Let’s make the most of the underutilized capacity of the private hospital system for educating our future surgical workforce

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Excerpt

Performing an appendicectomy requires much more than technical expertise but also, at a minimum, competency in decision‐making, communication and teamwork. Over 40 000 appendicectomies are done in Australia each year with considerable variation from region to region ranging from 103–360/100 000, but whether this variation is related to incidence and severity or clinical decision‐making is unknown.1 Around 20% of appendicectomies performed in Australia and New Zealand are normal on pathology, a much higher figure than the USA where computed tomography scanning is more liberally used. However, the choosing wisely campaign in Australia with advice from the General Surgeons Australia and the Royal Australasian College of Surgeons has counselled that if imaging is required then an ultrasound should be considered first at least in children and young adults, despite ultrasound being somewhat user dependent.2
Over 80% of emergency procedures such as appendicectomy are performed in the public sector. The paper by Yap and Cullinan in this issue of the journal on private sector acquisition of technical expertise in appendicectomy shows this is possible in the private sector but that there is still a long way to go.3 The paper also alludes to a reluctance by many private surgeons to let the trainee do the whole procedure making training in the private sector more suitable for the novice trainee. This makes training in the private sector a little limited were this to be the only model available.
Yet over 60% of elective surgery is done in the private sector where it is perhaps elective surgery that offers the best opportunities for training, thus taking advantage of the case mix of the private sector.4 For example, almost 50 000 laparoscopic cholecystectomies are done each year (205/100 000) with the majority of elective cases in the private sector.1
Another example providing highly relevant experience for the intermediate or becoming competent trainee is at the Epworth hospital, Melbourne involving more advanced orthopaedic registrars (Surgical Education and Training 4/5). The ability to perform, under supervision, more major cases helps move the senior registrar from competency to proficiency and has made this one of the prized jobs in the Victorian/Tasmanian orthopaedic program. Appropriately chosen lists with experienced consultants who have consistent teams consisting of the same anaesthetist, scrub teams and theatre staff allow the trainee to slot into the role of learner without the public hospital distractions of calls from emergency departments, ward staff, and junior residents. There is no evidence that patient care is at all compromised, in fact consultants will often take extra time to explain to the registrar aspects of the case deepening both the registrar and patient’s understanding across the competency framework and improving their care.
The presence of the surgical educator scrubbed for the whole case allows formative feedback and supports the deliberate practice and learning from both major and minor cases. This contrasts to the frequent unsupervised training in the public hospital system. Delegation may mean the consultant is either in the tearoom or possibly not even in the hospital at all, leaving the registrar who is reasonably so delegated to learn from being given a certain independence, albeit (in hospitals providing safe and quality care) with backup promptly available.
Other advantages for the more senior registrar include the ability to concentrate on examination preparation. Private hospitals by their nature tend to be efficient, allowing registrars to see plenty of cases, even though safe working hour restrictions impact more and more on training and dilute the clinical experience and exposure.
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