How Surgery Lost its Culture of Learning

Or, what happens when we neglect our history

A few weeks ago, I got the chance to attend a teaching and leadership conference held by the American College of Surgeons in Chicago. I spent three days learning how to be a good learner, and a good teacher, and getting to chat with other like-minded individuals passionate about surgical education.

It was wonderful — but somewhere, in the back of my mind, I couldn’t rid myself of the feeling that the profession of surgery used to be much, much more intimately tied with education. And somewhere along the way, it lost its culture of learning.

This essay will be a bit different from my usual narrative essays — it zooms out to look at institutions, but I hope you will stick with me! We are all, as humans, learners at heart, and I hope there is something in here that will inspire you to bring a passion for education to your own personal and professional lives.

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At the beginning of my third year of medical school, before I started my formal clinical rotations, I, and the other MS3s, were assigned to spend a day shadowing an anesthesiologist. It was important, they said, to understand what goes on behind the curtain before you scrub into an OR on the surgical side.

You will not be surprised to learn that within minutes, I was bored. I wanted to learn, but all I could see was an experienced older anesthesiologist administering a random (or so it seemed to me) cocktail of medications, pumping different gases, hooking and unhooking various IVs.

Then the surgeon entered the room, and very quickly I neglected the anesthesia side of the affair in order to peek over the curtain into the surgical field. The surgeon, who had started to operate on the colon, noticed me watching, and began to engage me in his work and tell me everything there was to know about colon cancer.

Here is the colon — you see? Colorectal cancer: what do you know about it? Do you know about lymph nodes? And here, do you see these taenia?

I was mesmerized. I couldn’t look away. And I was spellbound by this surgeon in front of me, this teacher who had turned his attention to a random student (not even his student) to help me learn something in the two hours I spent there.

The Anatomy Lesson of Dr. Nicolaes Tulp, 1632. Rembrandt | Source

The beginnings of modern surgical training here in the United States are typically attributed to William Halsted (1852-1922), who, after studying in Germany and learning about their training programs, came back and instituted a similar ‘residency’ in the United States. And, along with William Osler, Halsted introduced a more systematic and hands-on approach to medical training, including clinical clerkships and beside rounds. This, combined with the 1910 Flexner report, served to standardize medical education and postgraduate training.

The history of surgical training goes back further than this in Europe — surgery was once a trade learned by barbers, it was heavily focused on an apprenticeship model, and it was largely confined to theoretical learning in the lecture hall. And, going even further back, surgery has its roots in the East: in India, China, and the Middle East, among other places — but that is a topic for another time.

Despite this long history of a field steeped in tradition, many of the systems that were created in the 18th and 19th centuries, those foundational practices for surgical training, have since been lost.

In 2006, the New York Times published an article detailing the decline of grand rounds: Socratic Dialogue Gives Way to PowerPoint by Lawrence K. Altman, MD.

Altman describes how grand rounds were once centered on the patient, often one with a rare or serious illness, and engaged learners in the Socratic method¹ in order to reach a solution together.

Now, grand rounds are centered on PowerPoint presentations. They are given lecture-style, with minimal to no audience engagement. Worst of all, in the post-Covid era, they are often now given virtually, and the speaker is forced to address a sea of black screens.

“But in recent years, grand rounds have become didactic lectures focusing on technical aspects of the newest biomedical research. Patients have disappeared. If a case history is presented, it is usually as a brief synopsis and the discussant rarely makes even a passing reference to it.”

There are many other examples I can share.

A national analysis of surgical resident operative experience found that in recent years, there has been a decrease in advanced operative experiences — graduates are now entering practice (or fellowship) with a narrower range of experience.

The long-held paradigm of ‘See one, do one, teach one’ (which I still live by) has been replaced by competency-based training and entrustable professional activities.

In 1937, surgeon Eugene Pool gave an address called ‘The Education of a Surgeon: Past and Present.’ He said:

“The weakest and least developed feature in medical education is postgraduate surgery…In the early days of American medicine, operative clinics were mainly utilized for surgical instruction. They were widely attended and were often spectacular affairs. In visiting operative clinics I have often been impressed by the fact that they are relatively useless for purposes of instruction, and that from a humanitarian point of view, as Cushing has pointed out, they are ill-advised.” (emphasis my own)

Clearly, the education of surgeons has always been a concern; there is always something valuable from the past that gets lost, that few strive to achieve.

And today, in the days of electronic medical records, increasing liability, on overemphasis (and often, misdirection) of wellness and boundaries, and incredibly low levels of trust in the medical profession, everyone’s priorities appear to be elsewhere.

But there is substantial research to show that the quality of care is higher at teaching hospitals. It is not just us, the trainees, who benefit from a strong culture of education; it is also our teachers, who gain a larger sense of purpose from being teachers and mentors; it is hospital systems, who contribute to the next generation of physicians; it is patients, who receive better overall care; and it is communities and society at large that will grow stronger.

A recent study of third-year medical students looked into the overall experience and challenges faced during their surgery clerkship. Faculty and residents were surveyed to understand their perspectives of student experiences — they believed that clerkship experiences were shaped by students’ abilities to adapt to the operating room, students’ understanding of their role on the clinical team, and time constraints.

These are, to me, insane conclusions.

They are entirely focused on the students — if a resident or faculty physician believes that it is a student’s abilities and understanding that dictates their clerkship experience, then do you see how easy it is to tip into dismissal and blame?

And here, I believe, is the matter at the core of our failures in education: a lack of ownership and responsibility.

Ownership.

It is a word that students and residents alike will be familiar with — as early as the first year of medical school, we are told that no matter how early we are in our training, we must take ownership of our patients. It is our responsibility what happens to them. It is our duty to care for them.

But just as important is a sense of ownership with our learners, our peers, and our mentors.

We owe each other a willingness to participate. A hunger to learn. A responsibility to teach.

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In Case You Missed It: From the Archive

1. A cornerstone of medical education. Perhaps I’ll get into this more in a future essay.