1. Art and Diseño

SURGICAL EDUCATION AND TRAINING
From the International Federation of Surgical Colleges
Editor: Charles Wells, C.B.E., S.Pk., F.R.C.S.
FOREWORD
by
Sir Harry Platt, Bt., M.D., M.S., F.R.C.S., F.A.C.S.
President of the International Federation of Surgical Colleges
IN THIS BRILLIANT and provocative essay Professor Charles Wells has
given us a penetrating critique of the patterns of surgical education
and training now followed in countries whose surgical colleges and associations are members of the Federation. He finds that many systems of
surgical training have much in common. But he finds also the need for
new thinking and for imaginative reforms.
To the latter end he has looked at the medical student in embryo-in
school, in the university, and in the schools of medicine-emerging from a
different pattern of preparatory education. Professor Wells sees the type
of young man best fitted to be the future guardian of the Art and Science
of Surgery; thus with others he sees the surgeon of to-morrow as more
than an accomplished craftsman, the human biologist in action, in his
multiple tasks-the care of patients and in teaching and research.
The final word has not been said, but Professor Wells has shown us a
glimpse of the shape of things to come.
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INTRODUCTION
THE FEDERATION'S COMMITTEE on the Training of Surgeons having been
instructed to produce a brochure on the subject, questionnaires were
circulated by the secretary to Member Colleges and Institutions. Their
replies are reported and discussed in Part One.
In Part Two, the education and training of general surgeons and
specialists are discussed, and radical reforms are suggested. The thesis
is that only a complete re-organization of the vocational training programme from its very beginnings can prepare the stage for an acceptable
post-graduate scheme; that the post-graduate period is the latest and most
important; and that at present it cannot be adequately dealt with because
of lack of time and lack of suitable preparation.
Professor Ravdin has said that "specialist training based on internship
leads to specialism without knowledge of basic principles " and that " the
term ' postgraduate ' is no longer acceptable, ' continuing medical
education' being preferred ". It is hoped that these sentiments may be
seen to be embodied in this survey. If its content suffers from pragmatism, that seemed the only alternative to a tedious repetition of so
much that has been said, so much better, so often before.
All the papers presented at its meetings by members of the Federation
have been considered and many of them have been quoted. Their reproduction in full was intended but, because of the space involved, has proved
impracticable. A limited number of references to the voluminous and
growing literature on this subject are quoted.
The Committee has considered, amended and approved the document
in draft.
MEMBERS OF THE COMMITTEE ON THE TRAINING OF SURGEONS
Professor Sir Harry Platt, Bt. (U.K.), Chairman
Professor Sir John Bruce (U.K.)
Professor J.-L. Lortat-Jacob (France)
Professor F. Linder (Germany)
Professor Charles Wells (U.K.)
Dr. Frank Glenn (U.S.A.)
Professor Rene Fontaine (France)
Dr. Michael Trede (Germany)
Mr. Harold Edwards (U.K.)
Dr. Philip D. Wilson (U.S.A.)
Professor Claude Olivier (France)
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PART ONE
I. UNDERGRADUATE SURGICAL TRAINING
COUNTRIES OF MEMBER COLLEGES
IN
THE
A DIGEST OF REPORTS WITH SOME DISCUSSION
Pre-medical education
PRE-MEDICAL EDUCATION INCLUDES physics, chemistry and biology.
In the United States these subjects are taught during a four-year period
of " College " education, leading to a first degree of B.A. or B.Sc.
In the United Kingdom there is nothing equivalent to the American
College. The pre-medical subjects may be taken in the university of which
the medical school of the student's choice forms a part. No degree is
awarded.
Alternatively, in Britain, success in the school-leaving General Certificate of Education, at the advanced level, is acceptable. The latter system
has for years been favoured by custom in the older Universities of Cambridge and Oxford and in most of the Medical Schools of the University
of London.
To-day, most British Universities accept this arrangement gladly
enough because they are experiencing increasing difficulty in finding
medical places in the classrooms of physics, chemistry and biology,
disciplines that are already overcrowded with the growing body of science
students. The schools welcome the scheme because it gives added interest
to the sixth-form work. An incidental result is that a percentage of the
more brilliant schoolboys reach the advanced level in the General Certificate of Education, with high marks, a year or more before the average
and may be accepted into the university " Second Year " of anatomy and
physiology, etc., when barely 17, whereas they would normally have
entered the " First Year" at the age of 18. This, therefore, constitutes
or may constitute an advance of two years over the " normal ". Provided
the candidate is sufficiently adult this is probably all to the good, though
some take the opposite view.
Educationally the British arrangement may be deplored for two cogent
reasons. First, concentration upon science at school inevitably means
neglect of the humanities and, secondly, physics, chemistry and biology
for medical students should be taught by medical men; not vocationally,
in any narrow sense, but as three closely integrated disciplines, laying a
foundation for the understanding of human biology. Unfortunately,
even in the universities, this carefully orientated integration has seldom,
if ever, even been attempted, much less achieved. It is to be hoped that
the approach to a scientific education through a synoptic biological
introduction (described here by the President of the Federation, Sir Harry
Platt) will give the medical student what he really needs.
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Sir Harry Platt writes as follows:
" The broad strategy of the course leading to B.Sc. in Human Biology is orientated
towards the needs of the medical student. If carefully and intelligently planned its
content should provide the sort of instruction in bio-chemistry, biophysics, and human
biology (in its literal meaning), that is an appropriate introduction to the study of
pathological processes in man. For students committed to medicine, an intensive
study of human anatomy and human physiology can be offered so that the B.Sc. is truly
the counterpart of a ' new model ' 2nd M.B.
" The B.Sc. course for medical students is conceived as an integral part of a whole
which includes a reformed clinical curriculum, and a longer pre-registration phase of
education and experience. The essence of the revised clinical curriculum is the purposive teaching of the basic medical sciences such as human anatomy and human
physiology throughout the clinical years, with these subjects introduced in their symbiotic relationship to clinical science and practice.
" A university school of medicine in a university which has never possessed a medical
faculty should ideally be founded on two new institutional structures: (1) a school of
human biology on the university campus; (2) a university hospital (on the campus or
nearby) which contains, as integral parts of its intrinsic structure, departments of human
anatomy and human clinical physiology and bio-chemistry. Pathology and microbiology have already moved inside the compounds of some of the teaching hospitals.
Anatomy and physiology should follow in their train."
It is of interest to contrast the British system, wherein the young doctor
qualifies normally at 24, but frequently earlier, and not seldom at 22, with
the American system. In America the student leaves school and enters
college for about four years at about 18, passing on to medical school,
therefore, at around 22 and passing out of medical school as late as at 26 or
perhaps at 25.
This American system is suited to the affluent society of the United
States since it secures a college education (a near-University education
leading to a degree) for a larger section of the community than would
qualify for a university proper and ensures for the technical student, e.g.
the medical student, a grounding in the humanities. All this, however,
is at the expense of a later age of qualification in medicine and, in consequence, either a shorter period of post-graduate specialist training or a
later age of entry into full clinical practice. In fact, the period of postdoctorate training in America may be much shorter than in Great Britain,
whilst the age of entry into full clinical practice varies widely on both sides
of the Atlantic.
Except for the United States of America, the three-tier pattern of
education (school, college and medical school) has not been reported in
any of the questionnaires; but something like it may be found on the
sub-continent of India, where the universities themselves tend to consist
of a federation of colleges, each of which is a separate educational institution. The student may take his " inter-science" or pre-medical studies in
any one of a number of colleges before proceeding to " Medical School ".
Thi s system favours a liberal pre-medical education without undue
postponement of the age of entry to medical school.
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Medical school
Studies in medical school normally continue for five years, of which the
first two (or thereabouts) are mainly devoted to the pre-clinical subjects.
These are predominantly anatomy, physiology, histology, biochemistry
and a variable amount of psychology and pathology. The remaining
three years (two remaining years in the United States) are devoted to
clinical studies. At Oxford and Cambridge the total period is six years,
of which the first three are pre-clinical. An intercalated year after
2nd M.B. is offered electively to selected students in other university
medical schools. The successful student gains a degree in science at the
expense of postponement of medical qualification by one year.
In the United Kingdom, medical school education is generally described
as the undergraduate period, since the majority of students are working
towards their first degree. This also accounts for the fact that the degree,
when awarded, is a baccalaureate (Bachelor of Medicine and Bachelor
of Surgery or their equivalent) despite the long course of study. No exception to this rule is made even in the older Universities of Cambridge
and Oxford, where it is customary to award a first degree in science at the
end of three years. This practice strengthens the student's appreciation
of basic subjects at the expense of an extra year of study; but, although he
is no longer an undergraduate of the University, he is still only awarded
a Bachelor's degree on qualification in medicine.
