Issue 16 / 4 May 2015

SURGEONS do not fully recognise their position to influence wider society, says a leading surgeon, after research revealed that trainees and Fellows of the Royal Australasian College of Surgeons prioritise individual expertise over common goals.

Professor Guy Maddern, head of surgery at the University of Adelaide and director of surgery at the Queen Elizabeth Hospital and Royal Adelaide Hospital, told MJA InSight that while technical skills and direct patient care were vitally important attributes of surgeons, “we need to give equal weighting to all competencies of surgical practice”.

“If we only focus on what surgery can do for one individual, we lose sight of the broader issues of care”, he said.
Professor Maddern was responding to a study, published in the MJA, based on a 2010 questionnaire for trainees and Fellows of the RACS asking them to rate the importance of nine surgical competencies and their 27 attributes as defined by the college. (1)

The competencies were technical expertise, communication, professionalism, medical expertise, judgement and decision making, scholarship and teaching, collaboration and teamwork, management and leadership, and health advocacy. (2)

Based on 1834 questionnaires returned, the results showed statistically significant differences between the perceived importance of competencies and attributes.

The responses showed the attributes considered most important were competence, insight and recognising conditions amenable to surgery, while the least important were responding to community and cultural needs, supporting others, and maintaining personal health and wellbeing.

Key differences were noted for the competency of collaboration and teamwork, which was ranked as more important by trainees than by Fellows. Female trainees and Fellows regarded all attributes as more important than male trainees and Fellows.

The authors wrote that their results showed a greater emphasis on individual skills rather than on achieving a common goal, and that this gap needed to be addressed in selection of trainees, in current surgical training and in ongoing professional development for surgeons.

“Competencies that are not reinforced by educators, mentors, trainers and the broader peer group are more likely to be neglected, with possible detriment to clinical practice”, they wrote.

Study coauthor Associate Professor David Hillis, chief executive officer of RACS, told MJA InSight that the research provided a valuable insight into the surgical profession.

“Professionalism and competence for a surgeon is more than just technical skills. It’s about expertise in communication, teamwork, ethics as well as advocacy and leadership”, he said.

While the research indicated that these attributes were regarded as important by the trainees and Fellows of the RACS, there was still room for improvement.

Professor Hillis said the RACS should lead a cultural change that prioritised skills equally throughout a surgeon’s entire career.

“It is important that the RACS continues to rethink its approach to professionalism and surgical competence to ensure that all trainees and Fellows have the broader skills required of the professional surgeon in the 21st century”, he said.

Dr Charles Douglas, senior lecturer at the school of medicine and public health at the University of Newcastle, said the study reflected a high degree of consensus within the RACS that the current descriptors of professional obligations were appropriate and are “attributes and competencies to which we should aspire”.

However, Dr Douglas did not feel that any conclusion should be drawn from the relative differences in the prioritisation of competencies.

He told MJA InSight that if people feel they need to rank a set of priorities, something has to be prioritised last by default. “But the reality here is that there was surprisingly little difference in mean score for the most important and least important attributes.”

Dr Douglas said it was important to acknowledge that the study’s participants still considered responding to community and cultural needs as an important attribute.

“Saying that this was one of the ‘least important’ [attributes] is creating a misleading impression”, he said.

However, Professor Maddern believed the results of the research should inform appropriate adjustments to the existing curricula used in the training of surgeons.

Current examinations tended to have a clinical focus on technical skills, and “held back on incorporating the more generalisable and non-technical approaches to surgical practice”.

This included a greater emphasis on day surgery initiatives, home care programs, health advocacy and team work, Professor Maddern said.


1. MJA 2015; 202: 433–438
2. RACS; Surgical Competence and Performance
(Photo: Jan Van De Vel / Science Photo Library)

8 thoughts on “Surgeons’ priorities probed

  1. Ian Hargreaves says:

    Sue, you miss my point. 8 of the 9 attributes cited as important are also important in a physician or a physiotherapist. Any competent physicist scores 6/9, and Prof Hawking’s health advocacy gives him a clear 7/9. Therefore, these 8 are not competencies unique to a surgeon, but expected of all health professionals – a motherhood statement, so general as to be meaningless.

    In the olden days a cardiologist diagnosed the heart problem, the surgeon did the procedure. Now the cardiologist does it all, ie the bit of wire has replaced the entire surgical team. The wire is the surly, non-collaborative team-member, which does the job superbly, despite totally lacking the ability to supervise and teach junior staff. I suspect neither you nor Prof Maddern would refuse a stent, because its mindless technical ability to do the job of revascularising supplants a surgeon. Or insist that your blood count be done eye-to-microscope by a pathologist, who talks to you, not a machine which emails you a result. Or refuse to wear a seatbelt until you had talked to the Korean outworkers who sutured it – is suturing your seatbelt securely less important than suturing a laceration?

    As the son of a (non-medical) technician, and having worked with many technically gifted surgeons who fall well into the autistic spectrum, I occasionally wonder why so many doctors use the term technician disparagingly, and whether they sincerely tell their technician patients that there is no place for their autistic child to become a surgeon. The other question that puzzles me, is that as the RACS is marketing a ‘Non-Technical Skills for Surgeons’ course, why did the MJA not compel a conflict of interest declaration by the authors?

