Annals of Maxillofacial Surgery

: 2014  |  Volume : 4  |  Issue : 2  |  Page : 125--126

The nature of surgical education early in the 21 st century

Paul Sambrook 
 Head of Unit, OMS, The University of Adelaide, The Royal Adelaide Hospital, The South Australian Dental Service, Adelaide SA 5005, Australia

Correspondence Address:
Paul Sambrook
Head of Unit, OMS, The University of Adelaide, The Royal Adelaide Hospital, The South Australian Dental Service, Adelaide SA 5005

How to cite this article:
Sambrook P. The nature of surgical education early in the 21 st century.Ann Maxillofac Surg 2014;4:125-126

How to cite this URL:
Sambrook P. The nature of surgical education early in the 21 st century. Ann Maxillofac Surg [serial online] 2014 [cited 2021 Apr 18 ];4:125-126
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Full Text

Surgical education has evolved from an apprenticeship system to a highly evolved reference based system that has far more input from surgeon teachers.

In the past trainee surgeons were put to work in hospitals, they were seen as a cheap source of labor and were the backbone of the provision of services; it was not unusual to hear stories of junior surgical staff working horrific rosters with 36 h or longer shifts. The paradigm here was that surgical skills were acquired by practice and lots of it, and all of us would have been told "see one, do one, teach one," one can only sympathize with the unfortunate patients at the beginning of surgical terms or toward the end of surgical shifts.

Through the 1980's and into the 1990's surgical educators started assessing how skills are acquired, the pedagogy of surgical education started to change, at the same time and in parallel hospital authorities and government realized that adverse outcomes were more common during the periods when the hospital was staffed by inexperienced surgeons. The hospitals developed safety and quality committees and governments through industrial processes enacted working time directives. The statutory working time directives forced directors of training programs, accreditation authorities and hospital administrators to radically change the way junior surgical and other medical staff were utilized. In my own jurisdiction trainee medical staff can work a maximum of 7 days in succession including any remote call, any day after this 7 days results in the medical officer being paid double time and therefore a significant penalty to the health service and the OMS budget.

The bodies that award the qualification, in the British system, The Royal Colleges, have needed to look closely at what the essential requirements of surgical education are. The apprenticeship system has been replaced with a core curriculum and a series of competencies. Many agencies have used the standards developed by the Royal College of Physicians and Surgeons of Canada where the overarching goal is to improve patient care.

"The core knowledge, skills, and abilities of specialist physicians known as the CanMEDS physician competency framework, it was formally adopted by the Royal College in 1996".

"CanMEDS is an educational framework identifying and describing seven roles that lead to optimal health and healthcare outcomes: Medical expert (central role), communicator, collaborator, manager, health advocate, scholar, and professional."

These two quotes are from

In Australia and New Zealand, we have embraced this concept and developed a core curriculum and associated competencies to reflect the thinking as published by the RCPS (Can). This is a publically available document and can be found at and navigate to the OMS training pathway.

All trainees in Australia and New Zealand are required to achieve a standard as set out in this document, and the training now has significant contemporaneous assessment and individual assessment of operative procedures. There is still a hurdle examination at the end of training, but trainees can only sit this examination after all of the formative assessment tasks and procedures have been completed. Part of this process by necessity involves the assessment of logbooks of operative procedures and other educational activities. Trainees must demonstrate commitment to research and must have successfully completed a research methodology course. Prior to completion of training all trainees must at the very least have presented a paper at a national or international meeting.

Contemporaneous assessment and assessment of operative procedures only increases the workload of the specialist surgical staff. Again there has been a number of significant changes in thinking about the acquisition of surgical skills, for instance, surgically managing 500 patients with a broken jaw in the middle of the night without a mentor input is not training. Managing five patients with significant mentor input in hours likewise is not training. Trainees need to be assessed on the acquisition of skills in a stepwise fashion, mentor input is required until a standard is reached, trainees still then need to consolidate skills and be forced to make decisions in urgent and emerging situations. Repetitive numbers are still required for consolidation.

The changing landscape of surgical education means that there is far more input required from mentors, trainees have less opportunity to operate alone, they can only operate when they have demonstrated competency, and they need to achieve this in less time. Governments and other bodies are trying to reduce training time however in order to achieve improvements in patient care and a competent well-rounded surgical specialist there may need to be an increase in training time to achieve all of our goals or if not we will dilute the amount of material that can be considered core.

As more and more countries adopt this training paradigm it may be possible to look at a more global certification process to a core specialty, it may be possible to develop an exit examination that would satisfy a number of jurisdictions.