A similar system is followed throughout the British Isles and in
Australasia, Poland and South Africa (also in Pakistan, India, Ceylon and
Burma). An advantage of this system is that the medical man can proceed
to a higher degree, namely a Doctorate, through examination or, more
usually, through research and the production of an acceptable thesis or,
less commonly, through published work. In surgery, more commonly, a
Mastership is awarded on similar grounds.
In the United States of America, students in a medical school are all
post-graduates since they have already achieved a first degree in college.
Whether or not on this account, American students on qualification are
given a Doctorate and this custom is also followed in Canada.
Apart from the countries mentioned above it appears that, as in North
America, M.D. is the accepted designation in all the countries named in
this report except East Africa, Finland and Sweden, who issue licences,
and Switzerland, where a Federal Diploma is awarded; whilst in Holland
the qualifying degree is called "Arts" (again meaning Doctor), and in
Belgium the qualifying degree is " Docteur en Medecine, Chirurgie et
Accouchements " after seven years of study of which four are in clinical
work.
It is noted that in the United Kingdom there are, in addition to the
universities, alternative entries to medical practice through registrable
diplomas granted by the various Royal Colleges and other licensing bodies
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such as the Society of Apothecaries. The Royal Colleges also grant
higher diplomas by examination, but diplomates (unless they are also
graduates of a university) lacking a lower degree are not eligible for the
higher degree of most universities, such as M.D. and M.S. (Master of
Surgery). There may be some exceptions, wherein a university grants a
Doctorate or a Mastership to a non-graduate.
The examinations of the British diploma-granting bodies are
scrupulously conducted and rigidly supervised. Their alternative portals
of entry demand jealously guarded standards and have the merit of
judging a candidate on his examination performance, unbiased either way
by his previous academic record. They undoubtedly fulfil a most valuable
function.
Except for parts of the Continent of Europe (chiefly Central Europe), all
degrees and diplomas are granted only after a set-piece examination (indeed a series of such examinations) in which both written and oral tests
have to be passed. The written work is ordinarily in the form of essay
questions, but there is a growing tendency to favour the multiple-choice
question which lends itself not only to easier but also to more accurate
marking.
In some Central European countries written work, and even formal oral
and clinical examinations, play a lesser part in the examination system,
which depends more upon a prolonged exposure of the candidate to the
scrutiny and questioning of his professor. From the examiner's viewpoint this is a demanding and time-consuming task. In Italy, the university apparently has no set examination but each candidate must present a
thesis and defend it " in the presence of eleven professors ". Thereafter,
six months of rotating internship is followed by a State examination conferring the right to practise.
In France, the undergraduate system appears to differ from that in other
countries in that students are divided on merit into two streams from an
early stage.
In the initial, preparatory year the student takes biology, embryology,
physics and chemistry, as in other countries. The next two years are
devoted to clinical instruction in hospital each morning and, in the afternoons, to the basic science subjects of anatomy, physiology, pathology and
so forth in the " Faculty ". An examination is held at the end of each of
these two years.
At the end of this period a selection based on these examinations is made
between the students. The more successful are admitted as " externes des
hopitaux" (of the faculty). They undergo instruction in the various
clinical disciplines and also play an active part in the work of the hospital.
The less fortunate study in hospital as observers only, but any who do
particularly well may be promoted to " externe " rank.
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During the period of " externeship ", students compete by examinations
for acceptance as " internes " of the faculty hospitals. Those who succeed
go " on call ", take a more active part in the work of the hospitals and, if
surgeons, they operate.
The less successful students do a " probationary" period in some nonteaching hospital in an outlying district, assisting the heads of departments.
On the completion of their six years of training, all students take a
clinical and practical examination in medicine, surgery and obstetrics,
after passing which they must have a thesis accepted before they are
permitted to practise.
The presentation of a thesis based upon a period of research or special
study as part of the educational programme is also well regarded in some
centres in the United States. There the avowed aim of medical education
is to produce a graduate capable of thinking and acting for himself as an
intelligent, knowledgeable being, rather than a doctor fully trained in the
sense that he has been exposed to an extensive and detailed experience
in all the many medical disciplines.
This latter objective is the clear aim of the conventional medical school
in the United Kingdom, where any attempt to do research is an optional
and even an unusual part of a man's training until he is well advanced in
his post-graduate career. (In Britain the post-graduate stage can be
equated with the post-doctorate stage in the United States.)
Entitlement to practise
It appears that graduation alone leads directly to registration and the
right to practise in the Argentine, Australia, Finland, East Africa, France,
Germany, Hong Kong, Norway, Sweden, Switzerland, the Philippines
and the United States. After qualification an additional Government
or State examination must be passed in Canada (between Provinces),
Germany, the United States and the Philippines.
A period (usually a year) of internship before registration is required in
Canada, the United Kingdom, Eire, South Africa, Denmark, Austria
(3 years), Iceland, India, Israel, Italy (6 months), Japan and Poland. Of
these, Italy and Japan also demand a State Examination, additional to the
University degree, taken after the period of internship. The French
system, as described above, includes internship in the undergraduate
period.
With the exception of the United States of America, most or all hospitals
are State-controlled and lists of hospitals approved for teaching are said to
be available in all the countries except Austria and Denmark.
Discussion
The important part that surgery plays in the " undergraduate " teaching
programme was emphasized by a number of speakers at the Federation's
meeting in Atlantic City in 1965.
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The educational systems of the United States and the United Kingdom
have been described in greater detail than those of other countries for two
reasons. First, because the necessary information is readily available
and, secondly, because these two systems have influenced and are influencing educational programmes in so many other countries.
It is difficult for obvious reasons to compare the results, in the lower
echelons of the profession, of different systems of general medical education; whilst between the leaders of the profession in various countries there
is clearly little to choose. But, in this highly selected group of clinicians
and educators, the impact of post-graduate education and training, with all
its international associations, is great enough to overwhelm the influence of
earlier medical school teaching. And, in any case, the teaching to which
the leaders of to-day were exposed in their youth is certainly very different
from the teaching offered in the same medical schools now. Comparisons
are therefore difficult if not impossible.
One of the most remarkable things is that the pattern of medical
education up to the point of registration and licence to practise has hitherto
remained so nearly uniform throughout the world. This uniformity is the
more remarkable since the skills demanded of the unspecialized doctor
may be quite different in, say, a small country like Great Britain, with one
doctor to every thousand of population, on the one hand, and, on the other
hand, an enormous country like Africa with, for the most part, one doctor
to 60,000.
It is for many reasons fortunate that doctors the world over, being
similarly trained, are mutually interchangeable. But the urgent need in a
newly developing country is for a graduate " able to give an anaesthetic,
remove an appendix and care for a woman in labour "* as well as one
capable of supervising environmental hygiene and preventive measures
(Govt. of Pakistan, 1960), whilst, in the more advanced countries, specialists take care of these problems and ever greater emphasis is being placed
on basic science and the more sophisticated techniques of diagnosis and
treatment. This diversification of needs may, in the future, tend towards
greater differences in the patterns of medical education in different
countries.
Already in the United Kingdom, where medicine has become a State
monopoly, advanced thinkers are beginning to contemplate the possibility
of a different system of training doctors. This might be founded on an
introductory course for all students in basic science evolving, at a comparatively early stage, into a number of different channels of clinical and
para-clinical training for different kinds of doctors. Quite apart from the
* Almost the same words are used in a leading paper submitted to the British
Commonwealth Medical Conference (1965) by the Government of Ghana, followed
by the declaration that " special areas of emphasis are needed in their curriculum to
produce the doctors they (the developing countries) require."
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remote possibility of a sweeping change of this character, the need for
some sort of planning for a balanced output of specialists is already
apparent. The rigid structure of the National Health Service is out of
step with the existing freedom of choice in specialization. Some specialties
are starved whilst others have a superabundance of candidates and something will have to be done about it. It is of interest to note that Longmire
(1965) suggests that in the United States it might " be more logical and
efficient to create fewer specialists and keep them busy."
II. POST-GRADUATE EDUCATION IN MEMBER COUNTRIES
Fully accredited surgeons are formally registered as such in a number of
countries, including Belgium, Holland and Sweden. In some countries,
including South Africa, there are also registers of surgeons in the various
specialties. These offer some protection to patients and establish the
position of those registered. On the other hand, the practice may
weaken a surgeon's position if he ventures (as he may be obliged to do)
outside the scope of the specialty in which he is listed.
One effect of the Common Market in Europe may be the extension of
the principle of registration of specialists and the establishment of some
agreed standards of training.