  2. Sue Ieraci says:

    Ian – I agree that technical ability is a crucial attribute for a surgeon, because it distinguishes the craft group from others. However, I would say that cognitive ability is an equally important factor – including clinical assessment and judgement. The person’s communication skills need to be good enough to get an accurate history and agree to a plan with the patient, and they need to be able to communicate adequately with colleagues and theatre staff, and to supervise junior staff adequately and safely. All these things are part of the clinical process of patient care, and they distinguish the specialist surgeon from the technician.

    I would not be happy to have a technical procedure done by a surly, non-collaborative person, no matter how good their technical skills, because their surliness and lack of collaborative talent both predispose to error.  As a medical colleague, I am not happy to work with surly non-collaborators because they disrupt the work flow of others, do not adequately supervise and teach junior staff and generally disrupt the workplace. I don’t need my surgeon to be best friend or counsellor – I have access to other people for those things – but both patient care and workplace collaboration require clear thought and responsible, courteous behaviour.

    So, maybe both technical ability and cognitive ability should be placed above the other domains in importance, but they are not adequate in the absense of professional behaviour and collaboration. Otherwise, let’s just train technicians.

  3. Ian Hargreaves says:

    I apply what I call the ‘professor of medicine’ test. When a well-meaning surgical academic tells me what he thinks is important, I see to what extent the professor of medicine would fulfil those requirements. The College’s requirements are such that the professor of medicine would score 8/9. To take the matter further, Professor Stephen Hawking would also score at least 7/9, with a possibility of 8 if he has developed medical expertise relating to his own condition.

    Clearly the one crucial factor which differentiates a surgeon from a physician or a physicist, is our technical expertise. These days, many specialties are using devices such as robots to improve the quality of their surgery. It is certain that in the future, autonomous robots will be superior to humans in technical skills. This is despite the fact that such a machine would only score 1/9, or possibly 2 or if it was considered to be a team player. I have no desire to have my blood test performed by a collaborative leader, when the machine can do it quicker, better and cheaper. Nor do I have a desire to fly in a handmade aircraft, made by an expert team of communicative artisans, when a taciturn machine can weld it airtight with better safety.

    Giving equal weighting to attributes which are nice to have, but not essential to the crucial role of performing an operation, is clearly ludicrous. I have no qualms about having my surgery performed by a surly autistic technician with the dexterity of the famously surly and non-collaborative Michelangelo. Or by the professor of cardiology with his clever spring-wire stent, which has replaced many communicative, teaching, health-advocating cardiac surgeons.

  4. Tim Bailey says:

    When a craft group concentrates on its own agendas, in ignorance of feedback from those they provide service to, the inevitable result is self-congratulation. Despite many exceptions to this, over many decades of medical practise I have personally experienced failure by surgeons in general, to accept constructive criticism of their performance. The health care professionals who refer them cases, along with those who have to care for patients who have received surgical care, have a very significant insight into surgical performance and outcomes. This appears to be routinely ignored by surgeons as a whole – with some notable exceptions of course.

    It is of great interest to me that one of the prime surgical skills that was NOT in the RACS survey was “active involvement in peer review”. Of course, if you don’t look, you won’t find.

    According to my reading of recent articles, one of those areas in which feedback is ignored, appears to be the acceptance by several prominent members of the College of Surgeons, of the concept that female trainees should just ‘get over’ the common expectation that progression in training may be linked to granting of sexual favors to their supervisors. This is the most controversial area of ignorance, but definitely not the only one in my experience.

    In summary, are we, as a profession (surgeons and non-surgeons alike), by our silence on this issue, going to lie down and allow 19th century attitudes to continue to dominate what should be one of our most inspiring fields of service? I truly hope not!

  5. Annette Holian says:

    Interesting aspects of gender differences to surgeons core competencies. I wonder if the individual women spread their scores or most scored everything highly. In my experience female surgeons in general do value the non technical skills more than our male counterparts- at least in some specialties. This study supports my belief. I remain fascinated at the mind’s control over the healing process, particularly after injury or surgery. It is not just about the surgical procedure, though that has to be technically competent. Our direct personal contact with patients, our compassion and provision of a healing environment are critical to improving outocmes through patient centred care. Too often the focus is on the surgeon, their schedule, and the hospital systems and not on the patients needs. Perhaps it’s the nuturing culture instilled in females from a young age, that our role is to help others, that female surgeons and trainees recognise the value of these 9 core competencies. I certainly advocate for wider consideration of the value surgeons have to play globally given the burden of surgical disease.

  6. Randal Williams says:

    The top surgical competencies must always be technical competence, judgement ( knowing when to operate) and communication because that is what  patients primarily expect from us  The others are important, but must never take precedence over the key competencies.

  7. Rowan Story says:

    Whilst I understand Ex-doctor’s comments I think that the study makes many valid points. These seem most relevant in the gender differences. Especially given the recent discussions regarding female surgeons. An example of a surgeon who is in active practice, but also fully engaged in the wider world, is surgeon and author Dr Atul Gawande (“Complications”). He sets a shining example of intelligence and advocacy for all doctors. His involvement in the Global Surgery Project is a case in point.

  8. grahamrow@amamember says:

    This study is very reassuring.  I am relieved that surgeons continue to rate all aspects of technical expertise (slightly) ahead of  expertise in communicaton, teamwork, ethics, advocacy and leaderhip.  I would be very worried indeed if the priorities were reversed.  From my experience over four decades practice, surgeons, collectively and individually are quite capable of formidable teamwork, leadership, and when the need arises. My gratuitous advice to he Royal Australasian College of Sugeons; “It ain’t broke, so don’t fix it”.


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