Surgical leadership in Poland: ideas and challenges

Abstract The Polish system of undergraduate and postgraduate medical education, including specialization courses in surgery, provided only general guidelines concerning the issue of creating a leader or preparing for leadership. The process of building the position of a leader has had a rather spontaneous character thus far; it has been based on the individual, natural predispositions of a candidate for the position of a leader. There are no formal guidelines for this in Poland. It is required that graduates of medical studies or residents should acquire the so-called professional and social skills before they complete their specialization training. In the light of the ongoing debate, it seems worthwhile to give a thought on the role of a leader and to undertake harmonized actions to work out a common stance on understanding the issue of leadership and teach leadership skills as a part of a harmonized, methodologically correct system of education, so that the best ways of preparing residents to perform the role of a leader in surgical and other medical surroundings could be realized.

This author is to be congratulated to adress an important issue in surgical education, i.e. the importance of adding non-surgical skills to the standard training of young surgeons. He emphasizes a new approach in Polish medical and surgical education in this regard, especially in 5 academic centers. It has to be mentioned that Poland is not the only country where non-surgical skills are not taught during formal surgical training. This is true for almost all countries. To the reviewers knowledge the Royal College of Physicians and Surgeons in Canada was the first to describe a modern framework of competencies of future physicians and surgeons in 2000. (Frank, J.R., Langer, B., World J. Surg. 27, 972-978, 2003). According to this CanMEDS project, medical specialists should be: Experts in their specialty, Managers, Health Advocates, Scholars and Professionals andthis was new -Communicators and Collaborators. It was the first time that communication and social skills were identified to be important in medical/surgical education. Also it was clear that these virtues were not innate natural abilities but could be learned. The author leads these thoughts further and describes recent developments in his country.
To improve the manuscript the reviewer proposes the following: 1. the author should focus more on the activities in the 5 Polish centers or in his own university and describe more in detail how nonsurgical skills are taught. He especially should describe in what stage the SEFEAST project "Safety and interdisciplinary surgical care" is and also in detail what is or will be learned, who are the teachers and at what stage of their surgical education are the young doctors who attend.
2. instead the chapters "Introduction" and "Professional skills -knowledge or competency" can be shortened, e.g. the idea that each graduate or resident should acquire social skills is mentioned 3 times ( page 2, 2nd paragraph, page 3,2nd and 3 rd paragraph), also on page 4, 2nd paragraph of the chapter "Residency training in Poland" and on page 5, 5th line. Also it is repeatedly said that " this competence encompasses decision-making and readiness to take responsibility( page 4, last p. and in the middle of page 5. 3. What does the author think of learning soft skills from role models, though they can be formally taught? Can he comment on this? If it comes to top leaders, learning from role models can be a good tool (Rothmund, M. Surgical leadership, Brit. J. Surg., 2013;100: 577-579) 4. On page 3, last p., the author claims that in a operating suite the surgeon has the final say. What is his opinion on a "suite organizer", who in Germany is rarely a surgeon? 5. When it comes to organisations, the author should explain what "National Consultant" or "Regional Consultants" mean. 6. Finally, the author should comment on forming not only leaders but also team players in the surgical world, where nowadays hierarchies are more often flat compared to the past. I recommend to accept this manuscript with minor revisions. The author is describing ideas about the Polish system of undergraduate and postgraduate medical education and the challenges due to a lack of formal and binding guidelines concerning the issue of creating a leader or preparing for leadership. How the leadership in the Polish surgery is understood, depends on the tradition in individual surgical wards all over the country and different styles of practicing surgery, including specialist training in surgery. The surgical community in Poland comprises various scientific societies. Their leading representative is the Association of Polish Surgeons (APS) with its President, Board and APS regional branches, responsible together with a not in more detail explained "National Consultant" and the Ministry of Health for creating 3-5 centers of simulation training in Poland. There furthermore practical training the leadership in surgical training will be conducted too, with "SurgExcellence" creating a new concept changing specialization training. That is in contrast to Germany, where the responsibility of postgraduate education and specialization is transferred from the government to the German Medical Association (Bundesärztekammer) with its federal state medical associations (Landesärztekammern). The scientific surgical societies only have consulting functions and competencies. Undoubtedly residents should acquire adequate professional and social skills before they complete their specialization training. Surgery always has been, and always will be, a craft specialty. Therefore the acquisition of psychomotor skills is essential, but this must be done on the background foundation of adequate knowledge of other skills such as communication and clinical judgement. In mentoring programs of the past, all too often the teaching of operative surgery followed the age-old aphorism of ‚see one, do one, teach one'. It has represented the model for surgical education for over a century, however recent changes in education have reduced autonomy in training. This is no longer acceptable, not only on the grounds of clinical governance and patient safety, but also on the basis of professionalism [1]. In today's more complex health care institutions, leadership, management and business skills matter equally. Specific programs should be developed in order to equip faculty members with these skills, thus allowing them to deliver a new surgical curriculum, teach surgical proficiency on courses and in the operating theatre, test competency and to play the role of a mentor. In the UK, the four surgical Royal Colleges have joined together to develop an explicit surgical curriculum. This has been based on the CanMEDS roles, described in 2000 by the Royal College of Physicians and Surgeons of Canada as skills for the new millennium. According to this program a surgical expert should be defined as medical expert (in the integrative sense), communicator, team player, health advocate, manager, scholar and professional. Key competencies are assigned to these different roles, defining what a specialist must be able to do [2]. Considering training methods in surgery, it is important to recognize the principles of adult education. These principles were the basis for the Training the Trainers Manual: Learning and Teaching of the Royal College of Surgeons of England (RCSE) [3]. In cooperation with the RCSE the manual was transformed into a course by the German Society of Surgeons. Unfortunately this concept was only poorly received by the German Medical Association, which is responsible for the postgraduate medical education in Germany. The program was offered by the Surgical Society as an optional course, but was stopped due to a lack of uptake by residents in preparation for leading roles in surgery. Teach the teacher programs are offered from some medical faculties or university hospitals. The Harvard Surgical Leadership Program [4] for example is a postgraduate certificate program for surgeons seeking to step into and succeed in leadership positions and acquire the skills needed to excel as heads of departments, divisions, projects, and institutions at large. The curriculum highlights modern leadership strategies and executive skills for surgeons, the role of the surgeon as an entrepreneur and innovator and legal principles for surgical leaders. Within Europe, the working time directive has led to a system of shifts and rotas, which has along with a shorter overall period of training led to reduced time available to surgical trainees in which to learn their craft. In the light of this reduced training time, assessment of surgical competency is becoming even more important and should be a professional priority as well with patient safety and political imperatives in mind. It remains a concern that extended shifts in medical residency programs may adversely affect patient safety but also regarding the effect of current surgical resident duty-hour policies on patient outcomes, resident education, and resident well-being. Allowing program directors flexibility in adjusting duty-hour schedules for trainees did not adversely affect 30-day mortality or several other measured outcomes of patient safety [5]. Compared with standard duty-hour schedules, flexible, less-restrictive duty-hour policies for surgical residents could not be associated with inferior patient outcomes and showed no significant difference in residents' satisfaction with overall well-being and education quality [6]. Surgical competence and its assessment is one of the most hotly debated topics engaging the profession. The present paper gives an overview and describes how leadership is understood and imparted to candidates for the position of a leader in Polish surgery. After the reorganization of the education system, the paper is based on three years of experience of the leading institution for intensive recruitment and training of certified educationists at the Medical University of Lublin, the workplace of the author of this paper.

