August issue.indd

Attributes of trainers for postgraduate training in general surgery - a national consensus

¹Director of Clinical Skills Centre, Senior lecturer in Medical Education, Faculty of Medicine, Dentistry and Nursing; ²Senior lecturer in Behavioural Science Department of Epidemiology and Public Health;³Research Psychologist, Department of Medical Education; ⁴Assistant Director, Surgical Skills Unit, Department of Surgery & Molecular Oncology; ⁵Professor of Surgery, Department of Surgery & Molecular Oncology, University of Dundee

Correspondence to: R.J.C. Steele, Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee, DD1 9SY

This study was supported by a grant from the Scottish Council of Postgraduate Medical and Dental Education

Keywords: Surgical trainer, general surgery, Delphi, participative inquiry
Surg J R Coll Surg Edinb Irel., 1 August 2003, 215-220

Background: The aim of this study was to obtain consensus amongst consultant surgeons on the attributes of a good surgical trainer that can be used to inform continuing professional development programmes for trainers. Methods: good trainer attributes were generated from an intensive qualitative study using a participative inquiry process with consultant general surgeons and specialist registrars in the Tayside region. These good trainer attributes were then used as the basis of a modified Delphi study; the early rounds of the Delphi simultaneously sought participants’ views concerning stated attributes and sought to generate new attributes. A final Delphi questionnaire was sent to all 180 consultant general surgeons in Scotland to identify consensus. Results: The first two rounds of the Delphi process produced 45 attributes covering seven themes: interest in training, trainer as a team member, communication, receptiveness to trainee needs, trainer as a role model, reflection on practice and clinical and operative competence. The final survey identified significant consensus among surgeons. Clinical and operative competence achieved the highest consensus with 89.2% of surgeons believing it to be an essential attribute. Conclusions: The results indicate that there is consensus on the seven themes identified as essential for a trainer in general surgery. The recognition of the importance by trainers of non-surgical trainer attributes in the changed training structure is encouraging. Surgeons’ level of awareness of their roles as a trainer will help inform the level and direction of trainer training and support required as part of a flexible and continuing developmental process

INTRODUCTION
Variation in performance between surgeons is well established.¹ Increasing calls for professional accountability, growing patient expectations, an increase in litigation and the implications of the European working time directive has focused attention on the quality of surgical training.^2,3 The working group on specialist medical training in the UK has streamlined surgical training into shorter systematic programmes for specialist registrars and, despite the introduction of virtual reality simulation for surgical trainees, trainers in surgery have been given increasing responsibility for the training process.^4,5

Trainers require both subject expertise and personal attributes for effective training given the acknowledged wide diversity of roles as a teacher.^6,9However, there is little relevant literature on the professional surgical and nonsurgical attributes inherent in a good trainer in general surgery. Studies have concentrated on the content of surgical training programmes or trainees needs and assessment rather than the required attributes of trainers themselves.^13-16 For example, Baldwin et al (2000), by canvassing consultant surgeons’ opinions, identified technical skills, clinical skills, interaction with patients and relatives, teamwork and application of knowledge as critical domains by which the quality of a surgical trainee should be assessed.¹⁰

The views of trainers on their roles in the training process has not been sought, and yet surgeons with experience of the training process can provide an important perspective on the surgical and nonsurgical attributes required to perform the role. In addition, there is evidence from undergraduate experience that it is possible to change training practice if the trainer teaching is relevant.¹⁷ Knowledge of the desired attributes of trainers would inform relevant training support models based on the realities of current constraints and tensions to improve both the process and outcome of surgical training.

This article reports the results of a Delphi study aimed at identifying the attributes perceived as good by surgical trainers, as well as the level of consensus that exists amongst Scottish general surgeons.

METHODS
A two-step approach was used in this study, a participative inquiry followed by a Delphi study

Step One-Participative Inquiry Study
Twelve general surgery trainer/ trainee pairs from the Tayside region of Scotland were identified and agreed to participate in a participative inquiry process. Participative inquiry is a form of qualitative research that emphasises the involvement of the subject in both the data collection and analysis of data.^18,19Observations of trainee/trainer behaviours and dialogue with the participants about perceived training events took place over an eighteenmonth period. During semi-structured interviews the trainers and trainees reflected on key training events. This generated a variety of perceived trainer attributes which were used in the subsequent Delphi process. Results from the participative inquiry study have been published previously.²⁰

Step Two-The Delphi Study
The Delphi technique was used in the second stage of the study to identify surgical and non-surgical attributes, and obtain consensus about the good attributes of a trainer in postgraduate surgical training. The Delphi technique has been widely used to identify consensus in education and postgraduate clinical programmes and contains a number of interactive steps (Table 1).