Broadly speaking, the continental European and Scandinavian countries now follow much the same pattern. The would-be surgeon seeks
attachment to the chief of a service with whom he remains in successive
grades of seniority so long as openings exist or can be made for his continuing promotion. His freedom of choice is largely restricted to the area
of influence of the centre in which he trains unless and until he reaches
professorial status, when he may be invited to another centre. The head
of a service has under his control a large number of surgeons of all degrees
of advancement. The more senior teach the more junior, but it is difficult
to say, as a generalization, where the period of training (inevitably a long
one) ends, and where entitlement to independent practice begins.
Training programmes
The post-graduate surgical training programmes reported from the
various member countries are as follows:
In Austria the would-be surgeon in a teaching school spends two years
as Resident and/or assistant, ten years habilitation (Dozent), if there is a
vacancy at the appropriate time, and then becomes an Extraordinary
Professor proceeding to ordinary Professor. A non-teaching post of
" Oberarzt" may be reached after five years' training. These titles
correspond to diplomas or degrees elsewhere.
The Argentine alone of the member colleges reports following the Spanish
custom (perhaps generally accepted in Latin-American countries ?) of
subjecting candidates for senior teaching posts to a severe personal
examinational test often at about middle age. A minimum of five years is
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spent as " Attendant M.D." and thence at intervals, and for periods that
depend upon vacancies, the trainee proceeds through " Assistant M.D.",
" Aggregate M.D.", "M.D. of the Hospitals " to " Chief of Service (or
Ward) ".
In Denmark both the undergraduate and post-graduate training periods
are longer than the average. State or municipal authorities make hospital
appointments.
In East Africa a diploma in surgery, locally recognized, has been awarded
to local graduates after two and a half years' specialist training. But the
University of East Africa is planning a Mastership in Medicine (M.M.)
that may be taken in any one of the main clinical disciplines, e.g. M.M.
(Surgery). A year of internship leads to registration, after which a
" Primary" in basic science may be taken. The " Final" may be taken
after three years' approved in-service training. Since it is expected that
most candidates will spend some time in a basic science department after
registration, the total time from qualification to Mastership will be five
years in most cases.
It is expected that for the next several years candidates will be encouraged to spend part of their time abroad in a surgical apprenticeship.
So long as this continues, it is likely that there will be interest in the
American Boards and the British Fellowships as well as in experience in
other countries.
In Finland a diploma in surgery is granted after five to eight years of
surgical training.
In France the title " Ancien Interne des Hopitaux de Paris " (or elsewhere) indicates four years of specialist training in a faculty hospital
and is most highly regarded. " Chef de Chirurgie" indicates a surgeon
who has spent a further two years or more in a surgical service.
In recent years, the exclusive (and by some still cherished) channel of
entry to surgical practice, without examination, through " interneship "
of a faculty hospital, has been extended. A surgical diploma is now
offered by examination to candidates who may be " internes " of a faculty
or of other public or private hospitals recognized by the National Ministry
of Education and by the Ministry of Health. On the authority of the
Dean, an " interne " of a faculty hospital may be excused this examination.
Before the examination may be sat, a period of four years of surgical
training is required, part of which, in the case only of " internes " of the
faculty, may have been spent prior to qualification. The examinations
cover the basic science subjects as well as clinical surgery itself, and
"improvement " courses of instruction are designed to this end.
The examination is held annually and may be attempted not more
than three times.
In Germany the title " Facharzt fur Chirurgie " is awarded on the basis
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of time, place and quality of training for a minimum period of six years
after two years' internship. In addition a thesis is presented.
In Holland the training is by apprenticeship, and admission to the
specialist register is granted on the approval of the chief concerned, from
one of the 35 approved hospitals of which eight are teaching hospitals.
Where the candidate and his chief prove incompatible a transfer may be
arranged, but this is not always easy. Some sort of tribunal of appeal is
under consideration.
In Hong Kong the trainee serves as a " medical officer " attached to a
recognized surgical unit for three to four years. He is then sent abroad
for further training and receives recognition only if he obtains either a
fellowship of one of the Royal Colleges or his American Boards. Intending
specialists in orthopaedics, thoracic surgery and neurosurgery must spend
a minimum period of one year in general training. From qualification to
independent practice takes eight to ten years.
In Iceland a diploma in surgery is granted by the Ministry of Health,
but surgical training is usually gained outside the country.
In Israel six years' surgical training leads to membership of the I.S.S.
In Italy, after five years of training and submission of a thesis, the candidate receives the title of specialist in general surgery. National examinations must be taken to acquire the title " Libero Docente ", which shows
aptitude to teach surgery.
In Japan the period of specialist training is stated to be 16 years plus the
submission of a thesis. The title " Hakase ", equivalent to Master of
Science, is then awarded.
In Norway the training period has been raised from four to six years,
including a year in the basic sciences. The Norsk Kirurgisk Forening (a
member of I.F.S.C.) plays a part in the selection of candidates. A higher
degree-Doctor Medicinae-is granted on the merit of a weighty thesis.
The " Doctorand " must deliver two lectures and sustain a " disputas " in
which he defends his thesis against two or more who criticize it.
In the Philippines, after serving four to five years in a teaching hospital,
the young surgeon usually goes to the United States for further training.
The Surgical Speciality Societies set their own standards and consider
applications on merit. Higher qualifications are under consideration. The
pattern did not appear quite clear or wholly agreed at the time of reporting.
In Poland the training period in surgery of seven years is divided into
two stages of certified work in one of the university departments, special
surgical institutes or specially recognized district departments of surgery.
During the first three years, candidates for specialist rank work for three
months in medical clinics, 27 months in general surgery and three months
in orthopaedics and in accident wards. At the end of three years there is a
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theoretical and practical examination and the candidate is recognized as a
" specialist, stage one, in general surgery ". The second stage of four
years of training comprises two periods of six months each in surgical
clinics and two months in each of the following: urology, gynaecology,
paediatric surgery, orthopaedics, neurosurgery and chest surgery.
A contribution to the literature on original work and knowledge of two
foreign languages is also required. A diploma is then granted by the
District Health Officer after a statutory examination in one of the medical
schools.
In South Africa, much as in Britain, a diploma is granted by the College
of Physicians, Surgeons and Gynaecologists on examination after about
four years' training; and masterships and doctorates by the universities by
examination. There is full specialist registration.
In Switzerland, after five years as assistant and/or " Oberarzt " (Head
Surgeon) in a university clinic, or longer if part of the training is in a nonuniversity clinic, the applicant may become " Specialist in Surgery,
F.M.H." (Federatio Medicorum Helveticorum). Six to ten years' special
training is needed to become a teacher in a university hospital. Some
resemblance to the French system will be noted.
The United States of America have developed their own residency training programme leading to the examination of the Surgical Speciality Board
in which the candidate must succeed if he is to be accepted into a teaching
service. Failing this, there is nothing to prevent his setting up in practice,
either alone or in partnership, with access to a non-teaching hospital for
the care of his private patients, who now constitute the majority of patients
in the United States.
The residency programme operates as follows: After a period of internship, the budding surgeon becomes a Junior Resident at an approved nonteaching or in a teaching hospital according to his qualifications and
record. In a large teaching hospital he may be one of eight in his first
year, at the end of which the number is reduced to four. At the end of the
second year the four are reduced to two and in the fourth, or final, year
there remains but one Senior Resident. The group as a whole is responsible for the care of all the indigent patients and each more junior year of
assistant residents comes under the instruction and supervision of the
group in the year ahead up to the one Senior Resident, who has overall
charge.
This residency training programme was originally introduced by
Halsted at Johns Hopkins at a time when the scope of operative surgery
was more limited than it is to-day, and at a time when there were but a few
fully trained surgeons to cope with the urgent needs of a rapidly growing
population. The system undoubtedly served the surgical needs of the
public and the training needs of the profession to perfection in Halsted's
day and is still highly regarded as the cornerstone of American surgical
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training. However, Barnes Woodhall (1965) sounds a warning note that
if the " Resident-teach-Resident tradition founded in the days of
Halsted . . . is not viewed critically, it will be a fertile source not only of
good surgery but sometimes of poor surgical habits ". In these days of
highly sophisticated surgical endeavour there is a growing awareness of the
need for closer supervision by more senior staff members. A diminishing
number would agree with A. E. Braley (1965) that the " teacher ... should
intervene only in the presence of dire surgical complications ".
