My surgical training experience – a trainee’s perspective

Tagged Training; Comments 3 ; Posted 12 years ago by Kelvin Larwood

Having just completed six years of O&G training is a good time to reflect on my past training, and specifically in relation to my surgical experience. I would like to share some observations and ideas that current trainees may find useful. It is important to recognise there are many important attributes of a specialist: Knowledge and clinical skills, academic abilities and the development of professional qualities. Surgical ability is one of these important clinical skills.

A common concern of O&G trainees is the amount of surgical experience they are exposed to. Most trainees won’t enter a surgical sub-speciality or do advanced laparoscopic or pelvic surgery after their regular 6 years of training. Therefore, most of us will not have a chance to catch up with dedicated surgical training after the 6 years. Certainly, surgical skills and a minimum surgical competency are required for caesarean sections at full dilation, for placenta previa or a laparoscopic ectopic or ovarian cystectomy.

An increasing number of trainees and the introduction of less invasive and non-surgical treatments have resulted in a reduction in the amount of surgery that becomes available to trainees. We all have a love-hate relationship with the Mirena IUD. Despite this I believe there is every opportunity to gain the necessary surgical skills as well as the important decision making skills required to perform surgery well.

I want to share some approaches and ideas on how I tried to make the most of my surgical training and those ideas include:

1. I was trying to be proactive and made a decision about what I wanted to do surgically early in my career. What procedures I want to be comfortable doing and up to what level I would like to do surgery. Every one of us will be different in this regard but it’s important to determine for yourself what you want your future practice to look like.
2. With this decided it’s not solely and exclusively the responsibility of the college or training hospitals to train you. You will have the biggest impact on your surgical training and shouldn’t rely on other people to do it for you. We all need to be considerate of other trainees and be fair in providing surgical opportunities but it is up to individuals to make the most of their experiences.
3. If I had a theatre list coming up, I wanted to know what is on it beforehand, read the charts and make myself familiar with the procedures. As trainees, we are much more likely to do the procedure if the consultant is able to appreciate a level of interest and effort made on your part.
4. I tried to get procedures that I wanted more experience with booked onto lists I would be attending. By doing a number of similar procedures close together more will be gained form the experience. Look at your consultant’s waiting list and see what procedures are coming up. Discuss this with your consultant and see if you can arrange for certain procedures to be scheduled to lists you will be attending. At certain stages of my training I did this by looking through the wail list and tried to cluster a list of laparoscopies or a list of vaginal repairs.
5. Get involved with the flow of the operating theatre. We are not just the surgeons. When nearly finished a case make sure the next patient has been called for and in the anaesthetic bay, help the nurses get ready for the next case, help the orderlies move and position the patient, put in the IV for the anaesthetist. Don’t stand in the corner talking while everyone around you is working. You don’t want the last patient cancelled because of an inefficiently running theatre and you need to do your part in making theatre efficient. Every time the last patient was cancelled off the list because the theatre was running slow, I was NOT happy. If you finish early this is a bonus and everyone will like working with you or even better there may be a case on the emergency board that can be done (they might not like you for that but the waiting patient will).
6. Private assisting. There is a lot to be gained through private assisting beyond the financial reward. This adds to your experience and helps you understand and learn the steps of a procedure. If you have assisted a particular procedure many times privately when your chance comes to do the procedure you will get far more out of it. This was certainly my experience, when it came to doing more complex laparoscopic cases such as a total laparoscopic hysterectomy my private assisting experience was a significant advantage to me.
7. I found some good mentors and spent ample of time with them. There are some excellent consultants that are interested in training registrars. When selecting your rotations and elective years consider where these mentors are and try to spend time with them – your efforts will be rewarded.
8. Watch other people. I went to theatre whenever I could (during a quiet birth suite or your own free time). I don’t know a gynaecologist public or private who would deny any interested registrar coming to their theatre to observe. You will be surprised how much you learn and pick up by watching the movements of another surgeon. You develop ideas on what to do yourself as well as things you might not do if you were operating.
9. Courses/animal labs. There are numerous courses and labs available where extra skills can be gained and these are always worthwhile. Sometimes surgical companies put courses on just because they were asked. They might have a new trocar or a new surgical instrument that they want to see tested – and that’s in for them. I attended a RANZCOG/AGES laparoscopic course that I found particularly helpful in learning how to suture and tie knots. I also attended a couple of animal labs and a cadaver workshop that consolidated pelvic anatomy and side wall dissection particularly of the ureter.
10. Don’t knock back your chances. Sometimes you see people knock back chances because they are “just minor cases” or “nothing interesting, couldn’t be bothered”. A number of times a simple hysteroscopy D&C turned into a resection of a fibroid or polypectomy. Always, there is something to learn from minor cases and these are opportunities to improve your skills and improve your use of time. By the same token if someone senior is happy to supervise you, take the opportunity! If you have worked up a case stay back and do it if you possibly can. The ectopic case starting on handover is yours if you have worked up the patient (in my opinion).
11. Practice outside of the operating theatre, without a live patient. Practice on laparoscopic trainers that are often found in hand over rooms, overnight rooms etc. Spend time on them and you will be surprised how much it improves your ambidexterity skills. When watching TV, spend time tying knots. I remember practicing my knot tying while watching TV as a medical student. Then, while assisting in surgery the chance came to do a hand tie. I knew I could do it and offered to have a go. The Job was promptly done. Then I was allowed to become even more involved in the operation. Knowing you can do the simple things through practice outside of theatre means you can make the most of your chances when in theatre. If your consultant sees you fumbling over a simple knot, or s/he is not confident that your knots are secure they are unlikely to let you do the top pedicles of a vaginal hysterectomy.
12. Audit your work and follow up on patients you have operated on. This is not only appreciated by the patient but enables you to reflect on your practice and see where improvements can be made as well as reinforcing the good techniques you are developing. I started a six monthly gynaecology morbidity meeting where our department’s gynaecological complications could be reviewed and discussed. Audit tools such as SurgicalPerformance are also valuable will be FREE for us from the beginning o fnext month.
13. Be prepared to move. We don’t live in isolation and often have to consider partners/family in deciding where we work. However the final two years of training are a great way to seek out training opportunities. Make the effort to find or create a job that will meet your needs. There are some great senior registrar jobs and this can really cap off your training. This has been my experience.  I had invaluable experiences in both tertiary and regional hospitals, but it was my regional experiences that rely enabled me to consolidate my skills supported by forward thinking consultants.

Remember your surgical training and experience is largely up to you and you are the one to guide the direction and type of surgery you wish to be comfortable doing.