What evidence supports educational and training methods that develop excellent surgeons?

Evidence-Based Methods for Developing Excellent Surgeons

Structured mentoring programs combined with simulation-based education using deliberate practice principles represent the most evidence-supported approach to developing great surgeons, with formal mentoring improving both technical endpoints and professional development while simulation training demonstrably enhances patient safety and skill acquisition. 1, 2, 3

Formal Mentoring Programs

Structured mentoring should be the cornerstone of surgical training, as it addresses multiple dimensions of surgeon development beyond technical skills. 1

Key Components of Effective Mentoring

• Mentoring must be formalized and structured rather than the traditional informal, popularity-based system that currently exists in surgery. 1

• An effective mentor facilitates development of independence, self-confidence, job satisfaction, upward mobility, and decision-making/problem-solving skills in trainees. 1

• Focused mentoring has been shown to improve attainment of technical surgical endpoints, specifically demonstrated in laparoscopic colorectal training. 1

• The mentoring relationship should be goal-oriented and mutually beneficial, with both mentor and mentee deriving tangible benefits. 1

Critical Implementation Requirements

• Absolute confidentiality is paramount, with both parties signing a mentoring agreement and code of conduct at the outset. 1

• Goals must be set at each mentoring encounter with documentation of expected outcomes and intended actions. 1

• A mentoring scheme manager should exist with overarching responsibility for running the program. 1

• Mentors require formal training - currently only 8% of surgical trainees report having previous training in mentoring skills, yet 83% want formal coaching and mentoring training. 1

Current Gap in Practice

• Only 34-52% of surgical trainees currently have a mentor, despite 72% of those without one feeling that mentoring is important. 1

• This represents a critical deficiency given that 85% of trainees with mentors report satisfaction with their experiences. 1

Simulation-Based Education

The traditional "see one, do one, teach one" apprenticeship model is no longer considered the most effective approach due to patient safety concerns, increasing trainee numbers, and clinician workload pressures. 2

Evidence for Simulation Training

• Simulation-based medical education (SBME) with deliberate practice principles shows positive learning outcomes across all studies examining surgical skill development. 3

• Virtual reality simulators have sound evidence for effective training outcomes with demonstrated skill transfer to clinical environments. 4

• Simulation provides a controlled, real-life-like environment where trainees can practice technical and nontechnical skills through deliberate practice and structured feedback without putting patients at risk. 2, 5

Types of Simulation Modalities

• Full simulation (whole room or whole patient scenarios) addresses both technical skills and team-based communication. 1

• Partial task simulation using specific products (intubation heads, central line chests) for focused skill practice. 1

• Virtual reality for procedures including cardiac catheterization, colonoscopy, bronchoscopy, and laparoscopic surgery. 1

• Standardized patients for communication skills, history-taking, and physical examination practice. 1

Deliberate Practice Principles

• The extent and nature of practice, as well as practice structure, are critical to developing complex motor skills required in surgery. 6

• Deliberate practice requires repetitive engagement with specific tasks, immediate feedback, and progressive difficulty levels. 3, 6

• Contextual interference and distributed practice (spacing practice sessions over time rather than massing them) enhance skill retention and transfer. 6

Research Training Integration

All residents should receive training in basic research methods and biostatistics during residency, as understanding scientific methods is inherent to evaluating published material and clinical decision-making. 1

Structured Research Pathways

• Creation of surgeon-scientist training pathways leading to Masters and/or PhD degrees for those pursuing academic careers. 1

• Provision of curriculum-based training in clinical research, public health, or policy, ideally leading to a degree. 1

• Research training in surgery currently lacks the structure and organization that exists for clinical training, representing a significant gap. 1

Implementation of Practice Change

Environmental context and resources are paramount to practice change, followed by individual knowledge, technical skill, and personal beliefs. 1

Effective Change Interventions

• Multifaceted implementation of evidence-based protocols achieves highest compliance (up to 90%) when integrated with surgeon- and patient-level education, mentorship, collaboration, and reinforcing feedback. 1

• Guideline dissemination alone has limited effect; implementation requires targeted provider-level and patient-level education reinforced by reliable evidence. 1

• Knowledge, feedback loops with positive reinforcement, and perceived advantage of new practices are the most effective targets for interventions. 1

Skills Laboratory Requirements

Surgery departments should develop surgical skills laboratories with appropriate instruction programs and validated evaluation systems. 1

• Skills centers require standardized national standards for setup and monitoring. 1

• Laboratory training should precede clinical application to shorten the learning curve and enhance patient safety. 5

Critical Success Factors

• Mentors must be supported by professional bodies and employing organizations with protected time in job plans and recognition under regulatory frameworks. 1

• Contributions to mentoring should be recognized in revalidation processes and trainer assessments. 1

• Trainees must pro-actively engage in the mentoring process to derive maximum benefit. 1

• Surgical clubs, research opportunities, preceptorship programs, and high-quality clerkships meeting leading-edge teaching standards are essential for attracting and developing excellent surgeons. 1

Common Pitfalls to Avoid

• Avoid unstructured, obligatory 1-2 year research requirements without clear benefit assessment to the individual and specialty. 1

• Do not rely solely on guideline dissemination without accompanying educational, interactive, systematic, and regulatory components. 1

• Simulation training without deliberate practice principles and structured feedback fails to maximize learning outcomes. 3, 6

• Informal mentoring relationships without confidentiality agreements, goal-setting, and documentation lack accountability and effectiveness. 1