Out of the original eight Junior Residents, in addition to the man
selected to be Senior Resident, one or two others may be thought to have
done well and are likely to complete their training elsewhere and be
successful in their " Boards ". Some of the remaining five or so may give
up surgery altogether, but most will find their way into small-town surgery
or specialist disciplines. Of these, thoracic surgery and proctology require
a full four years of preliminary general training, plastic surgery three and
E.N.T. and urology one year each. Orthopaedics recommend one year
but do not demand it. Neurosurgery requires six months but most candidates do a full year. Ophthalmology and obstetrics and gynaecology
require no preliminary training in general surgery. (There may have been
changes since these facts and figures were recorded.) The Board of Regents
of the American College of Surgeons recommends two years of general
training for all specialists.
The Surgery Board and, alternatively, the Speciality Boards, include
basic science subjects in their examinations at the end of the training
period.
Not all general surgical residency training programmes are as highly
selective, in their rejection of the less well-regarded junior residents, as the
example quoted above, and it is probable that most men who embark
upon training go through to the end and finally enter surgery in some way
or another.
Fellowship of the American College of Surgeons is granted to those men
established in practice who satisfy a Committee of Fellows of their
competence as responsible and independent surgeons. This fact must be
borne in mind when comparing the F.A.C.S. with the F.R.C.S.
In addition to this programme of clinical training, the departments of
surgery in the United States offer facilities for the carrying out of, and for
training in, research, that are unrivalled anywhere in the world to-day.
These facilities are generously thrown open to highly selected students
from all countries, and their contribution is such that there are relatively
few heads of surgical departments in. for example, the United Kingdom
who have not profited therefrom, either personally or through the members
of the staffs of their departments.
In Canada, where the conditions of employment for surgeons are not
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unlike those in the States, a very similar residency programme is in operation. An obligatory year in basic science is included and the examination
at the end of the training period is conducted not by a Board but by the
Royal College of Physicians and Surgeons of Canada. The best candidates
are admitted to Fellowship (F.R.C.S. (C.)), which is a sine qua non for
teaching hospital service. Candidates who fail to achieve Fellowship must
still obtain the specialist certificate in surgery of the Royal College if they
wish to work as surgeons. Two grades of surgical specialists are thus
recognized in Canada as, defacto, in America and, as apparently intended,
in France.
Canadian orthopaedic, thoracic, urological, plastic and neurosurgical
trainees get at least one and more often two years of general surgical
training. Surgeons in E.N.T. and ophthalmology usually have a period
of general training, but this is not obligatory. Gynaecologists are not reported in the questionnaire.
As in the United States, a number of medical schools in Canada have
highly developed and well equipped departments of research from which,
as well as Canadians, higher surgical trainees from many other countries
derive benefit.
It is of interest that " distrust unquestionably exists both in America
and Canada towards a graduate who has not taken his whole residency
programme in the same hospital. In the British Isles a specialist is regarded
with some distrust if he has spent his whole training in one hospital."
Moreover, " British and European surgeons cannot understand how
America manages to produce surgeons of quality after a post-graduate
training period of only five years or so. American surgeons, for their part,
cannot understand what on earth British and European surgeons find to
do or learn in a training period that extends over eight, ten or twelve years"
(Aird, 1961).
Australasia. The Royal Australasian College of Surgeons is comparable
with the Royal Colleges of the United Kingdom and Ireland in its attitude
to Fellowship. The Primary Fellowship Examination has reciprocity with
that of the British and Irish colleges, except in regard to ophthalmology,
in which a special Primary has recently been approved (Brit. med. J.
1963, 1964).
In the regulations governing the final examination, the Australasian
college lays emphasis upon the importance of the candidate showing
evidence of experience in subjects other than, and additional to, general
surgery and the particular intended subject, whatever branch of the
specialty may be concerned. The College thus signifies its disapproval of
too narrow specialization.
Both Australasia and Canada have a special relationship with the
British College in the final examination for Fellowship in general surgery.
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In the United Kingdom, post-graduate surgical training is divided into
two formal stages and a third prior to selection for appointment.
The first stage leads to the Primary Fellowship Examination of a Royal
College of Surgeons, in the basic sciences: applied anatomy, applied
physiology and general pathology. The examination is conducted by
pairs of examiners working together, one being a professional basic
scientist and the other a surgeon with a special interest in and knowledge
of the particular basic science in which he examines. The standard is
high, with a pass-rate in the region of 25 per cent at each examination.
Most of the successful candidates have either taken a special course of
instruction or have held a junior post in one of the pre-clinical departments
concerned. There is, currently, a trend towards greater emphasis on
physiology and general pathology, rather than on anatomy, and a clearly
expressed intention to stress the applied rather than the academic aspects
of all three subjects.
The " Primary " may be taken one year from qualification, but is seldom
attempted in less than two years, i.e. one year after compulsory internship
and registration. The examination consists of both written work and
viva voce tests.
The second stage of post-graduate surgical training leads to the final
examination, which may not be taken until four years from qualification.
The preparatory work to be carried out during the training period includes
six months' surgical internship, six months in casualty or trauma, at least
six months in a surgical specialty, a further six months in the same or
another specialty, or in general surgery, and, finally, twelve months as a
Surgical Registrar, a post which carries clinical responsibilities and affords
continuous operative experience. All these posts must be held in approved
hospitals and the period of registrarship is subject to a certified declaration
of the duties performed, which must include a reasonable amount of
operative experience under skilled supervision.
The final examination consists of written work, the clinical examination
of patients and oral examinations in pathology, in operative surgery and in
surgical science. The standard is high and the pass-rate is in the region
of 25-30 per cent at each examination.
The third stage of surgical training in Great Britain leads to the candidate's selection against competition for a career post as a consultant.
There is a fixed number of posts and vacancies arise only on retirement
(at 65) or at earlier death. The selection is made by a committee appointed
according to regulations laid down by Act of Parliament. The Royal
Colleges are represented on all such selection committees and thus,
indirectly, exercise considerable influence on the length and pattern of
higher surgical training in both general surgery and the specialties, in the
period between " Fellowship" and appointment to a consultant post.
There is no territorial restriction related to a candidate's place of training.
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All candidates have served a number of teachers, the majority have been
to more than one medical school and many have been abroad before
appointment to consultant status. There are some 850 consultants in
general surgery in the United Kingdom, and 1,000 in the specialties, of
whom 400 are in orthopaedics and trauma and 300 in E.N.T. The Colleges'
assessors are all " external " in the sense that each is recruited from a
region other than that in which the appointment is being made.
Depending upon supply and demand, higher surgical training is currently continued for approximately four to seven or eight years between
admission to Fellowship of a Royal College and appointment to a consultant post, with independent practice in the United Kingdom. Study
is being directed to the feasibility and the advisability of stipulating periods
of training for general surgery and the specialties, partly or wholly
additional to the pre-fellowship requirements. The prescribed minimum
period is almost certain to be less than that at present enforced by the law
of supply and demand and is likely to be three years.
The whole of the post-qualification period of internship, registrarship
and senior registrarship is realistically, if not over-generously, remunerated
and no trainee-surgeon need run into debt. Apart from posts held in
professorial units (financed by the universities and representing perhaps
5 per cent of the whole), the trainee is a paid servant of the National
Health Service from start to finish, and is similarly Government-employed
after becoming a consultant. He may elect to go " whole-time " but most
consultants accept a reduced salary on a sessional basis with private
practice rights. For the great majority, the rewards of private practice
to-day form only a small part of their total income.
About half the candidates taking the Fellowship examinations come
from overseas, and teams of examiners go to selected overseas centres to
join forces with locally recruited examiners for the primary examination
in the basic sciences. The final examination must be taken in the United
Kingdom at one of the Royal Colleges and all candidates for the Fellowship of the Royal College of Surgeons of England must, in addition to, or
as a part of, their statutory training, spend at least a year in the British
Isles.
Overseas Fellows returning to their countries of origin are subject
neither to the jurisdiction nor the guidance of their College, once they
have passed the examinations. However, a certain number do return at a
later date for further training, particularly in the more esoteric specialties
and to gain experience in teaching and research.
Facilities for experimental and clinical research are well developed in
most, if not all, departments of surgery in the United Kingdom to-day,
but the training for Fellowship is so demanding and so intense that candidates are seldom advised to undertake serious research projects early in
their careers; nor are they thought to be ready for productive research at
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this stage. On the other hand, most universities offer a Mastership in
surgery that calls for a thesis based on original work on a topic of surgical
interest. This stimulates the efforts of most young men of promise, after
they have become Fellows, since a Mastership is almost mandatory if a
candidate hopes for appointment to a teaching hospital.
III. A CONSPECTUS OF EDUCATION FROM SCROOLDAYS
TO INDEPENDENT SURGICAL PRACTICE
It is evident in both general medical education and in the training of
their surgeons that different countries have different needs. Equally, it is
evident that the facilities, in the broadest sense, for education and training
vary from country to country, and thirdly that, for these and for other
manifest reasons, different kinds of doctors need different kinds of training.
