Surgical education and training have progressed through the centuries, with the most commonly used model being the apprentice model. With advances in medical knowledge and practice, the apprentice model has evolved and competing models have arisen. However, the apprentice model remains the gold standard today, but for future use, further evolutionary changes will need to be made to the apprentice model if it is to continue to remain an effective education paradigm.
The training of surgeons has undergone remarkable evolution in the millennia that have passed since the inception of the art of surgery. The path that surgery has traveled has at times been rocky and has not always paralleled the course that “medicine” in general has taken. Surgeons and surgery, in fact, have commonly been perceived as separate or apart from medicine for ages, and the history of training of surgeons reflects this. The distinction is apparent even in the ancient version of the Hippocratic Oath, which translates, “I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work” . This traditional divide persisted well into the Middle Ages and into even the modern era. At times, it was highlighted by differences in titles: surgeons were (and in some places still are) referred to as “Mister,” owing in many areas to the trade of “barber-surgeon,” which required no formal training, qualification, or degree, whereas physicians were referred to as “Doctor,” due to the recognition of the attainment of a medical education or university medical degree.
Surgical training and education have indeed come a long way, but in some fashion, they have also arrived very near where they began. Although it is certainly not the only method of training and has undergone many adaptations and variations, the apprenticeship model or apprenticeship method of training is inarguably where the training of surgeons began and, interestingly enough, has weathered passage of time well enough to be the paradigm of surgical educational training for the present.
Brief history of surgical training
Attempts at improving surgical education began almost a millennium ago, the first tiny steps in a long process to advance training in the craft of surgery and transform it from trade to profession. As medicine became more defined as a field of its own, efforts were made to separate the academic surgeons from barber-surgeons with little or no training. The College deSaint Come, established in Paris in about 1210 ad , was the first to do this by identifying the academic surgeons, those who had training or had attended the university, as surgeons of the long robe and the barber-surgeons as surgeons of the short robe . To systematically instruct barbers in surgery, a school was set up in France in the middle of the thirteenth century by the Brotherhoods of St. Cosmos and St. Domains .
However, the most common and well-established method of training surgeons—if any training was obtained—was by the apprenticeship method. Length of training and age when training began could vary, but a typical apprenticeship in the mid-sixteenth century would last 5–7 years and could start around the age of 12 or 13 . Further training, in the form of journeymanships, was available under the tutelage of the same or a different master, but was not necessary for the practice of surgery. Initially, apprenticeships began as simple, unstructured arrangements, involving family or friends, but as time passed, surgical apprenticeships progressed to more organized arrangements with formal rules. For example, in Edinburgh during the sixteenth century, the master was “obliged himself to teach and instruct” and “had the obligation not to transfer his Prentice to another Master” .
As surgery slowly evolved from a trade into a profession, the apprenticeship model has been the surgical education standard. This time-honored approach has remained in practice to the present day, although not always in its original form. In the most basic form of this model, surgery is taught by the student directly observing and then imitating the actions of a skilled mentor, both in the operating theater and in the clinical examination setting . In ways, this is the origin of the “see one, do one, teach one” mentality that accompanies the instruction of individuals who are being taught a new procedural skill . Though it has undergone evolution and, at times, fallen out of favor, the apprenticeship model is still viewed by many as the current standard for surgical teaching .
The introduction of the apprenticeship model greatly improved surgical education, as now an experienced mentor instructed the trainee, shared collective knowledge, and taught surgical techniques by demonstration and repetition. Surgical knowledge and techniques, though not scientifically studied to determine their benefit (or harm) to the patient or their success, were at least learned by instruction and example rather than trial and error . Still, there was absolutely no standardization or guidelines as to what knowledge or skills were to be taught, who should be trained, when training should start, or how long training should last. The apprenticeship system also promoted the “cult of the individual,” with the development of masters who established competing “schools of surgery” .
The end of the nineteenth century and beginning of the twentieth marked the first major shift from the previous apprenticeship training models to more formalized and structured training. The method currently in practice to train surgical residents in the United States is, in large part, due to the influence of Dr. William Halstead . Although not the first to propose it for acceptance, he is often mistakenly credited for this method . It was, interestingly enough, proposed by his contemporary, Dr. William Osler, in 1890, to the Board of Trustees at the Johns Hopkins Hospital; Halstead immediately and enthusiastically adopted it .
Halsted established a school for surgeons that emphasized safety in surgery and was characterized by the importance of meticulous hemostasis and careful tissue handling . He also was pivotal in popularizing the concept of resident training in the United States. In 1904, Halstead delivered a landmark lecture at Yale on the training of surgeons, proposing the adoption of a model of the German system of residency training, whereby trainees received increasing responsibility with each advancing year . The model allowed for improved structure and standardization in training, but it also introduced the “pyramid” structure in residency training, in which candidates would be eliminated each year, until culminating in the graduation of a single chief resident . The idea gained support and, in 1928, the American Medical Association House of Delegates approved the application of the underlying principles promoted by Halstead to approve residency programs and fellowships . Thus appeared the surgical educational training programs and residency educational models that are known today.
Modern models of residency training
The residency system of training did not eliminate the apprenticeship model for those who wished to learn the art of surgery; it was the catalyst of evolution. Residency gave the apprenticeship model the structure, standardization, and stability it needed to train modern surgical residents. In fact, the ideas introduced by Halstead still provide for the position of a master or mentor who supervises and instructs his or her apprentices. The position of mentor is so valuable and rewarding, not only to the trainee but the mentor as well, that the apprenticeship model is still viewed as the current gold standard in resident training . However, with the advent of this change in structure, it also opened the door to an alternative and competing model of residency training. As these particular residency educational training models have never been officially or formally recognized or described elsewhere, the present authors have taken the liberty of naming and briefly outlining each educational training model.
