The publication in 1999 of the
For these reasons, the thrust in many developed countries and organizations is to enforce many safety processes, procedures and initiatives that address quality and patient safety. We are currently monitoring surgical success on the basis of morbidities and mortalities and sometimes, surgical site infection but we lack the instruments and mechanism to accurately validate this and miss the “contribution” of errors or events chance in lessening if not preventing future adverse events or outcomes to patients. This understanding and awareness should be brought to the consciousness of everyone in the healthcare industry, which includes the training of residents in the various training programs.
The old and current model for training still is based upon the “Read one–See one- Do one” model (a “See one – Do one- Read during, again or later” may sadly occasionally happen). This would be ideal if there is full and complete oversight and supervision by the attending consultant. But in reality, how often does this actually happen and we allow trainees to be “independently” doing surgical procedures in the context of “training”. How often will a trainee be doing a surgical procedure on an actual patient for the first time “independently”?
With the present lack of a more objective measure for compliance to the requirements of a training program, we still currently utilize primarily the number or volume of cases performed by a trainee. More credit is given to independently done procedures versus supervised ones. But are there measures of quality that will show that the surgical procedures performed had favorable outcomes? Were the patients properly and adequately assessed and prepared pre-operatively, intra-operatively and post-operatively? More importantly, were the patients informed and educated properly with regards to the diagnosis, planned procedure(s) and the expected outcome of the intervention? What is the degree of supervision in a surgical procedure that will be performed by a trainee who will be doing the procedure for the first time? What is the expertise or competence level of the surgeon supervising? We have all been guilty of somehow losing the “PATIENT” in a system that promulgates “good” training that fails to consistently provide even minimum safeguards against patient harm.
The other issue that has a big impact on surgical training programs is the current system and culture in our heath care systems and institutions. What dominates is the hierarchal system of practice and training that discourages lower ranked individuals to correct or question the superiors. Many of the “scut” or daily work is delegated to the newest member of the team. This may limit direct supervision of “senior” over “junior” house staff members and overwhelms the most junior member of the residency staff with the floor calls and work. These include assessment and management of most of the surgical patients in the wards or out patient clinics. This system and tradition likewise promotes a “Train and blame” culture that focuses on and even highlights the errors and faults of the individual but fails to approach and analyze the problem from a systems perspective. Even problems occurring with private patients during a resident’s duty can be easily blamed on the “incompetence” of the resident. In the Philippine setting, the work of a floor resident is even made more difficult by the high nursing turnover that transfers to the resident many of the tasks or decision making that could have been done by a more experienced nurse.
These issues should be addressed in the residency training programs in the interest of quality health care delivery and patient safety. We should review the design of the surgical curriculum and implementation of training programs in the context of safety for the patient. The first is the appropriate and competent teaching and supervision of trainees. The “Read one - See one- Do one” or Apprenticeship Model in teaching is still very effective if done properly. The teaching and supervision is the responsibility of the consultant training staff should be the most competent (if not the expert) in the field and cannot be delegated to anyone else. How often does it happen that supervision is delegated to fellow residents or even more concerning, no supervision at all? Even the manner of promotion is based on the number of years and the minimum (!) number of procedures performed. We should look more not into the minimum numbers but the success and quality of surgeries performed, not determined by numbers. The basis for promotion may differ from person to person as every learner is different. (e.g one resident may require 2 cases while another resident –slow learner or less skillful- may require 10 cases before promoting). This may be a logistical nightmare in terms of maintaining the structure of a program but shouldn’t our patients deserve no less before we certify a surgeon from a training program as competent and qualified?
The trend now in developed countries is to utilize Simulators or Virtual Reality (VR) Training systems. This is a model currently used in the airline industry that require pilots to successfully complete hours in a flight simulator and training planes before they are certified to fly commercial flights. Programs who have adapted this require a minimum number of hours of exposure and successful outcomes in these medical simulator systems before the trainees are allowed to perform surgery on “real” patients. These training platforms may not come cheap but one can actually innovate to achieve similar outcomes of teaching procedures and developing surgical judgment.
Next is breaking down the traditional hierarchy in the surgical training programs. The teamwork concept should be put in place to include not only the resident staff but also all members of the healthcare team (interns, nurses, technicians and even consultants). We should likewise veer away from the traditional “train and blame” or culture of blame to what quality advocates term as a “culture of safety”. The culture of blame tends to pinpoint mistakes and errors to an individual and in turn leads individuals to hide or “bury” mistakes in the process, for fear of reprimands. A culture of safety likewise investigates mistakes and errors from a systems perspective by looking more as to defects in the process or systems that “allowed” a person to commit the mistake. Systems solutions provide a wider and broader scope in preventing the same errors from recurring.
Lastly we should incorporate the basic principles of quality and safety in the training programs. We currently look closely at outcomes and complications and often retrospectively, providing more of technical solutions. We have to teach the importance of proper and complete, documented assessments, care coordination with the other specialties, respecting patient and family rights, providing patient education and proper post-operative care monitoring and follow-up. We should also implement and emphasize importance of the “time-out” or universal protocol to ensure that a complete pre-operative assessment, pre-procedure briefing with the surgical team, determination of correct procedure/patient/operative site and post-operative debriefing is performed in all surgeries. Clinical quality and safety monitors should be done to measure compliance and guide improvement processes.
We have gone a long ways in teaching the science and skills necessary for good surgery. Now we have to revisit the basics of patient safety, specifically surgical safety, to ensure the delivery of quality healthcare, healthcare that is not only safe and effective, but also timely and patient-centered. This is our responsibility not only to our patients but also to our profession. We should remember that we have to teach our young surgeons well because the students and trainees of today will be those that will take care of US in the future.
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