Training specialist registrars in general surgery

Background: Owing to decreased hours of work and duration of training, there is a need to refashion the training of surgical specialist registrars (SpRs) in the United Kingdom. This requires more guidance for trainers, but consensus regarding good trainer attributes does not exist. This study describes the training practices of Tayside general surgical trainers working with SpRs and highlights good training practice involving technical and patient management skills. Methods: 1) Semi-structured interviews carried out with eighteen consultant trainers and twelve SpRs, 2) Action inquiry (i.e. observations and dialogue with participants) during ward, theatre, outpatient clinic and other hospital-based settings with eleven consultant and SpRs pairs. Results and Conclusion: Participants reflected on multiple training episodes and evaluated their impact. Relatively positive or negative impacts on their skill learning, self-esteem and relationship with the trainee or trainer were described. These are presented and discussed in terms of their implications for equipping trainers with techniques for training registrars and those factors which have hindered the adoption of successful strategies.

A more structured approach for training junior surgeons is urgently required. The Guide to Specialist Medical Training¹ has streamlined postgraduate training and created an implicit demand for greater consultant involvement in service delivery and supervision of specialist registrars (SpRs).² Registrar training time has been reduced and regular and documented assessment of trainee progress has become necessary.

In the past, surgical training was a gradual process, best described as an 'apprentice' relationship between the trainee and a consecutive series of consultant trainers. Other than the tacit expectation that trainers will impart technical and patient management skills, guidance for educational practice has been neglected in surgery.³ Other objectives have not been defined and, although consultants are assigned registrars to train, there has been little in the way of incentives or education designed to develop their role as trainers.^4,5

The cascade of change within the NHS since the early nineties coupled with the reduction in the time available for training has led to the need to identify more precisely the components of good training in order to help ensure the development of competent surgeons.^6,7 To date, however, few investigations have addressed how consultant surgeons approach training; most of the literature is anecdotal and case-orientated, and registrar learning has mostly been measured in terms of operation logbook entries.^8,9 The ways in which trainers guide their trainers have not been studied; activities such as supervision have usually been represented quantitatively and have referred to occasions when the consultant is present while the SpR is operating.¹⁰ That some consultants make better trainers than others has been a fairly universal conclusion, but what behaviours or attributes make this so has yet to be described in any way that might be useful to those wishing to improve their training skills.¹¹

This report describes an exploratory study designed to examine methods whereby consultant surgeons train their SpRs and to identify good trainer attributes.

All general surgeons working in Tayside hospitals (Dundee, Perth, and Brechin) were invited to participate after approval had been granted from the local Research Ethics Committee. Eleven consultants and their SpRs were randomly selected after stratification for training location for an intensive study. Seven other consultants and two additional SpRs gave interviews and one consultant also permitted one day of intensive observation. All general surgical consultants and SpRs in this region were male.

Participating consultants varied in age, experience level and interest in sub-specialty. All were British by origin, and their medical school training had occurred in England, Scotland or Ireland. Participating SpRs varied in experience (eight had accumulated 3 years of equivalent experience or less, and five others had 5 years or more) and nationality (eight were British, while five had come from abroad for further training).

The study took place in a 9 month period. Each of the 11 training pairs took part in an intensive period of observation for 4 or 5 days during which the fieldworker (first author) shadowed the consultant and SpR. When the two worked separately, only one could be accompanied but the fieldworker alternated her time between them as equally as possible. Individual interviews were also scheduled during this period with all consultants and SpRs participating in the intensive work, as well as other consultants and SpRs who only gave an interview during the study.

The observational method employed was action inquiry.^12,13 The fieldworker not only recorded ongoing events and behaviour as an observer, but also invited the participants to comment during this process. Thus, the participants collaborated with the researcher in obtaining information and discussing their own behaviour. Other applications of this method have shown that participants can link their experience, beliefs and perceptions to current behaviour and practices, and learn directly from the research process itself.¹⁴

All training pairs and additional consultants and SpRs gave semi-structured interviews towards the end of their intensive periods of observation. All surgeons, both trainers and trainees, were asked to describe examples in their own training of both poor and good training. All interviews above were audiotaped and later transcribed.

