anatomy Demonstrator. These examination requirements shaped the structure of many of the Pre-Fellowship Training Schemes, which were introduced in the 1960s. The new regulations for the revised AFRCS (or MRCS) give more opportunities for training in the other specialities with two years of carefully planned and structured training in the generality of surgery, including six months of orthopaedics with trauma experience.

The new training schemes are much more structured in content with an increase in taught course work and defined reading to cover the curriculum. This led the Edinburgh College, in common with the other Surgical Colleges, to develop improved electronic teaching material, augmenting the traditional textbook and allowing 'distance learning'. Training must also include a three-day course on Basic Surgical Skills and formal instruction in emergency resuscitation procedures or ATLS Certification.

Unfortunately, the combined effects of restricted working hours and a shorter period of training has resulted in a decrease in operative experience. Involvement in `Resident' type work also limits time for theatre work, but does provide experience in the continuity of clinical care within the surgical team. This makes it difficult for the basic trainee to compete for the small number of Specialist Registrar posts without an additional year of experience - effectively extending basic training back to the Pre-Calmanisation three year minimum. When added to the six years of Speciality Training in orthopaedics we are back to a ten-year training programme from qualification. Is this appropriate at a time when we are trying to produce sufficient trained specialists to fill the expected number of consultant vacancies? Now may be the time for orthopaedic surgery to design its own total comprehensive training programme, containing appropriate basic surgical skills from surgery in general, combined with more relevant basic sciences integrated throughout the training years. Whether this could be achieved within the existing College structure, or would require the BOA to `go it alone' I will leave others to argue and debate

The third figure, on the right of the painting, seems to be falling asleep while reading his book and is still in his working clothes. In this case it is armour, but it might just as easily have been theatre greens or a white coat! He is clearly near the end of his specialist training in orthopaedics, as there is a laurel wreath on his head, presumably signifying that he has passed the Intercollegiate Fellowship Examination.

We should ask what aspect of the Orthopaedic Training Programme has exhausted our Specialist Registrar. Is it the struggle to achieve selection, the overloaded teaching programme, or the stress of the final examination? The frequent changes in regulations and terminology for specialist training is confusing. They lead me to wonder if the programmes are really designed to educate our trainees, or just represent a means of controlling manpower requirements in response to ever changing Government policy.

In reviewing the method of trainee selection for orthopaedic surgery, there seems to be little support for the radical view that the trainee should be selected as early as the first post-registration year. The current timing at the end of BST seems the best compromise, with the advantage of exposing the trainee to a wider range of surgical disciplines before making a final career choice. This provides limited opportunities, however, for assessment of the trainee's performance during BST.

To overcome this, attempts have been made to adopt some of the techniques used by other professional groups, notably airline pilots, for testing an individual's psychomotor skills. The increasing sophistication of digital technology certainly allows the application of virtual reality simulation to tests of hand and eye co-ordination. The difficulty is in attempting to correlate these results with an individual's final performance as a technical surgeon. Less attention has been paid to assessing the subjective attributes of clinical aptitude and judgement. It seems that we should be able to make rapid and incisive decisions when working under stress, and to be more objective and practical in our solutions to clinical problems, compared with the more ‘feeling’ people-orientated concerns of our medical colleagues. The would-be surgeon must certainly be able to work in a team, but clearly finds it difficult when he is not their leader, a concept that some anaesthetists find difficult to accept!

Once appointed, the theoretical clinical knowledge base for the orthopaedic trainee can be provided by a formal programme of half-day release fitted into a three-year cycle of training. This can be augmented by attendance at National or Regional Meetings for more specialised topics. Very few trainees have the interest or wish to pursue basic research, but clinical research and audit methodology should form an essential part of training to support Clinical Governance and Self-Appraisal.

There has been an increasing emphasis on teaching technical operating skills, as the instrumentation used has become more complex and sophisticated. Operative Skills Workshops for the fixation of simulated fractures in plastic bones have now been extended to joint arthroplasty and spinal surgery. The missing ingredient is the interaction with theatre nursing staff, who also require training and need to interact with the operating surgeon. A greater emphasis on education of surgeons and theatre nurses in a joint working environment is required.

The limitation on working hours is another barrier to good surgical education, particularly where this interferes with continuity of care following an operative procedure, including the post-operative supervision. Training schemes with frequent planned rotations have broadened the exposure of trainees to a wide range of special interests, but have the disadvantage of limiting in-depth working relationships with individual trainers.

With the current shortage of consultant teaching time resulting from service pressures there is a danger of producing well-trained technicians with less developed clinical skills. Too early specialisation by trainees limits their exposure to a broad spectrum of orthopaedic experience, which may be a disadvantage given the pace of change they are likely to encounter in a working life-time. The minimum standards of proficiency and index operations required of all trainees should be specified. There is a need for more control in adjusting individual training plans, which if too rigid may not necessarily address the trainee's needs. One of the byproducts of increased specialisation within orthopaedics is the need to access support and assistance from surgeons in other disciplines. For example, an orthopaedic spinal surgeon training with neurosurgeons, or a hand surgeon developing additional skills in plastic surgery in the final years of specialist training.

Finally, there is a need to look at the place of the Specialist Fellowship in relation to the overall education process.