Only one conclusion can be drawn from these undoubted facts. This is
that long-established, time-honoured and widely accepted systems of
medical and surgical education are due for re-appraisal. The wealth of
words and wisdom that have been lavished on this subject in the last decade
or more bear ample testimony to the truth of this observation. But the
present is possibly the first occasion on which it has been possible to paint
the picture on a truly world-wide canvas, and with special regard to
surgery.
It may be accepted as a truism that principles cannot be enunciated
until they have been derived from a consideration of facts in some detail.
It now therefore seems an unavoidable necessity that each stage of the
surgeon's education as of to-day be considered separately before a synthesis
is attempted. This involves the reconsideration of schooling, the premedical period, the pre-clinical period, the clinical, the pre-registration
and the post-graduate (or post-doctorate) period.
Cognizance may at once be taken of the fact that these six stages of
study (five at least of which are vocational) may occupy anything up to
or even beyond a half of a man's useful lifetime and, in some cases, all of
his best and potentially most creative years. In general, too little attention
seems to have been paid to this time factor. In particular, the leisurely
pace of early education accords ill with the desperate race against the years
in later life. There can be few surgeons who, towards the end of their days,
do not think or say, " So much to do; so little time." Time is, indeed, at
the very heart of this problem.
Schooldays should be days of general education and should include
science subjects only in their due proportion. The British practice of
taking physics, chemistry and biology to an advanced level in the schools
is educationally indefensible but can be justified on the time-scale because
it enables the student to begin the study of anatomy, physiology, and so
forth at the age of 18 or sometimes a little earlier.
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The pre-mnedical stage, at which physics, chemistry, and biology are
studied is, in different countries, taken at school or in a pre-university
college or at medical school. In theory, medical school is the best place
for this basic instruction because only there can these subjects be integrated into a specially designed, pre-medical programme. In practice,
no medical school has yet even aimed at this ideal, much less approached
its consummation. One year is by custom devoted to these subjects in a
medical school.
The pre-clinical period rests firmly on a foundation of anatomy and
physiology in proportions that vary from country to country and from one
medical school to another. The integration of these two subjects, one
with the other, is in operation in Birmingham (England) and probably
in many other centres. How far it achieves its purpose is a matter of
opinion. Anatomy tends to be the tail that wags the dog. Physiology with
biochemistry have, in general, probably failed to establish the ascendancy
their importance merits. This may be because of their being taught as
academic disciplines, in isolation not only from one another but also from
their applications in the understanding of clinical medicine.
Because of the difficulty of apportioning teaching time fairly between
anatomy and the other subjects treated at this stage, a number of medical
schools have allocated one year to anatomy with fringe subjects, and a
following year to physiology with an outline of pathology and an introductory clinical course related to and illustrative of all these basic
disciplines.
Two years are usually devoted to the study of the pre-clinical subjects.
In many, possibly most, medical schools an intercalated year in anatomy,
physiology or biochemistry is offered to selected students, leading to a
B.Sc. or B.A. degree.
The clinical period in the United States includes exposure to research
projects, a considerable amount of seminar-type teaching and some choice
of elective subjects. In the United Kingdom the clinical period is a full
three years, rather longer than in America, and is rigidly divided between
the different clinical disciplines with the explicit intention of covering a
wide field in considerable depth. The student is exposed to prolonged
and close contact with patients. The amount of responsibility he carries
varies greatly between schools. In France the traditional pattern includes
a variable amount of clinical work and a great deal of formal lecturing.
In Central Europe a looser clinical attachment is the rule. About three
years is the minimum time occupied in these Continental countries and
it may be much longer.
Pre-registration internship for a year (in some cases more, though
occasionally less) is rapidly becoming standard practice. It is intended
to be a time of further clinical experience with increased responsibility
for patient care but with continuing supervision, active instruction and
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ample opportunity for study. These latter attributes are not always
appreciated by the interns nor are they always faithfully exercised by the
staff members.
Registration thus follows a minimum period of five years medical school
study; preceded by one year of pre-medical University education or two
years of sixth form schooling or (in the United States) four years (from
18 to 22) at College; and followed by a year of internship. In all, this
amounts to a minimum of six years from school-leaving under the British
system, with the possibility of registering at 24 or occasionally at 23.
Under the American system, the earliest predictable age of registration is
normally 26.
Post-graduate (or post-doctorate) education thus begins somewhere
between 23 and 26 years of age or 27 or maybe two years older than that,
29, in the event of there being a compulsory period of National Service.
Whatever the age and whatever the chosen career, at least a further year
or two of experience in hospital or in private practice or both is usual
before the doctor undertakes full clinical responsibilities for the care of
his own patients. In general practice in Great Britain, a traineeassistantship with or without a view to partnership is the rule to-day.
But it is the customs and practice in the training of surgeons in particular
that must be discussed now.
This, unfortunately, is not so easy as it might appear, because the milestones on the road from qualification to full specialization are not clearly
defined (or regulated by statute) in any country, in the way that they are in
the undergraduate period in practically every country. Perhaps the United
States, with her clear-cut residency pattern, comes nearest to a definition
of the minimum time and content of a training programme. This, for a
general surgeon destined to practise in a relatively isolated urban or rural
community, is four years in recognized posts. Whilst a similar schedule of
training also theoretically qualifies a man for a teaching post, a significant
further period of in-service training and education is the invariable rule.
Advancement depends upon a much longer, undefined period.
On the Continent of Europe, the whole system of training is essentially
of an in-service, apprenticeship character and the duration of any one
individual's post-graduate education appears to depend upon two factors;
first, his good fortune or otherwise in there being timely vacancies through
which he can make progress, and, secondly, his being accepted as a suitable
candidate for promotion and appointment. As in the United States, the
less fortunate in these respects find their way into community surgery, at a
relatively early stage of their post-graduate training.
In the United Kingdom, a minimum period of four years is demanded
between qualification and admission to the Fellowship of a Royal College
of Surgeons; and Fellowship is a prerequisite for all general surgical
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posts. It is further recommended by the Royal Colleges that another
three years of higher surgical training (in the grade of Senior Registrar)
should be expected before a candidate is accepted as a consultant by a
Ministry of Health, statutorily appointed, advisory selection committee.
This rule cannot be enforced but is generally accepted for guidance. It is
related to the notion that a surgeon should be prepared to accept an independent charge at the age of 32, or approximately eight years after qualification. This guiding rule applies to all consultant posts and selection for
teaching posts as compared with " community " or non-teaching posts,
depends not upon the period of apprenticeship but upon the luck of the
draw combined with the personal qualities and apparent potentialities of
the candidates.
In general, Australasia follows the British pattern and Canada adopts a
compromise solution combining many of the features of the American
training programme with an early Fellowship examination as a prerequisite
for all first-class hospital appointments.
Developing countries where doctors are desperately in demand can illafford such long periods of training. Those that send their sons abroad
for surgical instruction regard admission to a Fellowship or the satisfying
of an American Board as proof of both training and competence and
us-ually recall the successful candidates to duties at home. They cannot
afford the period of further training that is expected in the more advanced
countries. Indeed a number of developing countries, finding it impossible
to provide even a token service to their people with fully qualified doctors,
are reluctantly compelled to adopt a shortened course of medical education. Their " doctors " so trained cannot register for practice in other
countries and are consequently not subject to the temptation to emigrate
in search of richer rewards.
Training for the specialties such as gynaecology, orthopaedics, thoracic
and plastic surgery, neurosurgery and so forth presents such a complicated
picture at the present time that no good purpose would be served by
attempting a factual summary of current practice in different countries.
The problem is, however, highlighted by the position in Great Britain.
There, the first leg in specialization, at present, is the Fellowship of a
Royal College and the second leg some form of further recognition in the
specialty concerned. The obstetricians and gynaecologists, with their
own relatively recently established Royal College, emphasize the importance of endocrinology, general medicine and, not least, of the complex of obstetrics and maternal and infant welfare. The implication is
that the student has insufficient time for everything and least of all for a
Fellowship in general surgery when there is already a Membership and a
Fellowship available in the Royal College of Obstetricians and Gynaecologists. Orthopaedics, plastic surgery, thoracic surgery and urology, on
the other hand, specify the need for general surgical experience for periods
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ranging from two to four years (embodied in pre-fellowship requirements)
before embarking on a further four years of training in the specialty.
Neurosurgery regards neurological medicine as of equal value with
general surgery but still honours the F.R.C.S. Ophthalmology and
otorhinolaryngology have their own specialist Fellowships in the English
College, whilst both Edinburgh and Glasgow open their Fellowship to a
variety of specialists through examinations biased each towards their own
particular subjects, as also do Australasia and Canada. The United
States, similarly, has its Specialty Boards.