Reviewer 2: anonymous
In the ongoing debate about surgical leadership it seems a worthwhile contribution. The paper it is recommended for publication in the present form after a minor revision: Page 6: Please explain the term and meaning of "National Consultant" and the Concept of SurgExcellence Page 7: Please give a short comment to the status of implementation of the SEFEAST project "Safety and interdisciplinary surgical care" Author's Reply (AR): Thank you for this valuable publication. It was cited and incorporated to the manuscript.

Reviewers' Comments to Revision
The author leads these thoughts further and describes recent developments in his country. To improve the manuscript the reviewer proposes the following: 1. the author should focus more on the activities in the 5 Polish centers or in his own university and describe more in detail how nonsurgical skills are taught. He especially should describe in what stage the SEFEAST project "Safety and interdisciplinary surgical care" is and also in detail what is or will be learned, who are the teachers and at what stage of their surgical education are the young doctors who attend.
AR: The description of the SafEast Program including learning goals, preparation team and attendees was described at page No.7 2. instead the chapters "Introduction" and "Professional skillsknowledge or competency" can be shortened, e.g. the idea that each graduate or resident should acquire social skills is mentioned 3 times ( page 2, 2nd paragraph, page 3,2nd and 3rd paragraph), also on page 4, 2nd paragraph of the chapter "Residency training in Poland" and on page 5,5th line. Also it is repeatedly said that " this competence encompasses decisionmaking and readiness to take responsibility( page 4, last p. and in the middle of page 5.
AR: the paragraphs and repetitions were corrected or deleted.
3. What does the author think of learning soft skills from role models, though they can be formally taught? Can he comment on this?
If it comes to top leaders, learning from role models can be a good tool ( 4. On page 3, last p., the author claims that in a operating suite the surgeon has the final say. What is his opinion on a "suite organizer", who in Germany is rarely a surgeon?
AR: As the role of the surgeon is different in different locations among the Republic this sentence was deleted. Additionally was not precisely defined.