Although the need for an examination in the speciality is now accepted, we have not been good at reducing the burden of examinations in early training. It is important that the examination structure is constantly reviewed and audited to ensure that it is a test of competency to enter consultant practice, rather than just another check on the trainee's knowledge base. More attention should be paid to the log books of operative experience which, in their present format, give insufficient information on the quality of the surgical experience of an individual trainee. Preparation for examinations has been said to inhibit research activity because of the intensive reading required to acquire theoretical knowledge. This is disappointing as the examinations, when first planned, were intended to test clinical competence rather than book knowledge.

Here I should pay tribute to Professor J.I.P. James who, when Chairman of the BOA Education Committee, supervised the introduction of Orthopaedic Training Programmes and stimulated the Edinburgh College to introduce a Specialist Fellowship Examination. I was invited by the College to visit the American Board of Orthopaedic Surgery in 1978 to learn how they did things and was highly impressed by the organisation of their examination. There were no patients, but standardised case material was used to take candidates through several levels of clinical problem solving. When the first Edinburgh Specialist Fellowship Examination was held in December 1979, the Examination Board had produced a wide range of structured material for use in the four oral parts of the examination. Unfortunately, the structured component of the current examination is less, though the use of common material for all candidates does present logistic problems to prevent information leaks.

What is the ideal structure for the Intercollegiate Examination? The written component remains the most contentious part, but could probably be discarded if the orals were more structured and standardised for all candidates. However, the clinical examination is essential providing the examiner with an objective means of demonstrating a candidate's ability to elicit a history and physical signs, as well as showing how they relate to the needs of the patient. In the ten years since the examination was introduced there has been an impressive improvement in candidates' knowledge of the basic sciences and it should now be possible to integrate these into the clinical problem solving rather than examining them as a separate topic.

The older man at the back of the picture is clearly an ageing Consultant and will soon have no use for the pile of money before him. His drinking signifies pleasure, but the flask and glass indicate pleasure's fragility. Like many Consultants, his initial enthusiasm at having finally obtained that accolade against fierce competition has been dispelled by the frustrations of his job. His ideals have been dented by the constant battle against hospital managers to obtain funds for new equipment and implants, there are too few nurses to look after his patients, the registrar is on annual leave - and now they want to educate him!

A few years ago the achievement of consultant status meant the end of the need to learn - other than to keep up-to-date with your special interests by reading the Journals with an occasional attendance at a Meeting. The advent of continual medical education (CME) and the threat of re-certification (I gather the politically correct term is Revalidation) has changed all that!

Do we really need CME? It is easy to claim that our heavy clinical workload demonstrates that we more than fulfil our contracts and leaves us little time for learning. Unfortunately, the general public, as a result of the recent well-publicised problems, want more concrete evidence that surgeons are keeping their skills up-to-date. The advantages of CME are that it provides some objective record, as well as identifying the training needs of an individual. The disadvantages are that it inevitably increases the costs of clinical care because of the time spent attending educational meetings; it is not clear who will pay the bill. Educational activity, particularly self-learning, is difficult to monitor and administer, while theoretical knowledge, even when it is up-to-date, does not necessarily equate with surgical excellence.

What are the educational needs of the consultant? The increasing pace of development in our speciality, which was once reckoned to change every five years, now requires significant updates on an annual basis to allow the acquisition of new technical skills as well as theoretical knowledge. Personal development should allow for changes in working patterns, such as the major shift in emphasis from in-patient to day-case surgery. To provide this flexibility it is essential that all consultants, and perhaps senior trainees, should be introduced to basic management skills. They should all be able to understand the administrative problems, which result from their wish to look after patients to the best of their ability and the financial costs, which lie behind this so-called ‘clinical freedom’. If Clinical Services are to be maintained and improved at a time of increasing financial pressures in the NHS, then clinicians must be prepared to be involved in some aspects of its management.

Will the consultant of the future be prepared for the rigours of Revalidation? It all depends on what format the GMC finally introduce. Clearly, CME performance will form a major part of this and is already emerging as a requirement for retention on the Specialist Register. In addition, public and patients will look for further re-assurance on the clinical performance of individual consultants. Although Clinical Governance is meant to address this issue, it inevitably reflects Institutional and Unit performance rather than that of the individual. Peer-review of clinical practice probably represents the least threatening assessment, but at the same time the most expensive. Consultant logbooks would require a greater emphasis on complications and outcome, rather than just the operations performed. Academic performance and rating as a trainer, for those with trainees under their supervision, are less likely to be utilised but are important indicators of a commitment to maintain educational standards.

The keynote of life-long education in orthopaedic surgery must be flexibility. The speed of change and amazing advances which I have seen in my own working lifetime means that none of us will continue to practice in the same way, or even in the same sub-speciality, for more than a few years.

Sir Walter Mercer was a supreme example of a lifelong learner and I urge you to follow his example. In 1946, at the age of 50, he went to Baltimore to study cardiac surgery techniques with Dr. Blalock, returning with a case full of thoracic instruments and a set of new-found skills. We may not be able to emulate his wide range of surgical interests, but we can adapt and change our skills to ensure that our patients benefit from new methods of treatment, providing these are based on sound principles and proven results. If we can achieve that goal, then the art of the impossible will have at last become possible.

EDUCATIONAL REVIEW

Educating Orthopaedic Surgeons - The Art of the Impossible

The Walter Mercer Lecture, Delivered at the Annual Meeting of the British Orthopaedic Association in Glasgow 15 September 1999