versão On-line ISSN 2078-5151
S. Afr. j. surg. vol.52 no.3 Cape Town Ago. 2014
Martin D Smith
Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa email@example.com
The article by De Beer et al.ll] in this issue of SAJS is timeous within the context of changing paradigms in the training of surgeons globally. In South Africa (SA), the training of surgeons is the responsibility of the university departments of surgery. This function takes place on a training platform that is incorporated in the service platform, most commonly in the public sector. De Beer et al. examine a combination of activities on both platforms by analysing the views of SA surgeons on aspects of training, research and the practice of surgery in this country. The number of responders is small but statistically adequate. The study concentrates on perceptions that are of concern, but provides some insights into the way in which preparation for surgical practice is viewed.
There are eight institutions in SA training surgeons, often with different approaches to training. While examinations and registration are centralised, training remains the responsibility of the individual universities. This responsibility includes the training and teaching curriculum. The use of subspecialty units for training general surgery in the different departments is not uniform, the use of extended training platforms, especially in regional hospitals, is not uniform, the role of the private sector is not uniform, and lastly the availability of postgraduate fellowship training opportunities is not uniform. In addition, the availability of specialised equipment is not uniform across all provinces or between individual institutions in the different provinces. It is therefore difficult to draw conclusions that are relevant to all the institutions, and it would have been helpful if the data had been presented reflecting different institutions (without necessarily identifying them).
The premise is that the public sector can no longer provide the standard of training received by surgeons before 1990. The authors quote publications attributing this situation to a funding model that supports primary- and secondary-level care over tertiary care. However, the authors do not comment on the changes that have occurred in the Colleges of Medicine of South Africa (CMSA) and the Health Professions Council of South Africa (HPCSA), requiring a different approach to training. This includes the introduction of formal fellowships in vascular, gastrointestinal, trauma and paediatric surgery, and informal fellowships in breast and endocrine surgery. The HPCSA now requires demonstrated competency in research methodology and a unified exit examination through the CMSA. The CMSA has introduced a portfolio that requires a logbook submission. These changes have had an impact on the range of competencies required by the graduating general surgeon, but will not necessarily have impacted on the quality of that surgeon. As such, this study is important in building a body of evidence evaluating the many changes that have occurred during the study period.
The authors refer to salaries and working conditions as a major influence in retaining teaching skills. No mention is made of the impact of remunerative work outside of the public sector (RWOPS) on available skills and issues of supervision. RWOPS was introduced in the early 1990s. While the dysfunction in the public sector service platform has contributed to the challenges faced in training the next generation of surgeons, the uncontrolled abuse of RWOPS has also contributed to the issues identified in this study.
It is correct that some of the equipment for the training of advanced procedures is not freely available in the public sector. Some institutions recognised this problem many years ago and have used the private sector to address it, particularly in post-fellowship training. This is an important consideration in the transformation of the teaching platform to dismantle traditional silos in the training of surgeons and harness all available expertise in the training arena. Suggesting it without separating the responses into different institutions could lead to the wrong conclusions being drawn from the data.
The concept of practice management in this study reflects an emphasis on the private sector. What is probably correct is that there is no formal training in clinical governance to equip graduating surgeons for a career that requires skills outside the traditional surgeon's domain. Leadership remains an essential component of the surgeon's attributes, and these skills need to be improved through exposure to systems of governance.
There have been significant changes in the research environment, driven by a globally accepted paradigm that ongoing self-directed learning coupled with continued education (including reaccreditation in some countries) is essential for good clinical practice. The research is aimed at improving understanding of research methodology, thus improving ability to navigate the high volume of research outputs accessible to surgeons today. It is not primarily aimed at making researchers out of clinicians.
It is important that studies such as this examine the outcomes of our training programmes and that leaders in the field are provided with data against which to evaluate training, including curricular reform. This study reaches the conclusion that knowledge acquisition is probably adequate and that there are gaps in skills acquisition. This may be correct, but the study does not extend the interrogation of such perceptions. It reaches conclusions in this regard that are probably a reflection of the authors' own institution and may not reflect the reality of other training platforms across the country. Separation of the responders into institutions is required to make this study of greater value; however, the numbers from each institution may be too small to draw any statistically significant conclusions. Further research is required in SA to explore some of the questions that this study raises. The inter-relationship between the components of surgical training in SA has become complex, and reaching conclusions regarding the outcomes should therefore be tempered by an understanding of the shifting healthcare landscape, in SA and globally.
1. De Beer MM, Karusseit VOL, Pienaar BH. The perspectives of South African general surgeons regarding their postgraduate training. S Afr J Surg 2014;52(3):67-71. [http://dx.doi.org/10.7196/SAJS.1993] [ Links ]