Delphi 1
Thirty two statements concerning important attributes for a surgical trainer were generated from data from the participative inquiry study, from medical education literature reviews and from other professional groups (i.e. airline pilots and the army). Content analysis of these statements resulted in the identification of six broad categories of attributes to be used as triggers for the

The researchers refined the statements to ensure that each statement represented only one attribute category. A pilot questionnaire was then created which asked respondents to indicate their perception of the desirability and feasibility of each of the 32 trigger statements reflecting the attributes in the six categories. This questionnaire was distributed to seven individuals within Tayside to review the use of language and the interpretation of statements. The individuals included two orthopaedic surgeons, two urologists, one neurosurgeon, one ENT specialist, one medical educationalist, one ophthalmologist and one linguist involved in teaching English to foreign students. Appropriate changes were made to the form in the light of the comments. These individuals played no further part in the Delphi process.

A letter was then sent to 30 surgeons in Scotland to ask them to participate in the study. Since the Delphi 1 was concerned with identifying as wide a range of views as possible a deliberate sampling strategy was employed. This resultant panel consisted of both men and women, covered the whole geographical area of Scotland, included surgeons from a variety of ethnic origins and contained individuals with varying numbers of years since qualifying. The sample was drawn from the audit listing of all practising NHS and honorary NHS consultants currently employed by the health trusts in Scotland.

The recruited panel members were asked to carry out three tasks in this first round: to review the format of the questionnaire, to complete the questionnaire and to make additions from their own experience within each of the six categories identified. All 30 surgeons chose to participate in Delphi 1. While not all respondents fully completed the questionnaire many sent separate communications in relation to the study and its format. In completing the questionnaire a variety of new statements were generated within the six categories, and the comments and the additional attributes generated were incorporated into Delphi 2.

Delphi 2
The second Delphi included modifications to the questionnaire design. The desirability and feasibility responses from Delphi 1 were removed. Instead a strongly agree /strongly disagree Likert scale was introduced in relation to each statement.²¹ In addition, a representative sample of 12 statements, which had been generated from findings from the Delphi 1 were included to focus on good trainer attributes. Twenty six of the surgeons responded to this second Delphi, and new statements were again generated for the third round of the Delphi.

Delphi 3
All statements generated thus far were examined by two researchers in order to identify new themes or alter previous ones (JK & RS). Each statement was then allocated to a theme. Two further researchers (BW and PD) were then informed of the new themes and repeated the process of allocating statements to each theme. Results between the researchers were compared and discrepancies discussed. Theme definitions were clarified where appropriate. The following categories emerged from the re-classification:

All remaining statements were then re-examined and a number discarded. Statements were removed if they were deemed ambiguous or repetitious, and 45 statements remained in Delphi 3.

Written feedback from respondents in Delphi 2 indicated that the strongly agree/strongly disagree Likert scale did not adequately distribute the statements. Refinement to the rating was made to increase the sensitivity of the questionnaire by using a visual analogue scale that ranged from “beneficial” to “essential”. Points on the visual analogue scale were identified by manually measuring the marked line using a template. This made it possible to identify which attributes were regarded as more important than others and gauge the degree of consensus or dissent about the relative importance of attributes with each other.

The Delphi 3 questionnaire was then sent to all consultant general surgeons in Scotland (n=180), including those who had been involved in Delphi 1 and 2. Each participant was also given the opportunity to add any general comments.

RESULTS
106 completed questionnaires were returned, giving an overall response rate of 59%. In order to provide an indication of the levels of consensus concerning each attribute only those at the top third of the scale were considered as “essential”. The percentage of respondents rating each item as essential was calculated. Proportions along with 95% confidence intervals are shown in Tables 2 and 3.

The highest level of consensus achieved related to operative and clinical competence; 89% of surgeons regarded this as an essential attribute for a surgical trainer. However, no single theme dominated and each of the seven themes appears to be of similar importance although some manifested themselves in a wider variety of contexts than others. For example, trainer competence extended to a wider variety of practices and situations than the ability to be a team member.

DISCUSSION
This study has identified seven broad attribute categories with 45 behaviours which may be exhibited by a surgical trainer. All of these are regarded as (at least) beneficial by surgical trainers throughout Scotland and it is, thus, possible to say that there is consensus on the desirability of both the attribute categories and the 45 statements.

