Providing non-technical skills for surgeons

In Australia and New Zealand, the learned medical colleges have substantial autonomy to determine standards for the practice of their discipline, and to educate medical specialists in their chosen specialty. Until 1996 most of the curriculum content was directed at the acquisition of medical knowledge and appropriate technical skills. In that year the Royal College of Physicians and Surgeons of Canada described an initiative to improve patient care.1 The CanMEDS competencies define the competencies needed for medical practice. While the core of this framework remained the medical expert, around this core were a further six competencies: the professional, the scholar, the communicator, the collaborator, the manager and the health advocate. The Royal Australasian College of Surgeons (RACS) has further developed these competencies to include technical expertise and judgement and clinical decision making.2 Leadership has been incorporated into management skills.

In Australia and New Zealand, trainee surgeons undertake the Surgical Education and Training (SET) program conducted by the RACS in partnership with specialist surgical societies. Trainees have a clearly defined curriculum that identifies goals and requires the successful completion of examinations demanding a command of all aspects of the curriculum. The specialist surgical societies have tended to focus their attention on teaching clinical knowledge and technical skills. There are a number of courses delivering non-technical skills. The college delivers NOTSS (Non-technical Skills for Surgeons) and TIPS (Training in Professional Skills),3 while the MOSES (Management of Surgical Emergencies) course has been developed by General Surgeons Australia.

The challenge facing the RACS is how to teach non-technical skills to practising surgeons. Many will not have been exposed to these non-technical competencies during training. To complicate matters further, many surgeons feel they already have these skills in abundance or believe them to be irrelevant.

While there is a large corpus of literature on changing practice among medical practitioners, much of it is focused on family practice doctors. Moreover, most of the literature is directed at changing clinical behaviour rather than teaching non-technical skills. The literature provides a number of educational models, but none of them is ideal. Models focusing on group dynamics are difficult because of the large number of doctors needing exposure to these components, and the limitations on their time. Nonetheless, the RACS runs several courses, such as NOTSS, which are available for surgeons who wish to undertake this training.3 Running a series of courses for a large body of practising surgeons is difficult because of the infrastructure required, the restrictions around availability of pro-bono teachers and the vast number of courses needed.

Another way in which the RACS has dealt with this difficulty is by using the plenary sessions at its Annual Scientific Congress to address these issues. Being a college rather than specialist society meeting, the audience is large (about 1200 delegates) and eclectic, with a variety of surgical craft groups represented. Larger, well attended meetings allow for funding of international speakers and provide a platform for local experts. Further, attendance at a conference represents a significant component of a Fellow’s continuing professional development requirements.

Is this approach valid? A review of the RACS Annual Scientific Congress identified sufficient evidence that attending such a conference is worthwhile and may change practice.4 Conferences are made up of many component parts including didactic lectures, workshops, short papers, research and plenary sessions directed at a more general audience. Nonetheless, providing information alone may in itself not alter behaviour.

New information that is presented must be relevant to clinical practice. Clinicians then make changes to practice based on the perceived value of the new material. The presentation of this material by experts appears to help, but such experts of course are not always good educators. When planning a conference, it is essential to identify a clear set of educational objectives, based on a needs assessment with a clear set of educational outcomes.5 Plenary sessions can be used in this fashion, namely with a clearly defined set of objectives, good educators and a focused educational outcome.

It remains to be seen, however, whether exposure to appropriate information about non-technical skills in a conference format works, and in due course the approach used by RACS will need to be evaluated. The community is demanding more comprehensive professionalism from clinicians. It is imperative that surgeons recognise its relevance to good clinical practice.