All data were entered into a large database and coded (using NU-DIST software) for task (e.g, operation, out-patient clinic, ward round) or type of training activity (e.g, delegation of work, supervision, feedback to trainee). As well as reducing the data into reasonable, topic-related units for further analysis, this allowed cross-referencing of data. Three other research team members (BW, JK, PD) reviewed transcribed interviews to identify factors that could be used to evaluate training episodes.

Various aspects of training emerged as important as a result of this study and, for the purposes of reporting these, have been categorised as establishing roles, flexibility, communication, demonstration, delegation, feedback and establishing accountability.

Establishing a comfortable working relationship was seen as an essential foundation for training SpRs in operative techniques and principles of care. Two major characteristics of relationships designated as "good" by both consultants and registrars were identified. One was the mutual development of feasible expectations regarding the learning opportunities that the consultant could provide, and the other involved a clear understanding of what the SpR was expected to do as a service provider. At entry to assigned posts, only half of the consultants spent more than a few moments with their SpRs discussing these issues. Conflicts involving delegation of work or level of professional commitment were frequent. One SpR described his role in terms of what he perceived as his trainer's needs:" I feel I am here just to fulfill Mr. Elder's service commitment most of the time."

Other consultants allowed a longer and more explicit discussion about both the consultant's and the trainee's expectations at the start of an attachment, and some discussion took place regarding how feedback would be delivered. When trainers did this it added to the SpRs respect for them; such planning was interpreted by the trainees as demonstrating a strong degree of professionalism and responsibility for training, even when the consultant would not give the SpR all the experience he wanted.

One was lack of sufficient structure in the consultant's thinking about his expectations of a SpR or how to communicate with him. Another was a reticence on the part of the SpR to ask questions which would allow understanding of their role with a particular consultant. Finally, some consultants assumed SpRs would know what was expected of them. Some were rather chagrined at the idea of having to talk about these matters explicitly, and felt that earlier training should have adequately prepared SpRs for their role as well as equipping them with basic skills in surgical technique and patient management.

Good working relationships involved some flexibility in the consultant's stance. Although decisive in taking sole authority at times, the good trainer was also able to invite the registrar to comment on his decisions or opinions at other times. This was welcomed by some consultants: "Trainees can teach you little things that somebody's picked up working with somebody else."

For each consultant, ideas about where it was possible to train and where it was not may have limited attempts to find learning opportunities in some situations. There were usually good reasons for this. For example, out-patient clinics tended to be crowded, requiring parallel rooms for the consultant and his trainee, and almost no time for mutual discussion.

Some consultants gave the SpR an 'equal' role in making management decisions over particular cases, or asked their trainees to challenge the initially chosen course of treatment. Others simply varied routine by being more active during some ward rounds while remaining in the background during others. Some consultants made a point of finding occasions to sit and chat about a case's management or a recent complication, in order to engage and stimulate the registrar's thinking. This kind of learning was particularly valued by the SpR.

Creating regularly scheduled case meetings or conferences was another way of ensuring variety in training experience. At one hospital, weekly pathology and radiology meetings were established for both SpRs and consultants to discuss cases with practitioners from these disciplines. Case reviews were held on most wards, but although these enabled both junior and senior surgeons to hear other opinions regarding treatments and outcomes, they were usually too brief (e.g. 20 cases in half an hour) to permit questions or extended discussion.

The careful pacing of instruction was essential for guidance in theatre, or on occasions, in outpatient clinics. Most of the consultants used formal or directive instruction, especially in theatre, but occasional impromptu teaching or 'mini-lectures' on procedures or disease processes were widely employed. Three consultants liked to offer opportunistic lessons on anatomy and physiology, and later expressed the view that surgeons often focus too much on tissue pathology or dysfunction. Registrars appreciated situations where trainers did not rely solely on direct instruction, but used it when required.

Variation in communication or teaching style was important. Several SpRs indicated that it was easier to learn from some trainers simply because of the way they talked and imparted information. One spoke of a trainer that gave "his parcels of training exactly the same as he had probably done for a number of years." Worn-out speech, tired intonation, or use of stock phrases without reference to the current situation or the trainee often provoked irritation, as did the use of the same training tactics with each and every trainee. When, by contrast, a trainer appeared to look actively for opportunities to share their knowledge or thoughts, and permitted a twoway dialogue, SpRs felt these trainers were still enthusiastic about their work, or keen to teach well. It should be pointed out, however, that consultants often stressed that their willingness to teach and share ideas also depended on their trainee's attitudes: "If they are willing to learn, then the consultant feels like putting out more."