The “Osler” model of residency training
Referring to Dr. William Osler, very likely the greatest American clinical teacher, this model is the most up-to-date or modern version of the apprenticeship model. Osler introduced medical education to the clinical clerkship as it is known today—the backbone of the third year of medical school—and was one of the biggest advocates of mentoring, and thus, indirectly, the apprenticeship method of training . Osler emphasized that a closer relationship between an instructor and student(s) was not only necessary but vital, and portrayed professors as the “senior student anxious to help his juniors. There is no appreciable interval between the teacher and the taught—both are in the same class, the one a little more advanced than the others” .
The Osler model consists of one or more residents of differing postgraduate training levels (apprentices) closely working with one or more faculty members (masters or mentors). Rotations may vary the exposure of residents to certain attending physicians, but the essence of this model of training is that faculty are invested, committed, and involved in nurturing the education of their trainees. Staff physicians are not merely occasional lecturers or distant figures, but are actively involved in instructing residents while seeing patients during clinics, on wards, and during operative procedures. Residents are supervised, although the level and acuity of monitoring will vary based on the experience level of the residents. In addition, by mentoring and behavioral modeling, residents learn the art of practicing medicine (not just surgical techniques), something difficult to learn from textbooks or measure on examinations .
The model also allows for the practical marriage of science and tradition. Evidence-based medicine is not something solely mentioned in lectures, but is actively taught by faculty and observed and practiced by residents in the clinical setting. Residents directly benefit and acquire medical knowledge and experience from their teaching faculty. Surgical procedures can and have been studied systematically to evaluate almost all feasible aspects, from preoperative skin preparation and antibiotics to methods of performing incisions and techniques for dissection to complication rates and mortality. When new surgical procedures are introduced, they can be studied and evaluated first by the scientific community. In this way, a safe, effective, and validated operative procedure that has passed through the rigorous scrutiny of other physician-scientists can then be passed on to surgical trainees.
The apprenticeship model, and its various manifestations, has been used for nearly the entire history of modern surgical practice. It is viewed as being an effective method of training surgical residents, in that surgeons previously graduated from this system have practiced successfully . Many surgeons practicing today are products of this type of system, but some, who may believe they have been trained in an apprentice-style fashion, are actually graduates of a completely different model of training.
The Mall model of residency training
Referring to Franklin P. Mall, the Chief of Anatomy at Johns Hopkins Medical School, this model could just as easily be named after William Halstead. Mall and Halstead were not only contemporaries and friends, but also seemed to share the same educational philosophy: that of the “inductive” approach to medical education, which is “to teach by not teaching” . Mall is often credited as the father to the arguments supporting this style of education—the antithesis of mentoring and the apprenticeship model—which proposes that mentoring is not needed if only the best are recruited . Mall would assign his students a part of the cadaver to study, provide them with references, and leave. His staff would be present, but no formal instruction was ever provided. He believed students were responsible for their own learning. Although “brilliant students loved him,” his methods were found wanting by everyone else.
The Mall model consists of a group of residents of differing postgraduate years who are provided with educational resources, such as textbooks, training manuals, and surgical atlases, and who essentially instruct themselves and, at times, each other. Faculty members may be completely absent from the picture, or may have a loose association with the residents, but in no way does faculty involvement approach the level of investment given by faculty in the first model. Staff physicians may lecture to residents, but little or no outside clinical instruction is truly performed. If it is, it is usually sporadic and irregular, or it is lavished on a select resident or favorite, whereas in Halstead fashion, the remaining residents languish. In fact, those attending may even be physically separated from their trainees, with the faculty member in one facility and the resident in his or her own clinic or other location. The epitome of this model is the scenario of one or more trainees in the operating room, looking at a surgical atlas, struggling through a procedure while the faculty in charge are largely absent, either briefly checking in at times to see how things are progressing or never present. More senior residents may or may not attempt to fill the void by providing the incomplete instruction that their limited experience allows.
Some may argue that this is not a separate or different model of surgical training, but is still a version of the apprenticeship style of training, with senior house staff serving the role of master. In fact, some have argued that senior house staff can assume the mantle of mentoring . This view is, at best, naïve and the position itself grossly flawed. Upper-level house staff do not have the prerequisite surgical experience level, medical knowledge base, or clinic expertise to serve in the role of “master” or “mentor,” especially given the responsibilities and expectations of these roles. Although teaching more junior residents is certainly within the scope of responsibilities placed on senior residents, it is in no way an adequate substitute for replacing an attending physician. If such were truly the case, academic teaching surgeons would no longer be needed and a great many physicians (the authors included) would no longer have a source of income.
The success of this model can be argued as there are certainly products of this type of educational system who are or have been successfully practicing surgeons. Yet, similar to medical students exposed to this type of “teaching by not teaching,” brilliant trainees may flourish while less gifted residents flounder. Though some may contest that skilled surgeons may come from this educational training model, it begs the question if this method is truly the most effective, efficient, or even responsible way to produce future surgeons. Fortunately, the Accreditation Council for Graduate Medical Education (ACGME) has increased its vigilance in monitoring training programs and toughened its program requirements, such that new mandates explicitly state that “faculty schedules must be structured to provide residents with continuous supervision and consultation” . Though pockets of this model of residency training may still persist, with the continuing focus of the ACGME on ensuring adequate faculty involvement and supervision, the current trends in medical education, and the increasing scrutiny by the legal profession, it is highly likely this model will completely disappear.
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