The further consideration of these perplexing problems is proper to
Part II of this survey.
PART TWO
I. THE FUTURE OF UNDERGRADUATE EDUCATION
CURRICULAR MODIFICATIONS WITHOUT number have been framed, discussed, agreed and discarded with bewildering frequency over the last
several years. Few have been completely satisfying. Most have been
debated on the narrow basis of the changing needs of some particular
medical school. All have been bound more or less by tradition. None
has attempted the task that now faces the International Federation,
namely that of evolving a pattern of education that will form an acceptable
common basis for surgeons the world over as well as for the different
specialties into which surgery is now evolving. A main objective of any
new plan should be to ensure that specialization remains a process of
varied development from a parent stem and not one of fragmentation.
With these lofty aims in mind, it is plain that no good purpose can be
served by adding a little here and subtracting a little there. It is equally
plain that the object of the exercise must be to produce a pattern of broad
strategy rather than a system of tactical manoeuvres at each stage of the
educational programme.
First, a number of questions may be asked:
1. Is the total period devoted to vocational training and education
too long?
2. Is the age of entry into medical education about right?
3. Is the age of release from the thraldom of tutelage too advanced?
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4. Is too much time devoted to pre-medical and pre-clinical disciplines
in proportion to the heavy demands made on the student in later years?
5. Is it necessary or helpful to treat each of these preliminary disciplines
on a separate, detached and purely academic basis?
6. Is it reasonable to expect every medical student to master and satisfy
the examiners in some twenty-odd separate disciplines?
7. Is it possible to define the content of these basic disciplines that is
necessary for the education of every doctor, no matter what line he intends
following?
8. Is it necessary for every medical student to submit to every discipline
of the traditional clinical years?
9. Is there any point at which a common basic educational programme
for all medical students could be terminated?
10. If so, would it be possible to define, from such a point, a limited
number of broad streams of further vocational training instead of attempting to make every young doctor a specialist in every subject?
11. Does the present system succeed? Does the mass of knowledge
stick? If it sticks, for how long does it remain useful and applicable?
Until these preliminary questions have been considered and, if possible,
answered, the ground is insufficiently prepared for analysis of the particular
problems of surgical specialization. With these points in mind, the following ideas are put forward as a basis for future planning:
1. Young doctors in general and surgeons in particular are kept
under tutelage to too advanced an age and released to academic freedom
only when they are past their best.
2. Too little attention has been paid to the possibility of pruning the
period of medical education at the roots.
3. Much of the detail fed to medical students is forgotten, almost
deliberately forgotten, once the relevant examination has been passed.
4. Good students could be transplanted from school (at whatever
age) on achieving the required educational attainments, plus evidence of
reasonable maturity. By present-day standards a sufficient stage of
development is commonly reached at, say, 16.
5. The pre-medical and pre-clinical subjects need to be rewritten into
a text for medical students to be taught by medically trained men in a
course in normal human biology occupying, say, three years. Clinical
exposure should be introduced in the second half of this period.
6. A comprehensive, progressive, unspecialized clinical course with
continuing attention to basic subjects (Semb, 1965), and with close
patient-contact, occupying one year, should follow.
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7. This programme, occupying a total of four years, might lead to a
first degree in Medical Science, no right to practise being implied (Lancet,
1963). An intercalated year could lead to an Honours degree.
8. From this point onwards, the educational programme might
diversify according to the aims and intentions of individual students
(Sedgwick, 1921; Silver, 1961; Rutstein, 1961).
The hard facts of life require that, at this stage, there should be a limited
number of places only in each of the diverging streams, leading to a
reasonably balanced division of talent between the different branches of
the profession according to the needs of the community.
Three streams suggest themselves.
One could be for those intending to specialize in teaching and research
in the basic and para-clinical sciences. For these students the emphasis
would be on the learning of research and teaching techniques and the
further study of the application of the basic sciences to clinical practice.
Early part-time student-teacher employment would offer the inducement
of some remuneration to the graduate thus intending basic science. Clinical
instruction would occupy only a small part of the time of this group, with
the emphasis on the application of the basic sciences to clinical practice.
Students opting for pathology, bacteriology, biochemistry and so forth
would follow a broadly similar programme with special emphasis on the
subjects of special interest to them. Their course would probably be
slightly more intensive, might lead to a second degree in three years, but
would probably be followed by a year of internship with emphasis on their
special interests, before registration and full employment.
The second stream of students might include all those destined for the
work of a physician, the field of internal medicine, including general
practice. The emphasis would clearly be upon the clinical practice of
medicine and upon such background subjects as pharmacology, therapeutics, genetics, allergy, neurology, haematology and so forth. Intending anaesthetists would be included in the earlier years of the work of this
group before branching off in, say, their final year, more definitely towards their own specialty. The whole group would be instructed in the
emergency side of surgery and in the scope and range of surgical therapeutics. Pre- and post-operative care would be included in the programme for intending anaesthetists as well as practical experience in the
operating rooms.
A three-year course leading to a second degree would again be appropriate for the whole of this group, with the third year organized on the
basis of student-internship. Before registration a post-qualification, preregistration internship would also be called for.
The third and final stream of students could thus be destined for a
career in one of the surgical disciplines. Two years of student training
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with exposure to the observation and diagnosis of " medical " patients
but with the main emphasis on the diagnosis and care of " surgical"
patients would be the programme. The detail needs no emphasis here.
The third and final year, leading to the second degree, could again be in the
form of student-internship and should still probably be of a general nature
except for those destined for such esoteric subjects as ophthalmology and
otolaryngology. The ophthalmologists should certainly be allowed to
differentiate at this stage. Laryngologists would need special thought
since many are now moving into some of the difficult surgery of the neck.
At this stage of the discussion it is necessary to mention the problem of
the other major specialties, highlighted by the case of gynaecology and
obstetrics. Gosling (1965) writes: "The question to which we must
address ourselves is based on the assumption that we are, in fact, a distinct
professional discipline . . . and the speciality must evolve further during
the years ahead. This requires a willingness to experiment with programmes." A scheme such as the one outlined here affords the maximum
opportunity for such experimentation. Only a selective teaching programme for intending obstetricians and gynaecologists can ensure that
their precious time in their early, able, formative years is spent to the best
advantage. Once wasted upon the cluttering up of their minds with
irrelevant and unwanted matter, the opportunity is lost for ever.
Neurosurgery presents similar particular problems of integration.
Probably in both these cases the third clinical year, i.e. the year of studentinternship, would be the appropriate time for branching away in part from
the main stream of general surgical, undergraduate training with an
elective interest in medical neurology. Such detail cannot be pursued
further in this text, but it is essential to recognize that, if the broad scheme
is to be followed, such detailed problems will arise.
One further special case remains to be mentioned and that is the question
of overseas undergraduate students from the developing countries.
H. Orishejolomi Thomas (1965), Dean and Professor of Surgery at Lagos,
writes: " The principles are the same . . . but the practice and emphasis
differ according to the environment " and " developing countries must pay
attention to these differences...." It is not necessary to particularize.
The student from an under-doctored country needs a range and variety of
fundamental knowledge and skills, adaptable to his home conditions
(Govt. of Pakistan, 1960), of a sort that his Western cousins needed half a
century ago but have now forgotten. Only in a flexible teaching programme can his needs be cared for.
In the implementation of these ideas it is possible to see the limitations
of existing rigid curricula and to visualize a much more flexible educational
system. Different groups of students and even individual students will
each call for specially devised programmes of study. All this will constitute a new challenge to Deanship and should offer exciting new opportunities to both teachers and students.
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Lest there be any misunderstanding, it is important to emphasize the
principles underlying these proposals. They are based upon the assumptions that it is impossible for any one doctor to master all branches of
medicine; that the end-products of " continuing medical education" are
diversified; that diversification, though it may come too early, can certainly
come too late; and that it is timely to look again at our system of medical
education with these ideas in mind.
Underlying these ideas is a further notion, namely that there is an
optimal time for independent thought and individual action. In medicine
to-day these opportunities come, some may think, too late. Their timing
can be advanced by two measures: first, the streamlining of the courses of
study by the avoidance of undue emphasis on irrelevant matter; and,
secondly, by an earlier age of entry upon medical studies (Glenn, 1965).
Young men and women mature and marry to-day at an early age. It is
unrealistic to hold them back to the age of 18 from the long apprenticeship
of medical education. This point must not be overlooked in the consideration of the more complicated problems of teaching and learning.
