Patient Safety Leading Article Series, 2004

Over the rest of 2004 BJS will publish a series of leading articles dealing with issues of patient safety. A personal view of
the matter was sought from the perspective of a trainee, Paul Thorpe, British trained but currently working in Australia.
The trainees view, sadly but typically, tends to come last but not this time. Pauls article starts off the series. He notes

that hospitals lag behind the airline industry and it is tting, therefore, that the second paper is by Manfred Muller
of Lufthansa.

Leading article

Training and patient safety

P. Thorpe
14 Jillinda Place, The Gap, Brisbane, Queensland 4061, Australia (e-mail: plpjt@hotmail.com)

Published online in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.4618

Recently, after posting some generic

comments about Australian surgical
fellowships on a trainees private discussion forum I received an interesting call from my trainer. Prompted by
a conversation at a European meeting, he asked for access to the forum
to read my writings. This led to a
fairly intense discussion on how the
fellowship was structured. How does
this relate to matters of patient safety?
Well, it is indicative of the difculties
experienced by trainees in commenting on aspects of professional practice, that is to say the difculties of
putting their heads above the parapet.
Trainees often feel powerless to comment on patient safety, even if they
feel they have recognized a signicant
risk. There is an uncomfortable conict between duty to patients and duty
to trainers.
Most training systems incorporate
a feedback process. In the UK, this
is part of the formal Record of InTraining Assessment (RITA). This
involves a condential annual interview, which may be a suitable forum
for discussion of any threat to patient
safety that a trainee perceives. However, few surgeons in training have

enough condence in the security of

the system for such a discussion1 .
Nevertheless, as RITA becomes more
rmly entrenched, it may yet become
a useful arena for highlighting patient
safety concerns2 . This conict also
occurs when raising certain types of
safety issue through clinical governance systems, especially when concerns may have to be outlined to a
close colleague of the problematic surgeon not a comfortable prospect for
a trainee. A further interesting aspect
occurs when dealing with poorly performing fellow trainees. How does
one translate the jovial coffee room
chat into addressing whether or not a
fellow trainee requires closer supervision or retraining? It feels like talking
out of school, but perhaps trainees
should be encouraged to try harder in
this area.
The safety issue may be easier
to raise with respect to organizational rather than individual practice.
With unit audit, some trainees do nd
a way sensitively to raise problems
of patient safety and depersonalize
them enough to avoid uncomfortable
conict. But units vary in their attitude
to criticism, however constructive.

Copyright 2004 British Journal of Surgery Society Ltd

Published by John Wiley & Sons Ltd

OKeefe et al.3 concluded that the

maturity of an organization was reected in the way it responded to criticism, especially from new or transient
workers. Surgical trainees on short
attachments rarely feel comfortable
enough within an established unit to
be truly forthcoming.
If it is felt that there is any value
in expecting trainees to raise concerns
about patient safety, feedback mechanisms must be developed to protect
the individual. In this respect there is
much to learn from research and practice in the aviation industry, where
relationships between trainers and
trainees, between senior captains and
junior co-pilots, have been studied
extensively4 . Such work has led to the
development of training programmes
in cockpit resource management
and sophisticated (often anonymous)
near-miss and accident reporting systems. Anaesthetists have managed to
translate many of these principles into
training and practice, but the surgical
specialties often appear to have difculty even in admitting that a problem
exists.
Perhaps the assured, often driven
personality of the surgeon reduces the
British Journal of Surgery 2004; 91: 391392

392

ability to accept and act on even constructive criticism. Lingard et al.5 , in

their observation of team communication in operating theatres, noted that
the novice the surgical trainee
tended to respond to high-tension
events by withdrawing from the
communication or mimicking the behaviour of the senior surgeon. If this is
so, there is a requirement to emphasize
the need for appropriate assimilation
and response to expressed concern or
criticism as a crucial aspect of learned
surgical practice. This ability should
be incorporated into selection criteria
and training pathways for surgeons. It
also suggests that a senior surgeon,
comfortable in his or her skill and
experience, should recognize the wisdom of constant re-evaluation of personal working practice; furthermore,
the surgical trainer must respect the
trainees need to make constructive
criticism as well as to learn.
The second conict in patient
safety and surgical training concerns
the risk inherent in the training
process itself. In acquiring the skills
to treat patients successfully, it is
necessary for a trainee to advance
through stages of competence and
condence. Initially, there will be few

P. Thorpe

situations in which it is absolutely safe

for a patient to be treated by a trainee
without close supervision, but after
10 years of training there should be
few situations in which a trainee could
not function to the level expected of
a consultant.
There is a real conict in surgical
training at present. Many decry the
loss of traditional training, in which
many years of long hours were spent
in minimally supervised operating.
Many others stress the difculties in
the modern era of training new surgeons in an environment of close
supervision and limited hours6 . It
seems inevitable that surgeons must
adapt training methods to the new
world if high-calibre consultants are
still to be produced. Other organizations have met similar challenges
successfully. In all of this, however,
the balance of training new surgeons
and maintaining a seniors competence must be appreciated. It is easy
for trainers to spend all their time
supervising, while the trainees ght
hungrily for every operation. Training departments must be sensitive to
the needs of trainers as well as those
of trainees. Appropriate resources and
support are necessary to allow the

Copyright 2004 British Journal of Surgery Society Ltd

Published by John Wiley & Sons Ltd

www.bjs.co.uk

maintenance of expertise, or there will

be nothing to pass on to future generations.
References
1 Faux JW, Bailey IS. The surgical
registrar: learning agendas, the RITA
and structured training. Br J Surg
2000; 87(Suppl): 77.
2 Sim F. Record of In-Training
Assessment (RITA): a look at ethical
issues in assessment. Hosp Med 1999;
60: 676678.
3 OKeefe BJ, Lambert BL, Lambert CA
Conict, communication in a research,
development unit. In Case Studies in
Organisational Communication:
Perspectives on Contemporary Work Life,
Davenport Sypher B. ed.). Guilford
Press: New York, 1997.
4 Koonce JM. Human Factors in the
Training of Pilots. Taylor & Francis:
New York, 2002.
5 Lingard L, Reznick R, Espin S,
Regehr G, De Vito I. Team
communications in the operating
room: talk patterns, signs of tension
and implications for novices. Acad Med
2002; 77: 232237.
6 Skidmore FD. Junior surgeons are
becoming deskilled as a result of
Calman proposals. BMJ 1997; 314:
1281.

British Journal of Surgery 2004; 91: 391392