In both the participative inquiry and the modified Delphi studies, the single most important factor affecting the quality of training in the new shortened systematic programme for specialist registrars (from both the consultants’ and registrars’ points of view) was the trainer-trainee relationship. Certain attributes of the trainer were regarded as having lasting impact on how much trainees learned and how they felt about themselves as surgeons. These attributes included trainer behaviour towards the trainee (e.g. how they supervised or gave feedback), trainers’ values and beliefs in relation to the training process (e.g. their interest in developing their role as trainer; their desire to help registrars learn concepts of patient care as well as technical skills), and the trainer’s interpersonal skills (e.g. how well they could adapt to different trainees needs and training situations). This suggests that the non-surgical attributes are even more important for trainers in the new streamlined surgical training programmes.

The participative inquiry study focused on describing specific behavioural aspects of those attributes obtained within extensive exposures to training while the Delphi aimed to establish consensus on what were considered essential surgical trainer attributes across general surgical consultants in Scotland and, viewed together, they offer some strikingly consistent findings. Both studies identified that good trainers were viewed as flexible in their approaches, were receptive to registrar input and learning needs, and were interested in training within the current training context of postgraduate general surgery. These findings are consistent with previous research in the field of undergraduate medical teaching.

Strong similarities were also found in trainer views on training and the practice of training, but there were some notable differences. In particular, trainers put more emphasis on excellence in technical and clinical expertise than did trainees, as they felt more competent and confident in this aspect of their trainer role. Furthermore, despite the apparent consensus on the importance of non-surgical attributes of a trainer found in the Delphi study this was not always observed in the participative inquiry study in Tayside. Trainers reported feelings of isolation and lack of support in their training role, particularly in relation to the development of their non-surgical training attributes and in the extent of their roles as a trainer.

In addition to shedding light on the good attributes of a surgical trainer, this study has also demonstrated the use of the Delphi method and potential benefits of the Delphi in informing the foundation for educational support. The modification presented here in terms of the final wider Delphi in round three represents a potentially powerful way of both establishing the external validity of the study while simultaneously achieving wider ownership of the results. The latter may prove important in the subsequent acceptability of support programmes based on the study’s findings. These data will, therefore, be essential in informing the development of support programmes for surgical trainers as not only do the results suggest programme topics but also the relative attention that should be paid to each.

REFERENCES
1. Hermanek P, Hermanek PJ. Role of the surgeon as a variable in the treatment of rectal cancer. Semin Surg Oncol 2000; 19: 329-35
2. Adams C., The OXDONS Syndrome the inevitable disease of the NHS reforms BMJ 1995; 311:1559-61
3. Chesser S., Bowman K., Phillips H., The European Working time directive and the training of surgeons BMJ 2002; 325(7362): S69
4. Department of Health. Hospital Doctors: Training For The Future. The report of the working group on specialist medical training. London: DoH, 1993.
5. Paisley AM., Baldwin PJ., Paterson- Brown S., Validity of Surgical simulation for the assessment of operative skill Br J Surg 2001;88(11): 1525-32
6. Boendermaker PM., Schuling J., Meyboom-de Jong BM., Zwierstra RP, Metz JC., What are the characteristics of the competent general practitioner trainer? Fam Pract 2000; 17: 547-53
7. Kirk RM. Teaching the craft of operative surgery. Ann R Coll Surg Engl 1996;78:25-28.
8. Harden RM., Crosby J., AMEE Guide No 20: The good teacher is more than a lecturer- the twelve roles of the teacher. Medical Teacher 2000; 22: 334-337
9. Griffith CH., Georgesen JC., Wilson JF., Speciality choices of students who actually have choices: the influence of excellent clinical teachers. Acad Med 2000; 75: 278-282
10. Spigelman A., Baldwin PJ., Paisley AM., Paterson -Brown S., Consultant surgeons’ opinion of the skills required of basic surgical trainees Br J Surg 2000; 87: 517-8
11. Peitroni M The assessment of competence in surgical trainees Ann R Coll Surg Eng 1993; 75: (6suppl)200-2
12. Cheung MT., Yau KK, Objective assessment of a surgical trainee. ANZ J Surg 2002; 75:325-30
13. Lawrence PF, Alexander RH, Bell RM, Folse R, Guy JR, Haynes JL, Lauby VW, Stillman RM, Cockayne TW. Determining the content of a surgical curriculum. Surgery 1983; 94:309-17.
14. Macintyre IMC. UK surgical training: current problems and possible solution. J R Coll Surg Edinb 1996; 41:209-12.
15. Crofts TJ, Griffiths JMT, Sharma S, Wygrala J, Aitken RJ. Surgical training: an objective assessment of recent changes for a single health board. British Medical Journal 1997;314:891-895.
16. Douglas A. An inspirational teacher BMJ 1999; 319:889
17. Hunt V., Bulstrode C., Baldwin P, Bulstrode H., Mansfield C.,Training teachers - changing practice? J R Coll Surg Edinb 2002 :47 :619-22
18. Torbert WR. Why educational research has been so uneducational: the case for a new model of social science based on collaborative inquiry. In: Reason P, Rowan J, editors. Human Inquiry: A Sourcebook of New Paradigm Research. Chichester: John Wiley, 1981.
19. Argyris C, Putman R, Smith MC. Action Science: concepts, methods and skills for research and intervention. San Francisco: Jossey-Bass, 1985.
20. Reid M, Ker JS, Dunkley MP, Williams B, Steele RJC. Training specialist registrars in general surgery: a qualitative study in Tayside. J R Coll Surg Edinb 2000;45:304-10.
21. Likert R. A Technique for the Measurement of Attitudes. New York: Columbia University Press, 1932.