The policy of diversification at the optimal time must not be confused
with earlier plans, that have been tried and discarded elsewhere, to produce
medical, surgical and other " technicians ", cheaply, quickly and superficially trained (Fox, 1936; 1954; 1957). The object of the present programme is to produce better potential physicians, surgeons and other
doctors, ready to go forward into further and final training at the optimal
age.
II. POST-GRADUATE TRENDS
If the concept of " continuing medical education " enunciated by
Prof. Ravdin is to be accepted and implemented, what has been written
in earlier chapters about " undergraduate " medical education must be
regarded as a lead-in to "post-graduate" training. This idea has been
developed on the premise that there are different kinds of doctors needing
different kinds of preparation for the " finishing " period of their education
and training; and that it is bad business and faulty education to attempt
to shape them all in the same mould.
Given such a flying start, the problems of further education in the
different medical and surgical disciplines should be more easily solved,
although it will be necessary to avoid the temptation to specialize too
narrowly. The appropriate breadth and depth of treatment of both
applied basic science and of clinical subjects will continue to exercise the
thoughts of educators.
It may be profitable to look again at current methods and facilities in
the surgical schools of member countries, to see how their present trends
accord with possible further developments.
Three patterns of graduate training have already been described, the
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Continental, the American and the British. These are based on an inservice apprenticeship in a hierarchy on the Continent; an in-service
system of Resident-teach-Resident in America followed by one examination; and, in Britain, a two-tier examination with in-service training
characterized by a mixture of apprenticeship and a Registrar-teachRegistrar element, again in-service.
Whilst it is improbable that these basic patterns will change much in the
foreseeable future, certain trends are already showing themselves. The
Continental countries including France, Germany, Holland and Switzerland, are becoming interested in post-graduate examinations, and all
European countries are considering specialist registration because of the
increased freedom of exchange embodied in the Common Market and
the Rome agreement. In America, staff members are tending to be more
exercised about the supervision of the work of Residents as surgical procedures become more complex, a de facto system of apprenticeship being
firmly established in specialties such as cardiac and peripheral vascular
surgery. The American emphasis upon research has already been remarked and the American contribution to other countries in this respect
commented upon. The experimental laboratory plays a bigger part in
surgical training in America than it does elsewhere.
A real problem in post-graduate education, not only in the United
States but also in Canada and Australia, is that a large section of the
community is privately insured and privately treated. These factors have
two undesirable effects. First, the number of patients whose problems
can be studied to the advantage of doctors in training is reduced. Secondly,
doctors in practice are compelled to have regard to their own livelihood
and are consequently, for the most part, unable to be selective in the type
of case they accept. There are, of course, conspicuous exceptions to this
generalization and it must be admitted that it is not only in the countries
named that surgical bread and butter comes, and indeed has to come,
before scientific and technical advancement.
In Great Britain, criticism of the Fellowship has been freely voiced.
This criticism has, to some extent, been based on misunderstanding.
Admission to Fellowship has never been intended to be the hallmark of
surgical competence. The two examinations, which are extremely tough,
each with a pass-rate around 20-30 per cent, were designed to test the
candidate's knowledge of surgical science and techniques, his fitness for
further training and his potential as a future surgeon.
Changes have now been made in both the Primary and Final examinations. In the Primary, which is concerned with anatomy, physiology and
general pathology, more emphasis is to be laid upon the applied aspects
of these three subjects, which are also to be treated as forming a conspectus of human biology.
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SURGICAL EDUCATION AND TRAINING
Candidates for the Final F.R.C.S. Examination will in future be required to have had six months' experience in a major specialty, followed
by a further six months in the same or another major specialty, or in
general surgery. After this they will need to have had twelve months'
experience as a Registrar in general surgery, including operative practice
under supervision. These requirements are in addition to the previously
existing demand for six months in " Casualty " or in the surgery of
trauma.
Discipline in training has been strict on the Continent, where it is
exercised by the chief of the clinic; it is almost equally strict in America,
where uniform dress, punctuality and routine participation in teaching
sessions of all kinds are taken for granted. Canada is probably rather
more easy-going. In Great Britain and Australasia the graduate student
is allowed much more freedom in all these respects. This greater freedom
in relation to training is probably the natural counterpart to a greater
rigidity in the system of examinations. It has, however, led to a spirit of
" laissez-faire," not only on the part of the students, but also on the part
of some of those responsible for caring for them and their studies. This is
currently a cause for some anxiety in Great Britain, where the Royal
Colleges of Surgeons are, just now, actively engaged in calling the attention
of virtually all surgeons employed in the National Health Service to their
teaching responsibilities. A nation-wide network of advisers and tutors
has been established to direct, control and co-ordinate surgical teaching
activities on behalf of the Royal Colleges in general and the Royal College
of Surgeons of England in particular.
In these activities, the closest possible co-operation has been established
between the National Health Service and the Colleges. The effect of the
Health Service Act of 1948 has been to bring over 90 per cent of the patients
into the teaching pool, to the undoubted advantage of all concerned, not
least the patients.
Overseas Commonwealth countries and, to a lesser extent, nonCommonwealth countries, participate in providing junior hospital
personnel not only for Britain but in most of the countries that are more
advanced in their medical and surgical development. In return for their
services they receive the normal rate for the job and share with the native
born junior staff the advantages and facilities for specialized education.
A natural desire on the part of emerging countries to train their own
surgeons, and thus avoid the necessity for the loss of their services whilst
undergoing instruction abroad, is frustrated by a lack of suitable facilities.
This lack is felt not only in the specialty of surgery itself but in all those
other related disciplines upon which good surgical practice and adequate
surgical teaching depend. This implies no reflection upon the abilities of
individual surgeons themselves in the emerging countries. Such abundant
facilities derive only from an affluent society. They are bound to be
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CHARLES WELLS
lacking in a society whose financial resources are strained and whose
doctors are deplorably thin on the ground. So long as these disabilities
persist, the developing countries will be wise to accept such facilities for
specialist training as are offered elsewhere; but should endeavour to ensure
that the training received accords with their own needs.
The plain duty of all highly developed countries to assist the needy
countries in both undergraduate and post-graduate training has long been
appreciated and honoured, but it is only recently that the further need
to train teachers and leaders has been accepted as an independent project
calling for special appointments and a special programme. This programme must take into account, not only the techniques and the expertise
in which the host school is especially interested, but also the peculiar and
particular needs of the country to which the trainee is to return as a leader
and a teacher. That this development is now going forward was highlighted in the United Kingdom by the recent Commonwealth Medical
Conference organised by the Overseas Development Ministry.
A most valuable contribution to advanced training may be expected to
result from the interchange of young surgeons on an individual or on an
exchange basis between schools in different countries. The Federation has
a standing committee concerned with this activity and a schedule is available indicating those heads of departments and others who are willing and
able to accept young visiting surgeons seeking further experience. There
is abundant scope for the further development of this service. The
World Health Organization is co-operative (W.H.O., 1962).
These, then, appear to be the present trends in post-graduate, general
surgical education as they affect the various members of the International
Federation. Each constituent member College of the Federation has had
an opportunity to criticize and amend this document and no exception
has been taken to the facts reported or the views expressed.
At this stage, it may be helpful to reflect again that if the undergraduate
educational changes outlined in the earlier chapters of this brochure
materialize, the young surgical trainee will come to the stage of postgraduate instruction at a younger age, with a fresher, more alert mind and
with an educational foundation on which he should be able to proceed
immediately to build his own particular edifice of knowledge, understanding and expertise.
A study in detail of the actual courses of instruction, techniques,
organization and so forth adopted in the various member countries in the
post-graduate period would be of great interest. This would entail the
collection, analysis and editing of fresh information in response to a
questionnaire designed for this specific purpose. The necessary information is not at present available.
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SURGICAL EDUCATION AND TRAINING
III. POST-GRADUATE SURGICAL EDUCATION AND THE
MAJOR SPECIALTIES
The list of specialties within surgery is formidable and still growing.
Neurosurgery, ophthalmology and gynaecology (with obstetrics) draw
much of their inspiration from medicine also and rest upon a detailed
understanding of certain particular aspects of the basic sciences to the
neglect of much that concerns the general surgeon. The orthopaedic
surgeon, when he examines a patient, covers up all the very parts of the
body that the general surgeon leaves exposed. The plastic surgeon acquires
a technique all his own and is possibly more aloof from the general run of
his colleagues than any other. Thoracic surgery in the last two decades
has almost revolutionized surgery itself. Peripheral vascular surgery and
cardiac surgery both stem in some measure from thoracic surgery. They
demand tremendous courage and clinical devotion. Urology, for long a
diagnostic monopoly, now constitutes one of the largest groups of highly
specialized workers with equally highly specialized interests in surgery,
the basic sciences and their own specialized machinery.
