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‘Surgical experts are made, not born’ (Sadideen, et al., 2013).

The ‘making’ of a surgeon can begin when a medical student first immerses himself/herself into a surgical clinical attachment, bringing to life the televised drama associated with the operating theatre, centred on a bloodied patient who is worked on by a team but the spotlight focused on the surgeon (ABC, 2017). Positive experiences can have a significant bearing on the career choices made by medical students (Sutton, et al., 2014) and foundation doctors (Marshall, et al., 2015). However, in the current post-graduate training system, foundation doctors apply for Core Surgical Training with only 16 months of clinical (foundation) experience, of which 50% or less will be dedicated to a surgical specialty. By the time a Core Surgical trainee applies for Higher Surgical Training assuming there were no breaks in training, the trainee will have had 40 months of clinical experience, but 16 – 24 months of these will be surgical. This equates to a maximum of 6 different surgical rotations (specialties).

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While it may be easier to experience the different specialties during foundation and core training, (Dean, 2016) appreciates that it can be difficult to acknowledge and understand the spectrum of a Consultant’s clinical and non-clinical work in that specialty. Surgery is a competitive specialty with some surgical specialties being more competitive than others (Kennedy & Howes, 2014). Consequently, there is an increasing trend towards medical students and foundation doctors choosing their specialty early on and tailoring their portfolio according to the relevant person specifications. While this encourages identity formation and active involvement within that community of practice, the narrow field of vision can prevent trainees from actively experiencing other specialties. Thus, they fail to consider their career options and more importantly, their naïve enthusiasm in one specialty blinds them from the challenges faced by Consultants within their chosen specialty.

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Undergraduate medical education and post-graduate surgical training carry a significant cost. Results from a recent GMC survey revealed a 5% attrition rate amongst surgical trainees (General Medical Council, 2016). Recruitment has been compounded by a decline in interest amongst surgical specialties, possible explanations for which have been elaborated on by (Wenzel, et al., 2002).It is therefore imperative that medical students and foundation doctors make an informed decision based on multi-specialty clinical experiences but also by seeking advice from seniors.

From their survey of general surgery residents, Reed et al. state that the type of procedures and techniques, the exposure to positive role model(s), and the ability to balance work and personal life were factors most likely to be very important in making specialty choices (Reed, et al., 2010). The influential role of mentors as a source of career advice has also been demonstrated by (Berman, et al., 2008) and (Sutton, et al., 2014). Interest in the field and presence of clinical opportunity have also been cited as influential factors (Sutton, et al., 2014).

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The current national clinical climate is geared towards achieving efficiency in clinical service provision, making cost savings and improving patient outcomes through safer practice. Therefore, keen medical students and foundation doctors may feel peripheral or neglected, especially in the intense environment of the operating theatre where teaching is not every surgeon’s priority. Literary evidence shows that student involvement in the operating theatre positively correlates with student’s interest in a career in surgery (Berman, et al., 2008) (Marshall, et al., 2015).

This disconnect between maintaining interest amongst prospective surgical trainees but also delivering an efficient clinical service is evident from a survey of Foundation Year 1 doctors in the UK, which concluded poor theatre attendance amongst this group of doctors, thereby resulting in half the group feeling that they did not have sufficient surgical experience to make an informed decision about pursuing a surgical career (Magos, et al., 2015). There are several online resources providing detailed information on a career in surgery and the surgical subspecialties (BMA, 2017) (Royal College of Surgeons of England, 2017) (Dean, 2016) (National Careers Service, 2017). But none of these provide a positive immersive realistic experience.

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William Halstead championed the apprenticeship model for surgical training in 1904 (Scott, et al., 2008). A century later, this model has been slowly eroded by the political, social, and financial challenges faced by modern health care and the evolution of surgical technologies, thus creating an appetite to train future surgeons in minimally-invasive techniques involving laparoscopic, endoscopic, endovascular, and robotic procedures. Wallenburg et al. summarise this transition aptly:

“Traditionally medical education is characterized by reliance on expert knowledge gained through lengthy periods of dedicated ‘hands on’ training and socialization. Contemporary reforms take in a shift from apprenticeship-based training based on ‘learning by doing’ and role modelling to time-restricted, streamlined, competency-based training programmes” (Wallenburg, et al., 2016).

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The explosion of simulation into medical education and surgical training over the last two decades heralds the making of a 21st century surgeon. (Chikwe, et al., 2004) outlined the problem with surgical training while (Kneebone, 2011) has addressed the drivers for simulation. Therefore, it is in the professions’ best interests to ensure that prospective medical students, current medical students, and foundation doctors are given as much information and immersive experience to stimulate genuine interest, but also to attract a high standard of well-informed, committed and driven individuals.