Applications are invited for research grants (up to £6,000) from surgical trainees and recently appointed consultants who are Fellows/Members of the College in good standing. The closing date for receipt of applications is Friday 5 September 2003.

Applications are invited from practitioners of surgery or dental surgery who have made a significant contribution to the clinical and/or scientific basis of surgery. The courtesy title of Professor will be accorded to the individuals for the duration of the College year in which their lectures are delivered. Applicants must be Fellows/Members of the College, in good standing. The closing date for receipt of applications is Friday 5 September 2003.

• The John Steyn Travelling Fellowship in Urology The closing date for receipt of applications is Friday 5 September 2003.

Applications are invited from Fellows/Members of the College in good standing. The closing date for receipt of applications is Friday 12 September 2003.

Applications are invited from Fellows/Members of the College in good standing. Grants are awarded towards travel overseas to gain further training or experience and are restricted to the cost of one return airfare only. Travel for the sole purpose of attending a scientific meeting will not be supported. Requests for retrospective awards will not be considered. The closing date for applications is to be confirmed.

Awards & Grants Secretary,
The Royal College of Surgeons of Edinburgh,
Nicolson Street,
Edinburgh,
EH8 9DW

PLEASE NOTE THAT THE MAURICE WOHL RESEARCH FELLOWSHIP, PREVIOUSLY ADVERTISED IN THE JUNE ISSUE OF THE SURGEON, HAS BEEN WITHDRAWN. THE NEXT AWARD WILL NOW BE MADE IN 2004.

TABLE 1. THE DELPHI PROCESS
Step 1	A panel of experts is recruited
Step 2	A set of statements is generated relating to the research topic
Step 3	Experts are sent a questionnaire listing the statements and asked to respond to these on a given scale
Step 4	Results are examined and statements, which have failed to be agreed upon, are either reworded or dropped
Step 5	Results and the new questionnaire are fed back to the respondents
Steps 4&5	Repeated until consensus is obtained

TABLE 2. TOP TEN ATTRIBUTES REGARDED AS “ESSENTIAL” BY THE LARGEST PROPORTION OF SURGICAL TRAINERS. THE THEMES ARE DESCRIBED IN THE TEXT OF THE METHODS SECTION UNDER DELPHI 3
THEME	ATTRIBUTES RANKED	PROPORTION BELIEVING ATTRIBUTE AS ESSENTIAL
G	1. has a high level of operative and clinical competence	89.2% (95% CI = 83.1% - 95.3%)
A	2. shows interest in the trainee	87.6% (95% CI = 81.2% - 94%)
B	3. treats all junior staff and nursing staff with respect	87.4% (95% CI = 80.5% - 94.3%)
E	4. knows own limitations	85.6% (95% CI = 79.6% - 91.6%)
G	5. is someone the trainee can respect clinically and professionally	85.4% (95% CI = 78.5% - 92.3%)
A	6. knows when to let the trainee do the operation on his/her own	84.7% (95% CI = 77.5% - 91.7%)
F	7. is approachable	83% (95% CI = 75.5% - 98.3%)
D	8. engenders self confidence in the trainee	79.8% (95% CI = 71.8% - 87.8%)
G	9. demonstrates logical assessment of emergency admissions	79.8% (95% CI = 71.8% - 87.8%)
G	10. demonstrates the importance of safety (pre-operative)	78.4% (95% CI = 70% - 86.8%)