In the face of this diversity of interests, where should the common
thread of surgical education be sought? Is it realistic to expect each one
of this motley crew to conform to the same pattern? Are the problems
that are posed solved by insisting that such and such specialists shall have
done so many years of general surgery whilst others may be required to do
something either more or less?
In Great Britain, the Royal Colleges have subscribed to this last suggestion and each of the specialist bodies has co-operated in defining the
minima required. At present these are not so much requirements as
recommendations, but they carry much weight in selection committees
and they will acquire legal force if specialist registration is adopted. At
the same time, some, perhaps many, feel that there is something artificial
in the sort of machinery that prescribes the length and content of a man's
education by statute. Moreover, it is a method that is not always applicable and that has in it an element of danger, namely that specialists may
break away from the parent stem of surgery and establish their own
criteria. This has already happened in the United Kingdom in the case
of gynaecology and obstetrics, a separate Royal College having been
established with its own Charter. Sir George McRobert (1963) opened
a correspondence on the subject and was followed by McClure Browne
(1963), who writes that it is " difficult to see the justification for the obstetrician and gynaecologist to be a general s-urgeon as well ". None the
less, precisely this double qualification is called for when a gynaecologist
and obstetrician seeks appointment to a teaching department or an important hospital. This vexed question is currently exercising surgical
thought in the United States also.
Howard C. Taylor, Jr. (1965), quotes the Committee on Graduate
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CHARLES WELLS
Training of the American College of Surgeons as recommending that
" formal training in the Surgical specialities should be preceded, not only
by internship, but by one or two years of basic surgical training ". He
himself would like to see a " training programme in relation to an analysis
of the job to be done ", whilst he quotes the American Board of Obstetrics
and Gynaecology as prescribing " a minimum of three years approved
progressive Residency composed of eighteen months in clinical obstetrics
and eighteen months in clinical gynaecology ". He says that this statement " has effectively . . . excluded the possibility of intensive training in
endocrinology or gynaecological pathology, or of rotation through other
clinical departments . . . during the prescribed minimum three years ".
Quotations of this character could be repeated time without number.
To the present writer they all seem to be saying something about a desperate scramble against time at the end of an incredibly long and tedious
vocational training that has failed to fit the man " for the job to be done ".
John R. Gosling's assertion (1965) that obstetrics and gynaecology is " in
fact a distinct professional discipline " has great force and must be heeded
if an acceptable solution to this educational tangle is to be found. It
applies equally to other specialties.
The Royal College of Surgeons of Edinburgh established a Committee
on the Training of Surgeons in 1960. They reported in 1963. They
favoured some flexibility in the choice of a training programme and deplored both too early specialization away from general surgery and also
postponement of this decision to too late a date. They also recognized
that obstetrics and gynaecology constitute a special case and that intensive
training in general surgery is inappropriate for the intending ophthalmologist. For all other specialties they advocated a substantial period of
general surgical training before specialization. They found the Primary
Examination in its present form suitable for all disciplines.
To the contrary, in 1963, Gayer Morgan wrote in a letter: " There is still
the handicap of the ordinary Primary and this has shattered the hopes
of many able medical men who aspired to become members of our
speciality" (ophthalmology). He goes on to advocate " a primary . .. of
the head, neck and central nervous system.... " The Australasian
College has accepted jlust such a plea. There are many who share this
view or something very like it in relation to other specialties. In the
Royal Colleges, anaesthesia has established its own Primary, with special
emphasis on subjects of particular interest to anaesthetists, including
pharmacology and physics as applicable to anaesthesia.
It is possible that on the Continent of Europe the less formal educational pattern has already evolved into something like what is suggested
here through the wider freedom of choice permitted to individual students
throughout their training and the lesser emphasis on examinations.
B. K. Rank (1964) has urged that member Colleges should take positive
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SURGICAL EDUCATION AND TRAINING
action to keep the surgical specialties under their own umbrella. But it is
evident that, despite all the thought and care that has gone into the preparation of the specialist training programmes, the link between general
surgery and the specialists is under great strain and that it will almost
certainly break unless some new, overall, educational approach is accepted.
In the post-graduate period every stop has been pulled. The undergraduate period has not been tailored with the logical end in view. Rethinking of the whole vocational training complex seems to be called for.
A line of action has been suggested in this Brochure from the Committee
on the Training of Surgeons of the International Federation of Surgical
Colleges.
MEMBER INSTITUTIONS OF THE INTERNATIONAL FEDERATION OF
SURGICAL COLLEGES
Academia Mexicana de Cirugia (Mexican Academy of Surgery)
Academia Peruana de Cirugia (Peruvian Academy of Surgery)
Academie de Chirurgie
American College of Surgeons
Argentine Surgical Association
Association of Surgeons of Ceylon
Asociacion Espaniola de Cirujanos (Spanish Association of Surgeons)
Association francaise de Chirurgie
Association of Surgeons of East Africa
Association of Surgeons of India
Association of Surgeons of West Africa
Chirurg6w Poiskich (Polish College of Surgeons)
Colegio Brasileiro de Cirurgios (Brazilian College of Surgeons)
College of Physicians, Surgeons and Gynaecologists of South Africa
Collegium Regium Chirurgorum Universitatum Daniae (Royal College of University
Surgeons of Denmark)
Dansk Kirurgisk Selskab (Danish Surgical Association)
Deutsche Gesellschaft fur Chirurgie (German Surgical Association)
Hong Kong Surgical Society
Israel Surgical Society
Japanese Surgical Society
Nederlandse Vereniging voor Heelkunde (Dutch Association of Surgeons)
Norsk Kirurgisk Forening (Norwegian Surgical Association)
Osterreichische Gesellschaft fuir Chirurgie und Unfallheilkunde (Austrian Society of
Surgery and Traumatology)
Philippine College of Surgeons
Royal Australasian College of Surgeons
Royal College of Physicians and Surgeons of Canada
Royal College of Physicians and Surgeons of Glasgow
Royal College of Surgeons of Edinburgh
Royal College of Surgeons of England
Royal College of Surgeons in Ireland
Schweizerischen Gesellschaft fur Chirurgie (Swiss Surgical Society)
Skurdlaeknafelag Islands (Icelandic Surgical Association)
Societa Italiana di Chirurgia (Italian Surgical Society)
Societe Belge de Chirurgie (Belgian Surgical Society)
Societe Hellenique de Chirurgie (Greek Surgical Society)
Suomen Kirurgiyhdistys (Finnish Surgical Association)
Svensk Kirurgisk Forening (Swedish Surgical Society)
Turk Cerrahi Cemiyeti (Turkish Surgical Society)
REFERENCES
AIRD, I. (1961) The Making of a Surgeon. London, Butterworth.
BRALEY, A. E. (1965) Amer. J. Surg. 110, 69.
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CHARLES WELLS
BROWNE, J. C. MCCLURE (1963) Brit. mzed. J. 2, 750, 1125.
Correspondence (1963) Brit. med. J. 2, 743.
(1964) Brit. med. J. 1, 1506.
Fox, T. F. (1936) Lancet, 2, 328, 393, 450.
(1954) Lancet, 2, 748, 803.
(1957) Lancet, 2, 935, 995, 1053.
GLENN, F. (1965) Unpublished data.
GOSLING, J. R. (1965) Amer. J. Surg. 110, 44.
Lancet (1963) 2, 1049.
LONGMIRE, W. P. (1965) Amer. J. Surg. 110, 16.
MCROBERT, SIR GEORGE (1963) Brit. med. J. 2, 682.
MORGAN, G. (1963) Brit. med. J. 2, 743.
PAKISTAN (1960) Medical Reforms Commission, Report. Peshawar University Press.
RANK, B. K. (1964) Int. Fed. Surg. Coll. News Bull. 4, 17.
RUTSTEIN, D. D. (1961) Lancet, 1, 498.
SEDGWICK, W. T. (1921) Pub. Hlth. Rep. (Wash.) 36, 109.
SEMB, C. (1965) Unpublished data.
SILVER, G. A. (1961) Lancet, 1, 271.
TAYLOR, H. C., jr. (1965) Amer. J. Surg. 110. 35.
THOMAS, H. 0. (1965) Lancet, 2, 383.
WOODHALL, B. (1965) Amer. J. Surg. 110, 73.
WORLD HEALTH ORGANIZATION (1962) Press release, EURO/I 56.
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Anonymous
SYMPOSIUM: SOME ASPECTS OF THE CANCER PROBLEM
THE COLLEGE IS to hold the second in its series of week-end symposia on
specialized topics at an advanced level on Saturday and Sunday, 7th and
8th January 1967. The subject will be " Some aspects of the cancer
problem ", and full details are given on the inside back cover of this issue
of the Annals.
298