Often the consultant's rate of communication was not optimal for the SpRs ability to assimilate information. As one trainer put it: "He (a former trainer) was patient. He took the time to show me. I need to bear that in mind when I try to teach somebody."

What was most notable here was that training pairs did not talk about this problem. SpRs complained that consultants were over-controlling after tasks or procedures were delegated to them and were quick to blame consultants' inability to 'let go.' Trainers sometimes perceived a problem with confidence when the SpR asked for more help.

These were common reactions that added to the reluctance for either side to work on establishing better strategies for communication.

Expressing irritation or using harsh tones rarely had a positive impact on a SpR�s work, particularly in theatre where pressure was already high. Irritation was often associated with incidents where consultants believed registrars correctly perceived the meaning of their communications when often they had not. In these cases, the SpR was left feeling confused as well as responsible for provoking his trainer's displeasure.

In these cases, trainers rarely perceived their registrar's confusion. Instead, they believed their instruction or suggestion was being ignored, or not taken seriously enough.

Approximately one-third of the trainees experienced regular explosive bursts of irritation or dismay from their consultant trainers during operations and, in only one case, was this described later as an unusual incident. Trainers who were considered the best supervisors in theatre were noted for their quiet and relaxed vocal tone, varying intonation to indicate urgency or need for attention. They were likely to slip into a more casual or humorous tone to provide tension relief at intervals. For example, the consultant diverted the tension everyone was feeling by talking about his own history and training.

When asked if they ever demonstrated techniques, all consultants said that they did so all of the time. In practice, however, demonstrations often involved performing procedures without comment, merely allowing the registrar to observe. Some consultants took more care to see that their SpRs were following as they explained the procedures. Registrars considered good demonstration to be a key training strategy, and this involved a commentary of some sort.

Good demonstration involved some organisation of information, and the essential aspects of demonstration technique that SpRs appreciated are given in Table 1. In the opinion of the trainee, the importance of demonstration sometimes made the difference between an acceptable and a good surgical trainer: "He was there and showed me what to do. He would also do the same things himself at times and allow me to see how he did it. But the other [trainer] would do things for himself in his work and not show you. He couldn't work with the trainee."

Allow the trainee to observe closely
Specify what to look for in advance
Encourage questions
Don't overload with irrelevant information - keep messages succinct
Try to assess how much the trainee is taking in
Modulate delivery of information according to the ability of the trainee to assimilate it

Some SpRs felt that too few opportunities existed for refining their skills of clinical judgement with trainer assistance. They believed consultants underestimated the importance of demonstrating their reasoning or judgement processes to them. "For me I need rationale. I'm just starting."

Good trainers sometimes thought out loud, or shared the reasons why they formed an opinion about the patient's disease, or took one particular course of action and not another. Possibilities and alternative ideas might be entertained and rejected or initial concepts might be completely modified in light of new data. This process was almost never linear and precise. Potential benefits of demonstrating clinical thinking are given in Table 2.

Offers on-the-job case-related training in how to formulate diagnoses or management strategies
Helps integration of theoretical knowledge and practical experience
Demonstrates the process of decision-making
Raises wider issues (e.g. time constraints, ethical considerations, current controversies, patient factors)
Demonstrates personal characteristics of trainer, adding a human dimension to the logic of decision-making
Improves relationship between trainer and trainee
Shares emotional stress of decision-making

Registrars believed they learned more from those trainers who revealed the complexity of their thinking. A few mentioned that some trainers pushed away questions when registrars asked about how they had come to certain choices: "You just do what I say, This is what the patient has and this is what you do."

Another problem sometimes arose when a consultant invited his trainee to debate the issues surrounding a patient's management, but the registrar did not accept this invitation or see it as a learning opportunity. One SpR murmured acceptance of changes to a patient's management made by his trainer without question, even although he acknowledged his disagreement with these changes to the fieldworker. When asked why he did not express his views, he said it was not the sort of thing trainees were supposed to do. Yet later, the trainer confirmed that he had been attempting to provoke his trainee into debate without success.

Having the ability to delegate well was universally considered to be a fundamental attribute of a good trainer. Registrars were emphatic about their desire to obtain more operative work, but delegating operations involved far more than 'giving up' cases to the trainee. Those trainers described as good delegators gave their trainees increasing degrees of responsibility while managing efficiency and quality of care.

