Why does it take so long to train a surgeon?

Why does it take so long to train a surgeon? The typical trainee will not finish training until the age of 35-40 years old. I am currently 34, and still have years of moving around the region, jumping through hoops and fighting to get operating time and sign-offs to look forward to. Surgical training is not a comfortable place, and I have not met a single trainee who is content with year after year of no fixed routine, no certainty, constantly moving around, no time for friends and family, difficulties setting up a home, financial worries and concerns about the future. Furthermore, new consultants are now very much not expected to be the finished product, and it is anticipated that they will still be learning how to operate and function as a senior surgeon for some time after completion of training!

Elsewhere in the world however, surgical training is often much quicker than our minimum of 8 years of surgical training. The Americans for example, despite all of their advanced technology and leanings to litigation, only have a 5 year residency program[1]. At the other extreme of healthcare complexity, in the developing world organisations such as CapaCare[2] can train a surgeon in as little as 2 years, with apparently similar outcomes to conventionally trained surgeon in the appropriate context[3][4].

So why is our training so inefficiently long-winded? Really, it can only be because there is so much time devoted to paperwork, administration and service provision, and too little effort given over to actual training or structured development. Operating time in theatre is infrequent, sporadic and frequently unproductive when it does materialise. When I eventually escape the overbooked, unsupervised clinic, or my overflowing admin pile, I spend much of that precious theatre time holding a camera or a retractor whilst the consultant operates. Instances of good quality teaching and mentoring are so infrequent and fleeting that they feel like precious, unobtainable events that only occur once in a blue moon. Worse than this however, is when they do occur, I frequently find myself too unprepared and shattered by the grind of service provision to even make the most of them. When, out of the blue, a consultant suddenly allows you to mobilise the left colon, the thought of the twenty referrals that you need to see if A&E is often so distracting that you almost wish he would just mobilise the damn thing himself to save time.

There is a real need to standardise and incentivise trainers and placements, and thereby let us poor trainees out of the inefficient, longwinded program sooner and better trained. The usual routine in the current system is to spend 4 or 6 months putting in the groundwork, staying late, coming in on your day off and sorting out all of your boss's admin work to the point where, despite the exhaustion and frustration, you are finally starting to achieve a little access to operate, and your boss has started to remember your name. Then, the moment you are starting to see a flicker of progress, you are moved on and need to start again from scratch!

Even worse, the pressure on consultants to just to get on with the operation and forget about training has been exacerbation manyfold by the ongoing COVID-19 pandemic, as demonstrated by the below chart[5], which illustrates the total operation numbers recorded in eLogbook by General Surgery Trainees, comparing June 2019 with June 2020:

Or this[6], which demonstrates just how much our opportunities have been decimated in the past couple of years;

It can be extraordinarily difficult to maintain motivation when you have been supposedly training for years, and yet haven’t been given the opportunity to do anything more significant than hold a retractor and slavishly endure untold hours of paperwork.

What are your experiences of surgical training in the UK and elsewhere? Could 8 years of slogging away be made any more efficient, effective or enjoyable? Do you have any ideas about how the ground lost during the COVID-19 pandemic can be reclaimed?

References

1. https://www.absurgery.org/default.jsp?certgsqe_training
2. https://capacare.org
3. Beard JH, et al. Surgical task-shifting in a low-resource setting: outcomes after major surgery performed by nonphysician clinicians in Tanzania. World J Surg. 2014 Jun;38(6):1398-404.
4. Beard JH, et al. Outcomes After Inguinal Hernia Repair With Mesh Performed by Medical Doctors and Surgeons in Ghana. JAMA Surg. 2019;154(9):853–859.
5. http://www.nact.org.uk/getfile/9988/
6. https://twitter.com/JCST_Surgery/status/1452635676164468739?s=20