Br. J. Surg. 1990, Vol. 77, July, 822423

Professor 1. Taylor and Professor 1. D. A. Johnston* (on behalf of the Association of Professors of Surgery)

Departments of Surgery, University of Southampton and *University of Newcastle, UK Correspondence to: Professor I . Taylor, University Surgical Unit, F Level Centre Block, Southampton General Hospital, Southampton SO1 6 H U , UK

Surgery in the undergraduate curriculum - a statement by the Association of Professors of Surgery

This is our second document produced on academic matters related to surgical practice. Our first publication discussed the place of research in postgraduate surgical training’. In this second paper we wish to discuss the present position of surgery in the undergraduate curriculum and whether changes in clinical practice and modifications in educational philosophy might necessitate alterations in emphasis during the clinical years.

Background Traditionally ‘surgery’ has maintained a high profile in all medical school curricula although in recent years there has been a diminution in emphasis on the surgical specialties. It should be noted that ‘surgical’ teaching really means the performance and interpretation of clinical method and management in patients on surgical wards. We teach basic clinical methods on patients who require surgical rather than medical treatment. It should be emphasized that we d o not attempt to teach surgical craft or operative technique and that we try to avoid surgical dogma and bombast.

In order to achieve these aims most medical schools include general surgical attachments in the third year to emphasize basic clinical skills, followed by a fourth year in which the surgical specialties are included. In the fifth year smaller ‘firms’ are designed to provide more intensive and advanced tuition with increasing emphasis on acquiring higher skills and appreciation of management decisions. There is great benefit in part of this training (usually in the fifth year) being undertaken in district general hospitals.

Table I shows the median time for attachments in each of the surgical specialties for UK medical schools. Within the general surgical attachment most schools include a series of seminars or topic teaching (usually in the third year) but the emphasis is always on bedside dedicated teaching, out-patient tuition and informal discussion.

Importance of surgery in the curriculum Surgical patients have always provided a rich harvest of symptoms and signs to which students can apply their basic scientific knowledge, and as a result of which observe living pathophysiology and the often rapid changes that can be produced by appropriate (and sometimes inappropriate) intervention. These personal observations by the medical student make the course exciting and gratifying. In addition basic practical aspects of clinical management can be demonstrated and taught. These include hands-on experience with venepuncture, the setting up of intravenous infusions and central venous catheter insertion, urinary catheterization,

learning the principles of sterile techniques in the operating theatre, closing wounds and placing sutures, observing wound healing and breakdown, and the value of appropriate treatment.

Surgical attachments are an essential part of the undergraduate curriculum because of the unique nature of surgery which allows students to be taught:

(a) To become skilled in and to learn the importance of careful history-taking, appreciating in the surgical patient how such care will often aid correct diagnosis in the urgent and emergency situation.

(b) To become skilled in eliciting and interpreting physical signs which can indicate urgent life-threatening conditions and to learn to separate these from more chronic, less urgent, situations.

(c) To learn the appropriate use of investigations, especially interventional investigations. This includes particularly the various uses of endoscopy in both general surgery and the surgical specialties.

(d) To appreciate the importance and need for careful, accurate and speedy decision-making.

(e) To become familiar with the spectrum of surgical care available and to develop a critical attitude to assessing its value in relation to less invasive forms of treatment. This often involves collaboration with colleagues in other disciplines, e.g. gastroenterology, neurology and rheumatology.

(f) To observe and become involved with the management of surgical emergencies, especially in life-threatening conditions resulting from trauma, major haemorrhage, acute sepsis, vascular, respiratory and alimentary obstruction.

(g) To understand and be involved with the management of acutely critically ill patients, especially in relation to cardiorespiratory support, circulatory support, fluid and electrolyte balance and pain relief.

Table 1 Suryury in ihu curriculum ~ ~

Median no. of weeks (range)

Percentage of medical schools

General surgery (with urology teaching)

Orthopaedics Ear, nose and throat Ophthalmology Neurosurgery/neurology Cardiothoracic

22 (13-28)

5 (2-8) 2 (1-6) 2 (1 -4 ) 2 (1-6) I

I 0 0

100 100 100 64 32

822 ~~~

0007-1 323/90/070822-02 C 1990 Butterworth-Heinemann Ltd

Surgery in t h e undergraduate curriculum: I. Taylor and I. D. A. Johnston

(h) T o acquire communication skills, particularly with anxious and depressed patients and to explain in simple lay terms complex procedures which are indicated or which have been carried out. This involves experience in the counselling of patients and relatives.