Trainees knew that delegating was not an easy task for a trainer and that multiple issues were at stake. However, they expected a consultant's involvement with their work to decrease over time, and the amount of independent work given to them to increase. Consultants varied in the amount of work they delegated; some trainers would not 'give up' much at all and, in cases where the training relationship was troubled by frequent conflict or where respect and expressed liking were poor, very little surgical work was delegated. When it was, the consultant often did not stay and supervise. Even when the relationship between trainer and trainee was comfortable, most trainers agreed they had difficulty letting go. This was a source of frequent complaint among registrars: "No registrar actually working with him does any operating. He had enormous difficulty delegating."

One barrier to finding better ways to delegate appeared to be the consultants' difficulty in coping with anxiety. Trainers often felt pulled between the need to give their SpR operative experience and give their patients the best possible care. A related problem for young consultants or those just learning particular techniques (e.g. laparoscopic methods) was that they too needed to accumulate experience.

Graded delegation over time seemed to be difficult as it was rarely practised. When consultants did delegate in this way, they would segment operations into small, feasible 'chunks' of work that could be given to the SpR while the consultant performed the rest of the operation. This was popular with the trainees: "It improves my technique until I get to be the principal operator."

This principle was particularly useful in parts of procedures where repetitive actions were necessary; the consultant could demonstrate a few times, then permit his registrar to perform subsequent repetitions, then take over the instruments again and continue. Delegating well appeared to have several components. These are listed in Table 3.

Balancing training with service and patient needs
Maintaining ultimate responsibility for outcomes of care
Establishing lines of communication with trainee
Specifying the degree of responsibility expected of the trainee
Progressively identifying components of a procedure for the trainee to perform
Supervising early skill development closely
Mastering anxiety regarding letting go
Being close at hand when trainee is working solo for the first time
Assessing trainee's competence and progress and feeding this back

Essential to good training in general was the liberal use of brief, constructive and situation-specific feedback: "What you need is balanced feedback. Trainees need compliments too! We work better when we hear we are doing well."

Communicating critical comments in a constructive way was difficult for almost all consultants; timing was important.

Skills in delivering feedback had not been developed in most consultants' own training. Some who had worked abroad felt that the Scottish tradition inhibited the delivery of feedback; directing critical remarks to a person was not an acceptable social practice 'but talking behind your back' unfortunately was. Registrars commented that they often knew when a consultant was displeased with their work. They relied on non-verbal cues, particularly facial expression and vocal tone, and were quick to sense, but sometimes misattribute, tension or irritation. The problem with these implicit communications was that they did not specify what the problem was and, more than occasionally, trainees drew incorrect conclusions.

Trainees collectively recognised that delivering feedback was a difficult task and, as a consequence, many did not expect too much. Yet every SpR wanted more, particularly performance-specific feedback. They also felt that consultants were not aware of how far small reassurances or bits of feedback would go in building their confidence: "What you need to do first is to give people regular feedback. Right from the outset."

In addition to reassurance, registrars wanted to learn precisely what skills needed further work, and wanted to know how their current trainer felt, even though they already recognised that differences in opinion existed regarding the best techniques to use or how a patient could be best managed.

Consultants and SpRs sometimes differed in how they saw each other's responsibilities, including accountability for patient care and responsibility for training outcomes. Everyone agreed that the consultant surgeon was ultimately responsible for the patient and treatment, but when trainees were left in charge or were delegated an operation, the majority described feeling uncertain about the extent and limits of their responsibility. Most consultants grappled with remaining in charge, yet wanting to provide opportunities for trainees to assume appropriate responsibility for their work.

Consultants' opinions varied as to what extent peri-operative care and continuity of care should be the responsibility of the trainee. Some argued that understanding the importance of these issues were self-evident and should not need comment or guidance from the trainer. Others believed that they were topics for basic surgical training if not medical school, and felt angry or disappointed when their SpRs did not exhibit behaviours that were consistent with an awareness of these issues. Deciding where and when surgery best fits into overall disease management and ethical issues were other topics that at least some surgeons believed were essential parts of training.

