Inspirational surgical education: The way to a mature specialist identity

7th February 2013

 

‘‘You never really understand a person until you consider things from his point of view, until you climb into his skin and walk around in it.’’ (Harper Lee, to Kill a Mockingbird)

Surgical education should be inspirational, and for this inspiration to occur students and trainees need space within the medical school and post-graduate surgical curriculum to explore a range of specialities and future career opportunities. Furthermore, once an individual has chosen their specialty they should continue to develop and be motivated within a programme of inspirational lifelong learning.

In the past decade surgical education in the UK has undergone enormous change. Medical school teaching has moved from a factual and specialty-specific knowledge based training to less fact-based curricula designed to produce generically safe doctors. There has been a modification of post-graduate training involving the earlier career specialisation of junior doctors. Coupled with the implementation of the European Working Time Directive in August 2009 and the proposed acceleration of the time taken for specialist trainees to become consultants we are witnessing a reduction in pre-specialisation specialty exposure. Within surgical specialty training there has been a loss of the ‘apprenticeship’ model and there will be the introduction of General Medical Council relicensing and recertification for established consultants in 2010.

These changes appear to have produced an early training system for which the primary aim is to produce safe generic doctors.7-9 Of course, the production of safe doctors and surgeons for the future must be one of the primary aims of surgical education, but it should also be about so much more. It should inspire the individual, allowing them to mature in their future professional role astrue ‘specialists’.

Plastic and reconstructive surgery as a small and growing specialty has not been immune to these changes. More specifically it has been shown that current UK practitioners in plastic and reconstructive surgery chose to specialise in this area of surgery as a result of inspirational clinical experiences both as students but most importantly as qualified doctors. These experiences only occurred when
surgical training curricula had sufficient space to allow for such possibilities. It appears that more flexible and less prescriptive curricula encouraged the development of a mature specialist identity, which resulted in these practitioners becoming plastic surgeons. This editorial hopes to stimulate a debate on how we construct a cohesive model for plastic surgery education, beginning with the inspiration
of future plastic surgeons as undergraduates through to the continued motivation and development of current and future specialists within the confines of a changing educational landscape.

A mature specialist identity has been defined as a construct developed over time in the mind of the trainee through a process of reflection based on direct specialty experiences. Its development requires self-awareness regarding personal strengths and weaknesses, likes and dislikes, and professional aspirations. By reflecting on these characteristics and mapping them to the attributes of a potential specialty, a trainee gradually achieves an alignment between the two. This process provides a mature picture of their specific professional aspirations. Analogies have been drawn between the new medical student and a totipotent stem cell, with the student being referred to as a totipotent stem doctor. Through undergraduate education the medical student begins to develop a professional identity as a generic doctor, but like the stem cell, has the potential to become any one of a number of mature surgical
or medical specialists. Inspiration, gained from role models and through a wide range of clinical experience, linked to the concepts of being are essential for the development and alignment of this mature specialist identity.
  
Given the above there should be concern for the future of our specialty since direct clinical exposure and educational opportunities in plastic and reconstructive surgery are currently lacking in undergraduate curricula and foundation training programmes.10 It can be inferred that current curricula do not appear to provide future surgeons with the space and inspiration to develop a mature plasticsurgery specialist identity and therefore make a fully informed, inspired career choice for this specialty.

If this situation prevails a number of potentially detrimental effects for specialty recruitment may occur: trainees may not choose specialities such as plastic surgery which are under-represented in the early surgical curriculum or they may make poorly informed career choices into specialities of which they have little experience. The effects of attracting misinformed trainees may have negative consequences both for the specialty and the patients these surgeons will ultimately manage. Indeed, an uninspired career choice may also diminish the ability of the ‘trained’ surgeon to withstand the rigours of working in a clinically and administratively demanding environment such as the NHS.

To begin the process of constructing an inspirational plastic surgery educational model, a schema for the modification of both undergraduate and early postgraduate curricula may be proposed so as to maximise the development of being and space within junior surgical curricula and allow inspired, informed career choices for those individuals who may be interested in pursuing a career in plastic surgery. These suggestions have been designed to maximise specialty exposure, by enhancing space within the curricula, and therefore enabling the development of a mature specialist identity, whilst accepting that we should not return to the excessive knowledge-driven curricula of pre-Tomorrow’s Doctors or the ‘lost tribe’ of senior house officers produced by pre-Modernising Medical Careers training.

Subject areas in the undergraduate curriculum should be clearly labelled by specialty, e.g. hand surgery should be taught and labelled as plastic and reconstructive surgery rather than being represented in modules such as ‘mind and movement’. This would allow early specialist interests to be recognised by undergraduates.

Inspirational role models within the specialty should lecture early in undergraduate courses to educate individuals about specialty subject areas. This would provide both general education for future generalists and careers education for potential future specialists. Such arrangements would allow students to identify areas they may want to explore further and reject hose that do not interest them.

Medical school curricula should provide space for reflection and make students aware of the importance of reflecting on specialty exposure to inform their career choices. Special study modules (SSMs) should be freely available, particularly for those poorly represented specialty areas in undergraduate teaching. Such modules should aim to give a true representation of the breadth of the specialty through direct clinical exposure rather than just laboratory research. Flexible foundation programmes should include more opportunities for specialty exposure. Specialty standalone jobs should also be available to allow individuals the opportunity to explore specific areas of interest. It should become mandatory to gain specialty experience prior to choosing a specialty as a career

Schools of surgery should provide core training as recommended by the Tooke report with more opportunities for specialty experience in areas of interest. Flexibility after ST3 level would allow trainees to change specialty, rather than lose a trainee to surgery completely. Specialty associations need to play a more proactive role in surgical education. With this in mind BAPRAS is providing new opportunities in the form of introductory days to plastic surgery for medical students and by launching a series of Advanced Educational Courses in Plastic Surgery in association with e-learning modules in order to facilitate and inspire life-long learning for consultants and trainees both nationally and internationally.

In summary, as a specialty we need to work on providing inspirational undergraduate and early post-graduate education to allow potential future plastic surgeons the space and opportunity to develop a mature specialist identity within our specialty. In this age of early specialisation it is essential that we provide for trainees through direct experience and reflection, the opportunity to embrace our specialty rather than make erroneous career choices.

In addition, whilst establishing the firm foundations of our specialty within the undergraduate and early postgraduate training curricula, we need to construct a continuing advanced specialist surgical education programme. This needs to be inspirational to feed the minds and spirits of current plastic surgery trainees and continue to encourage and nurture a culture of motivational life-long learning within the community of established plastic surgery specialists.

Joe O'Donoghue
Honorary Secretary, BAPRAS

Acknowledgements
Dr Roberto Di Napoli, Senior Lecturer in Education, Imperial College, London for his guidance and enthusiasm with the dissertation on which this editorial is based.

This article was originally published as an editorial in JPRAS
 

 

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