(i) To supplement teaching on anaesthesia and to apply the pharmacology of various drugs including analgesics.

6 ) To emphasize the important ethical, moral and social issues involved in surgical practice and to introduce discussions on cost-benefit analysis.

(k) To appreciate the appearance of normal and abnormal tissues in the operating theatre.

( I ) To develop a healthy critical faculty.

Recommendations Members of the Association of Professors of Surgery are aware of a range of difficulties which surgical teachers face in common with other clinical teachers in providing a comprehensive and wide-ranging clinical teaching programme along conventional lines.

In recognizing these problems, but nevertheless being aware of the importance of surgery in the undergraduate curriculum, the Association has discussed a number of possibilities which might more effectively utilize the time available within undergraduate curricula for surgical attachments.

These suggestions are designed merely as ‘bare-bone’ guidelines which should be taken into consideration by medical schools, the University Funding Committee and General Medical Council, and ultimately curriculum committees as mechanisms for enhancing undergraduate training:

(1) A clear statement of the objectives of surgical attachments should be available to all students in their first clinical year.

(2) A generally agreed ‘core curriculum’ including surgical principles should be agreed by boards of surgical studies and emphasized throughout the third year teaching.

(3) Surgical attachments should include specialty exposure allowing principles of management to be exemplified by observing treatment of specific organ abnormalities.

(4) Out-patient teaching should be enhanced. This will necessitate better facilities for teaching in out-patient departments, and patient numbers should be limited to enable teaching to occur in a calm and unhurried atmosphere.

(5) Arrangements should be made to enable students to be taught on patients attending for day case surgery. This would require careful organization of lists ahead of admissions.

(6) Students should be encouraged to comment on the teaching expertise and enthusiasm of each firm and note taken of comments on poor teachers. The consumers’ views should be taken into account. Equally a formal clinical assessment should be conducted at the end of each teaching attachment or curriculum block to identify accuracy in clinical skills.

(7) It is important that assessment of surgical teaching should be used to determine selectivity and funding in addition to research output.

(8) National Health Service (NHS) consultants involved in teaching undergraduates should have this recognized clearly within their contracts. In addition to out-patient teaching, teaching on business ward rounds and during operating lists, the Association feels that a minimum of 2 h of dedicated bedside teaching per week is necessary by NHS consultants involved with undergraduate teaching. (9) If the ‘knock-for-knock’ arrangement between medical schools and the NHS is phased out, the Association supports the idea of Service Increment for Teaching funding ‘following the student’ so that units which have developed a strong commitment and enthusiasm for teaching will be suitably rewarded.

(10) Specific tuition in trauma and in the care of the critically ill should be included in the curriculum, probably during the surgical attachments.

(1 1) Clinical curriculum subcommittees should allow a degree of flexibility to enhance the contribution that surgery can make to undergraduate training. This will inevitably mean taking account of the rapidly changing practices of surgery. In addition consideration should be given to enable students to study a subject-in-depth for a period of up to 6 months. Surgery and its specialties afford many such excellent opportunities.

Conclusions The wide range of experience that can be gained in eliciting and interpreting clinical symptoms and signs, as well as in learning the value of management and decision-making, ensure that surgery attachments must form some of the most important components of all medical school clinical curricula. Nevertheless changes in surgical practice have meant that in order to ensure that students continue to benefit from these attachments and obtain the necessary exposure and training, various alterations in work patterns are necessary. The Association of Professors of Surgery hopes that by recognizing the problems and providing recommendations for updating surgical teaching, ‘surgery’ will continue to maintain its high profile in the undergraduate curriculum.

Acknowledgements This paper condenses the views expressed in two debates by the Association of Professors of Surgery. Many professors contributed but we are particularly grateful to Professor M. Baum and Professor K . Hobbs.

References 1 . Taylor I, Johnston IDA. Research and surgical training. Ann R

Coil Surg Bull 1989; 71: 89-90.

Paper accepted 15 March 1990

Br. J. Surg.. Vol. 77, No. 7, July 1990 823