In this study we have investigated an important and relatively unexplored area of postgraduate medical training. Using a participative, qualitative method was helpful in yielding insight into the complexity of training and the barriers that prevented the adoption of useful strategies. For example, it is well known that delegation is difficult for many consultants and most registrars feel the opportunities in theatre are inadequate. There was consensus that the health service has increased this problem by pressurising surgeons to cut waiting lists while giving very little support to training. That some consultants don't 'give away' enough operations to their SpRs, and others give away too many difficult procedures before the trainee feels ready to handle them alone was the topic of many conversations between the SpRs.What these findings clarify is that delegation of responsibility was confounded by several factors. One involved how consultants handled a perceived opposition between providing good care and the need to train. Another depended on the presence or absence of certain skills, such as being able to divide operations into procedural segments, some of which could be delegated to the trainee while the consultant remained the principal operator for the rest. Other factors included consultants' comfort level with their own technical skills in different procedures, their style of coping with multiple pressures, differing levels of interest in training or their ability to supervise.

Most consultants had a specific policy for allocating responsibility for patient care but individual assessment of SpRs skill levels were not necessarily part of this policy. Specialist registrars at the same stage of training differ in their abilities and, therefore, what training needs they represent;¹⁵ merely asking the SpR if he can do a procedure or has performed a technique are not necessarily good ways to establish what he needs to learn.¹⁶

Appraisal can be difficult and, in this study, was felt to be inadequate by most of the SpRs. As Kwolek et al (1997) have demonstrated, trainers may well rely on relatively global judgements of a trainee without identifying performance deficiencies when making their appraisals.¹⁷ Performance appraisal for SpRs appears to be one area of training practice in need of revision. On-the-job feedback, specifying aspects of performance requiring attention associated with general encouragement, is one useful strategy.

As our findings indicate, another source of tension is the trainee's need to process a large amount of information during complex procedures. Being able to handle such stress has traditionally been one of the defining characteristics of surgical trainees, but whether it should remain the sole environment for conceptual and skill learning begs another question. Development of other training structures such as in-house courses or skill-training laboratories has been widely advocated.^18-19 Skill development laboratories allow practice with prepared tissue, and provide opportunities for trainers and educators to divide complex surgical skills into more fundamental psychomotor components. Rosser et al (1998) have described a standardised skill acquisition programme for teaching laparoscopic surgery where individual dexterity drills with targeted performance goals were structured within interactive supervision with a trainer.²⁰ Such training would help surgeons at all levels to refine their surgical skills and it offers objective evidence of skill acquisition.

In addition to practical resources to assist the teaching of skills and techniques, however, there is need for fundamental conceptual changes. There appears to be a lack of a consensus definition of good training; indeed, consultants' observed training practices were highly variable. Trainees received conflicting input from different trainers, and it is crucial, therefore, to establish a consensus regarding the knowledge, skills and training experiences that should be standard for all general surgical SpRs.^21,22

For example, less experienced trainees argued against spending time to learn the subtleties of communicating with patients, claiming that surgeons perform their healing work in theatre when the patient is usually unconscious. However, at least one study has shown surgical trainees to be deficient in communication skills,²³ while another has demonstrated a link between improved communication between surgeon and patient, and patient outcome.²⁴

The majority of trainers expressed interest in training well and considered this an important part of their role as surgeons. Some had attended specific workshops for trainers, and although they were enthusiastic about ideas they had taken away, they found it difficult to put them in practice once back in their own hospitals. In addition, these exposures to educational practices and principles were fairly brief, occurred in a single exposure, and offered no follow-up or continuing education component. Regular practice and integration of principles into action have been demonstrated as important in order for the trainer to remember new skills or use with some facility.²⁵

In conclusion more research is still needed to understand the factors that promote or inhibit positive and flexible training interactions, that build feasible and relevant expectations, and that make both the consultant and SpR feel competent about their roles and work. Further observation of training scenarios and trainer behaviour will be important in this respect, but larger studies to obtain consensus views about important trainer attributes will be necessary to refine and generalise the findings reported here. Only then will it be possible to develop appropriate and specific materials and techniques for training surgical trainers.

In the meantime, we believe that this study has highlighted certain aspects of the trainer-trainee relationship which can be formulated in to simple guidance to enhance surgical training for all trainees.

Establish roles

Correspondence: Prof. RJC Steele, Department of Surgery and Molecular Oncology, University of Dundee, Ninewells Hospital and Medical School, Dundee DD 1 9 SY, U.K.

EDUCATIONAL REVIEW

Training specialist registrars in general surgery: a qualitative study in Tayside

Establish roles