Evidence in surgical training – a review

Abstract The first residency programs for surgical training were introduced in Germany in the late 1880s and adopted in 1889 by William Halsted in the United States [Cameron JL. William Stewart Halsted. Our surgical heritage. Ann Surg 1997;225:445–58.]. Since then, surgical education has evolved from a sheer volume of exposure to structured curricula, and at the moment, due to work time restrictions, surgical education is discussed on an international level. The reported effect of limited working hours on operative case volume has been variable [McKendy KM, Watanabe Y, Lee L, Bilgic E, Enani G, Feldman LS, et al. Perioperative feedback in surgical training: a systematic review. Am J Surg 2017;214:117–26.]. Experienced surgeons fear that residents do not have sufficient exposure to standard procedures. This may reduce the residents’ responsibility for the treatment of the patient and even lead to a reduced autonomy at the end of the residency. Surgical education does not only require learning the technical skills but also human factors as well as interdisciplinary and interprofessional handling. When analyzing international surgical curricula, major differences even between countries of the European Union with more or less strict curricula can be found. Thus far, there is no study that analyzes the educational program of different countries, so there is no evidence which educational system is superior. There is also little evidence to distinguish the good from the average surgeon or the junior surgeons’ progress during his residency training. Although some evaluation tools are already available, the lack of resources of most teaching hospitals often results in not using these tools as long it is not mandatory by a governmental program. Because of decreased working hours, increasing hospital costs, and increasing jurisdictional restrictions, teaching hospitals and teachers will have to change their sentiments and focus on their way of surgical education before governmental regulations will emerge leading to more regulation in surgical education. Some learning tools such as simulation, electronic learning, augmented reality, or virtual reality for a timely, sufficient and up to date surgical education. However, research and evidence for existing and novel learning tools will have to increase in the next years to allow surgical education for the future generation of surgeons around the world.

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Comments to Authors:
Dear Editors, Dear Authors, the manuscript titled "Evidence in Surgical Education" is an important contribution to the surgical field of training and education. We suggest publication and have the following comments: Line 48-53: Although one can guess it from the text, I suggest to emphasize two important facts about the German surgical training system: 1. The official trainer of the institution (not necessarily the senior surgeon, who trains the residents) certifies that the resident has acquired the necessary knowledge and skills and performed the demanded procedures. The content of the certification is not checked by II Fritz et al.: Evidence in surgical training -a review an independent source. 2. Surgical quality is not part of this certfication to distinguish the good from the average surgeon. A practical test (e.g. in index procedures on a simulator) is not performed.
Line 263-: The content of the discussion is in many aspects redundant to the initial chapters of the manuscript. I suggest to incorporate the additional content of the discussion in the sub-chapters and to use the content of "conclusion" as the discussion chapter.
There are two aspects that in our view should be added to the discussion and for future perspective: 1. In some disciplines, comprehensive surgical simulation curricula were established based on multiple studies. Their positive effect can be considered as "proven" and are especially needed in disciplines with complex equipment (e.g. robotic surgery, videoscopic surgery, microsurgery). For cardiac surgery, for example, the TSDA published a 178 page long curriculum (https://www.tsda.org/ wp-content/uploads/2016/01/Cardiac-Surgery-Simulation-Curriculum-TSDA.pdf), that is available for free but most likely not used in most teaching centers in the US. An US-study financed by governmental (!) authorities (Mokadam NA, et al. The Annals of thoracic surgery. 2017;103(1):322-8.) established its usefulness. Nevertheless, the overall adoption rate is low, because costs and resources impede broad implementation. Governmental regulations do not require simulation training and financial reimbursement for surgical training is low or does not exist. The same is true for the DRG-system in Germany that does not promote good (or even any) surgical education.
2. To my knowledge, there are no national requirements in Germany to finish simulations courses as part of a surgical curriculum or as prerequisite for board certification. In Switzerland simulation courses are part of the residency curriculum for vascular surgery, for example. Making simulation courses mandatory is the easiest way to increase the adoption rate in teaching hospitals. However, this leads to another problem: The political lobby to improve surgical education is small, although the interest to improve patient care is high. What is commonplace in aviation (high regulatory standards for training to ensure quality and safety, e.g. including regular simulation courses for fully certified personnel) is not used in surgery. Surgical education in many countries currently depends on dedicated and motivated individuals that use the small resources they have at hand to teach the next generation surgeons at their institution. Although I hate to advocate more regulation in our line of work: Regulations and proper payment are probably the only way to increase the overall interest in research on surgical education and to increase available evidence on effective surgical teaching and training. The review is dealing with a very interesting topic. Surgical education is very important. Today, various teaching tools with modern learning platform are available.

Reviewer 2: anonymous
The language is sometimes difficult to understand and needs minor revision. In summary very interesting report which should be published in Innovative Surgical Sciences.