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A small proportion of medical students and foundation doctors rotate through cardiothoracic surgery, which has seen a decline in applicant numbers. In their study, Tesche et al. used high fidelity cardiothoracic simulators in conjunction with mentored instructions on first and second year medical students and demonstrated that they were an effective way to introduce medical students to cardiothoracic surgery (Tesche, et al., 2010). Mentored exposure and high fidelity simulators have also been used with preclinical medical students on an elective vascular surgery course to stimulate continued interest in vascular surgery, in addition to demonstrating improved technical performance (Lee, et al., 2009). A prospective, randomised, crossover study of medical students exposed to a high fidelity, haptic enabled endovascular simulator also demonstrated significant increase in interest in vascular surgery after exposure to simulation (Markovic, et al., 2012). It is worth noting that these studies involving high fidelity simulation failed to exhibit majority of the features that lead to effective learning (Issenberg, et al., 2005).

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High fidelity simulators often come with a significant start-up and maintenance cost and require a dedicated housing suite. If simulators are to be used primarily to generate interest amongst medical students and foundation doctors, cheaper low fidelity options should be explored. In their study, Anastakis et al. showed that training on low fidelity bench models was equivalent to training on cadaveric models, thereby inferring strong potential to transfer to the operating room (Anastakis, et al., 1999). Regular small-group teaching of basic surgical skills using low fidelity bench top models prior to medical students commencing their surgical rotation has been shown to increase confidence in basic surgical skills, which translates to greater motivation and participation within the surgical team (Hamaoui, et al., 2013).  A more recent study by George et al., using low fidelity models in the form of bench top heart models and animal hearts combined with other engagement activities, demonstrated a significant effect in stimulating undergraduate medical students towards a career in cardiothoracic surgery (George, et al., 2017).

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In their randomized trial involving pre-clerkship medical students, Gawad et al. used the combination of a low fidelity (box trainer) and a high fidelity (virtual reality) laparoscopic simulator on each of the two groups studied.  Students in the supervised group demonstrated significant gains in knowledge, technical skill, and attitudes towards non-technical skills compared to the self-directed learning group. The former group were therefore more confident in assisting intra-operatively. Although not formally measured, the authors expected this pre-clinical exposure would enhance learning, maintain motivation, and increase interest in a surgical career (Gawad, et al., 2014).

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Learning in the operating theatre can be inhibited by multiple factors (Evans & Gusberg, 2012) and so simulation offers the best recreation of this environment to allow students to learn theatre etiquette, surgical skills, and teamwork in a controlled, standardised setting. The ‘OR assist’ elective, developed at the University of California, uses low fidelity models set up within small-group teaching to facilitate first and second year medical students’ learning of basic surgical skills and theatre etiquette (University of California San Francisco, 2017). Students benefitted from interacting with surgeon teachers, and although no significant change in the likelihood of participants pursuing a surgical residency was observed, the authors identified positive changes in attitudes about surgery resulting from the elective (Sammann, et al., 2007).

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Simulation does not always have the desired effect of stimulating interest in surgery amongst medical students. Berman et al. failed to observe an increased interest in surgery between interested and uninterested groups of medicals students after participation in laparoscopic simulation. Although the students regarded the simulated laparoscopic task trainers as useful for skill development, actual operating room experience was superior in driving an interest in surgery (Berman, et al., 2008). This demonstrates the significant effect on engagement of context and authenticity of simulators and the simulation.

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Distributed simulation offers a low cost, portable simulation facility whose authenticity can be manipulated by its’ context (Kneebone, et al., 2010). It can be used advantageously to depict the numerous skills possessed by the different groups of specialised surgeons. Furthermore, it offers students an immersive environment that does not jeopardise patient safety nor impinge on effectiveness of clinical service provision. For each surgical specialty, interested students and doctors can have a schedule within the simulated setting to appreciate the pros and cons of their interested specialty. This exposure can be integrated into the students’ undergraduate curriculum in the form of clinical attachment, special study module (Antiel, et al., 2012), course (Hamaoui, et al., 2013) or clinical project. For doctors, the simulated experience can be combined well with a clinical rotation (Akhtar, et al., 2014), taster week, clinical project, and their portfolio.

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The Surgical Exploration and Discovery (SEAD) program was founded at the University of Toronto with a view to providing interested medical students with exposure to surgical specialties early in their career. The 2-week program, encompassing 9 surgical specialties, employs structured operating room observerships, hands-on surgical skills simulations, and informal discussions on surgical lifestyle and career discussions with staff surgeons and residents (University of Toronto, 2017). Since its’ inception in 2012, the SEAD program has been successfully reproduced at the University of Ottawa (Head, et al., 2016). The SEAD program is an ideal working example of the benefits of simulation as an adjunct in exhibiting surgical specialties as a career. Currently in the UK there is scope for the implementation of such a program at the regional level and should be considered as a feasible alternative to the 2-week taster sessions.

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I have discussed medical students’ and foundation doctors’ inadequate exposure to surgical specialties experienced when making career decisions. Incorporating evidence from the literature, I have identified the influential factors when deciding on surgery as a career. Based on the studies and successful programs from North America, I believe simulation has a role in addressing the problem of limited exposure to surgical specialties. There is limited, but emerging, data from the UK. Controversy exists as to whether high fidelity vs low fidelity models serve a better purpose. Regardless, simulation can be utilised as a powerful tool in the correct context to recreate authentic clinical settings that enable medical students and foundations doctors make an informed career choice - the right step forward on the journey to becoming a surgical expert.

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