TABLE 3. REMAINING ATTRIBUTES REGARDED AS BENEFICIAL OR ESSENTIAL BY SURGICAL TRAINERS THEME ATTRIBUTES RANKED PROPORTION BELIEVING ATTRIBUTE AS ESSENTIAL
THEME	ATTRIBUTES RANKED	PROPORTION BELIEVING ATTRIBUTE AS ESSENTIAL
C	11. listens to trainee opinions	77.6% (95%CI = 69.2%-86%)
D	12. has insight into what a good trainer should be striving towards	75.8% (95%CI = 67.2%-86.4%)
E	13. shows willingness to be educated by whoever	75.7% (95%CI = 67.2%-84.2%)
F	14. demonstrates fairness	75% (95%CI = 66.4%-83.6%)
C	15. demonstrates clear patient explanation	72.7% (95%CI = 63.8%-81.6%)
G	16. keeps up to date to teach evidence based practice	71.2% (95%CI = 54.4%-72%)
D	17. allows adequate professional leeway in outpatients for trainee but always available to patients	69.6% (95%CI = 60.4%-78.8%)
F	18. has a consistent behaviour pattern	69.1% (95%CI = 59.7%-78.5%)
B	19. can develop good interpersonal relationships which contributes to the clinical team	68.9% (95%CI = 63.2%-81.4%)
F	20. demonstrates the ability to deal with difficult situations i.e. with patients or other members of staff	68.6% (95%CI = 59.5%-77.7%)
C	21. laughs and shows compassion to fellow human beings	68.6% (95%CI = 59.5%-77.7%)
D	22. will discuss new ideas with trainee	67.6% (95% CI = 58.3%-76.7%)
A	23. takes junior staff slowly through operations	67.3% (95% CI = 58.1% - 76.5%)
D	24. works closely with the trainee to ensure clinical learning	66.3% (95% CI = 56.9% - 75.7%)
G	25. assesses complex problems	66.3% (95%CI = 56.8%-75.8%)
B	26. has a harmonious relationship with colleagues	65.7% (95%CI = 56.2% - 75.2%)
D	27. assists operations without imposing himself/herself on trainee and interrupting at regular intervals	65.3%(95%CI = 55.9%-74.7%)
G	28. demonstrates tight organisation of patients, results and clincal work to avoid things being being overlooked	63.7% (95%CI = 54.2%-73.2%)
C	29. prioritises investigations on the emergency ward round	62.7% (95%CI = 53.1% - 72.3%)
A	30. resolves personality problems between trainee and staff	62.7% (95%CI = 53.1%-72.3%)
G	31. can organise surgical practice in ways to enhance learning	62.5% (95%CI = 53.1% - 72.9%)
G	32. will introduce new techniques to his/her practice	62.5% (95% CI = 53.1%-72.9%)
G	33. demonstrates how to sort out difficult/complex problems	61.2% (95% CI = 51.6%-70.8%)
G	34. adheres to national clinical guidelines	56.7% (95%CI = 46.7% - 66.7%)
C	35. has clear management protocols	56.7% (95%CI = 47% - 66.4%)
E	36. explains timings clearly and will repeat if required	54.9% (95%CI = 44.5% - 65.3%)
F	37. demonstrates commitment to CME and other aspects of professional development	51.5% (95%CI = 41.7% - 61.3%)
G	38. attends on time	51.5% (95%CI = 41.7% - 61.3%)
G	39. can develop a management strategy	47% (95%CI = 37% - 57%)
F	40. demonstrates several ways to attack the same problem with same result (technical aspects of the system)	45.6% (95%CI = 35.8% - 55.4%)
E	41. sets an example by attending all in house meetings	43.7% (95%CI = 33.7%-53.7%)
F	42. puts own specialty in perspective and focuses on principles as they apply to a specialty	41.7% (95%CI = 32%-51.4%)
A	43. demonstrates efficiency particularly in time management	40.8%(95%CI = 31.7%-49.9%)
A	44. sends for patients for different grades of staff to operate on	32% (95%CI = 22.9%-41.1%)
A	45. goes over the case at the operating table the day before with the trainee	19.8% (95%CI = 11.9%-27.7%)