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How Should Surgeons of the Future be Trained?

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A few Thursdays ago I had the pleasure of visiting a special operating theatre at St Mary's Hospital in Paddington, London. I was particularly excited as the hospital is part of my old alma mater, the Imperial College School of Medicine.

Having qualified in 1999, I have rarely been back to any of the west London hospitals I had trained at, which form the backbone of medical training at one of the world's leading academic institutions.

As I walked in through the main entrance of the hospital on Praed Street, I was hit by the traditional sights and sounds of the hospital shop, the long queue of patients and medics at the coffee shop waiting to pay for their sandwiches, and the familiar 'ding' of lifts arriving at the ground floor waiting to take people up to different floors. Medical students and junior doctors were happily cruising around with stethoscopes hanging around their necks. All of this was reassuringly familiar.

But beneath the veneer a lot has actually changed in NHS hospitals over the last 12 years. And as someone who has practised medicine in the community for the past nine years I have fresh eyes when it comes to hospitals. I didn't see a white coat in sight, the icon having been binned in favour of rolled up sleeves and alcohol gel because of infection risks. But there are some changes that are not so visible. Changes in both working practice and the law regarding The European Working Time Directive, has had an impact on the time doctors can spend on their training.

Needless to say, all specialties in medicine require high quality training to ensure safety and competence, but the field of surgery is one area that is particularly important. Surgery - at its extreme - really does mean life or death. The operating theatre is effectively a chamber of variables where literally anything can happen while the patient is 'asleep' - particularly in emergency situations. Bleeding, sepsis, shock, cardiac arrest, drug reactions - the list of potential complications is huge. The patient is looked after by a team of professionals - an anaesthetist, surgeon 1, surgeon 2, a scrub nurse and operating department assistants.

One of the problems with recent developments in the working patterns of trainee surgeons is that their time in theatre, where they learn their hands-on surgical skills, has been cut dramatically, because of the reasons mentioned above. To put it into quantitative terms, in the 1970s, a surgeon may have racked up 40000 hours of actual operating time before becoming a consultant. That number is now nearer 10000 hours. Of course the 1970s surgeon would have been working Draconian 100-120 hour weeks which was and is totally unacceptable. The challenge for the surgeon in training now, is how to work a reasonable number of hours and get enough experience to be a competent senior doctor. And imagine it from the patients' perspective. Any way of improving the quality, skill and safety of the person due to cut you open is, without doubt, a welcome change.

Imagine then, a scenario where the training could be done in a safe and controlled environment where no harm could ever come to a patient. Sounds too good to be true, but that is exactly the facility that exists at St Mary's Hospital in Paddington, London.

The SOS or Simulated Operating Suite opened in 2008 and offers a new way to train surgeons. I was in this operating theatre for the afternoon, with a full surgical team led by surgeon Miss Sonal Arora, a specialist registrar, who completed her PhD thesis on simulation in surgical training. Two things struck me. Firstly, just how realistic the set up in theatre was. Everything, bar the patient - a highly complex mannequin with hydraulics to mimic real life surgical situations using virtual reality - was as it would be in a live operating theatre. The second thing was just how effective a tool this could be for the future of surgical training. At one point, the scenario controller, a surgeon called Alex Almoudaris turned up the heat from the control room by changing conditions within the theatre as well as the physiology of the 'patient' to make things more challenging. At one point the patient suddenly stopped breathing properly and this was followed by an episode of severe blood loss. I remember feeling genuinely nervous as my pulse raced up from 60 to nearer 100 beats per minute. But the team remained steadfast. I could not help but be impressed at how they kicked into action effortlessly. There was clear communication, strong leadership, and intuitive teamwork - skills which have not been taught in a formal way in years gone by, yet are crucial to patient safety. And if something catastrophic were to happen clinically, then no-one would come to any harm. And to cap it all, a recording of the event can be watched back by trainees to get feedback in order to both assess their own performance and learn from mistakes.

Arora has high hopes for the future of simulation in multidisciplinary training, but robust studies are needed to prove that it is an effective training tool based on measurable outcomes. I asked her whether she could see it as a training tool for all future surgeons. "That's the vision..." she replied, optimistically.

During the afternoon I was allowed to have a go myself. Why not? There was no possibility of harm after all, (apart from to my own ego). It took me a minute or two to get to grips with the instruments and suddenly, I found myself enjoying cutting away at the fat around the cystic artery and placing clips on various structures. "You're good at this... Perfect!" said Arora at one point, which made my day. Alas, if only surgical management were that easy.

I left feeling hopeful that simulation training would be adopted in future as a de rigeur training method for surgical teams in years to come. Other disciplines like anaesthetics have used simulation for several years already, with great success. And if it's good enough for fighter pilots and their ground crew, I cannot see how it would not be good for surgeons and their teams - and above all, for patients.

Our universal motto as doctors is 'primum non nocere' - or 'first do no harm', and this invention will, I am sure, only help surgeons of the future better uphold that very important professional tenet.

(See the SOS theatre in use on The Health Show on BBC World News this weekend: http://www.bbc.com/healthshow)