5.
When it comes to organisations, the author should explain what "National Consultant" or "Regional Consultants" mean.
AR: The role of Polish National Consultant was explained in P.5-6 including the description of the SurgExcellence program P.6 6. Finally, the author should comment on forming not only leaders but also team players in the surgical world, where nowadays hierarchies are more often flat compared to the past. AR: This remark was added to the Page 6 I recommend to accept this manuscript with minor revisions.
Reviewer #2: The author is describing ideas about the Polish system of undergraduate and postgraduate medical education and the challenges due to a lack of formal and binding guidelines concerning the issue of creating a leader or preparing for leadership. How the leadership in the Polish surgery is understood, depends on the tradition in individual surgical wards all over the country and different styles of practicing surgery, including specialist training in surgery. The surgical community in Poland comprises various scientific societies. Their leading representative is the Association of Polish Surgeons (APS) with its President, Board and APS regional branches, responsible together with a not in more detail explained "National Consultant" and the Ministry of Health for creating 3-5 centers of simulation training in Poland. There furthermore practical training the leadership in surgical training will be conducted too, with "SurgExcellence" creating a new concept changing specialization training. That is in contrast to Germany, where the responsibility of postgraduate education and specialization is transferred from the government to the German Medical Association (Bundesärztekammer) with its federal state medical associations (Landesärztekammern). The scientific surgical societies only have consulting functions and competencies. Undoubtedly residents should acquire adequate professional and social skills before they complete their specialization training. Surgery always has been, and always will be, a craft specialty. Therefore the acquisition of psychomotor skills is essential, but this must be done on the background foundation of adequate knowledge of other skills such as communication and clinical judgement. In mentoring programs of the past, all too often the teaching of operative surgery followed the age-old aphorism of 'see one, do one, teach one'. It has represented the model for surgical education for over a century, however recent changes in education have reduced autonomy in training. This is no longer acceptable, not only on the grounds of clinical governance and patient safety, but also on the basis of professionalism [1].
In today's more complex health care institutions, leadership, management and business skills matter equally. Specific programs should be developed in order to equip faculty members with these skills, thus allowing them to deliver a new surgical curriculum, teach surgical proficiency on courses and in the operating theatre, test competency and to play the role of a mentor.
In the UK, the four surgical Royal Colleges have joined together to develop an explicit surgical curriculum. This has been based on the CanMEDS roles, described in 2000 by the Royal College of Physicians and Surgeons of Canada as skills for the new millennium. According to this program a surgical expert should be defined as medical expert (in the integrative sense), communicator, team player, health advocate, manager, scholar and professional. Key competencies are assigned to these different roles, defining what a specialist must be able to do [2]. Considering training methods in surgery, it is important to recognize the principles of adult education. These principles were the basis for the Training the Trainers Manual: Learning and Teaching of the Royal College of Surgeons of England (RCSE) [3]. In cooperation with the RCSE the manual was transformed into a course by the German Society of Surgeons. Unfortunately this concept was only poorly received by the German Medical Association, which is responsible for the postgraduate medical education in Germany. The program was offered by the Surgical Society as an optional course, but was stopped due to a lack of uptake by residents in preparation for leading roles in surgery.
Teach the teacher programs are offered from some medical faculties or university hospitals. The Harvard Surgical Leadership Program [4] for example is a postgraduate certificate program for surgeons seeking to step into and succeed in leadership positions and acquire the skills needed to excel as heads of departments, divisions, projects, and institutions at large. The curriculum highlights modern leadership strategies and executive skills for surgeons, the role of the surgeon as an entrepreneur and innovator and legal principles for surgical leaders.
Within Europe, the working time directive has led to a system of shifts and rotas, which has along with a shorter overall period of training led to reduced time available to surgical trainees in which to learn their craft. In the light of this reduced training time, assessment of surgical competency is becoming even more important and should be a professional priority as well with patient safety and political imperatives in mind. It remains a concern that extended shifts in medical residency programs may adversely affect patient safety but also regarding the effect of current surgical resident duty-hour policies on patient outcomes, resident education, and resident well-being. Allowing program directors flexibility in adjusting duty-hour schedules for trainees did not adversely affect 30-day mortality or several other measured outcomes of patient safety [5]. Compared with standard duty-hour schedules, flexible, less-restrictive duty-hour policies for surgical residents could not be associated with inferior patient outcomes and showed no significant difference in residents' satisfaction with overall well-being and education quality [6].