 Welcome to this edition of Literature in Surgical Education. I'm John Topper, a surgeon in the Division of General Surgery at Khorotyskir Hospital in Cape Town, affiliated with the University of Cape Town. Now, let's have a look at the journal article for this video. We're looking at the comparison of Canadian and Swiss surgical training curricula moving on towards a competency-based surgical education. Now, that's from the Journal of Surgical Education, volume 74, number one. That's the January and February 2017 edition by Henry Hoffman and colleagues. And you see there, they were from the Department of General and Vistal Surgery at the University Hospital in Basel, Switzerland, and the University of Surgery, Queen's University, Kingston, Ontario, and Canada. Now, what is at stake here? Really, it's about the reduction of trainee working hours and how that impacts safety and that's patient safety and the training of the trainees. Now, in Switzerland, there is a 50-hour work week. And in Canada, 80-hour work week cap. So registrars, trainees, residents, really not allowed to work any longer than this, based on the fact that working longer than this might lead to fatigue and that obviously impacts on patient safety. Now, there are still some outstanding questions. Is there a reduction in quantity and quality of training and does this really improve patient safety? Reducing these hours does really impact on patient safety. Now, the reports regarding the impact on training and safety are really mixed and the authors do refer to two papers there that show no impact, quite good papers there, but also several papers that show that there is an impact on both patient training and the effectiveness of training. Now, irrespective of these mixed reports, the authors are really concerned about the diminution in the degree of independence given to trainees and they posit the solution. They think that there should be a transformation of surgical curricula from a pure unstructured time-based training to highly structured competency-based programs and I think many programs throughout the world are moving in that direction. So this mention of the development of several initiatives to implement a competency framework, both for evidence-based training models and very, very important, investment of trainees' competency with validated tools in various domains, really good validated tools, not just subjective thoughts on what trainee skills might involve. And they do reference quite a few articles there that you can have a look at. Now, the authors give overview of the current training logistics in Switzerland and Canada and the changes that are being made at the moment and are going to be made over the next couple of years and that makes for some very good and interesting reading and especially for us as we plan what to change for the future as well. Now, the objective of the study was really to compare two surgical training programs in the Academic Teaching Hospitals in Switzerland and Canada, so one unit in each of these two countries. Now, with the potential to identify opportunities for program enhancement, which is why we're reading this paper, now really through a comparison of the essential training elements in the two programs. So this was a cohort study, so an online survey as most of these are these days, completed by what they sent to faculty and trainees of the two institutions between September and October 2014. And the questionnaire consisted of 40 questions. It was originally developed through some modification, iteration through reviews by the authors, pilot tested on a subset of five individuals, reviewed again and eventually sent to the faculty and trainees. There were three parts to the questionnaire, demographics, then nature of the training program just to see what the difference between the two are and then really, importantly, the views on training in this era of duty-hour restrictions for the consultants or the attendings and the trainees in both of these institutions. Now, the specific training elements that they looked at is the following. And I think most training programs will have these tutorial lectures, then virtual reality training simulation, surgical skills training, teaching ward rounds, objective assessment of technical and non-technical skills. I think that's a new one and that's where the effort should go. Then the use of established benchmarks for performance, very, very important. And the use of postoperative debriefing. Now, I think some of these are quite unfamiliar to many institutions. So in the questionnaire, a definition of either structured or ad hoc was given based on whether most of the above was provided on a regular basis. So if most of the above was available in the training programs, that was seen as a definition for structured and if not, it was a definition for an ad hoc training system. So let's look at some of the results and I'll just discuss some of those as well. The response rate, 37% low, but what you can expect from these online surveys, still 105 respondents out of 284. So I think we can learn something from the results of the study. Now, the training programs structured or rather unstructured. Remember that's based on the definitions that I gave and you see quite a difference between the group here in Switzerland and the group in Canada. We saw see that only 25% of the consultants thought that the training program was structured or rather structured and only 3% of the trainees versus 86% and 75% in Canada. On the question of informal ad hoc tutorial assistance in the OR, you see that's fairly even in Switzerland. The consultants, 75% of the consultants thought there was some informal ad hoc tutorial assistance in the operating room. 50% any of the Basel trainees thought so. And you see that to the current theme that the trainees would agree less with these statements, 60% and 52%. So at least more than 50% do feel that there is some ad hoc tutorial assistance in the OR. On the question of informal teaching ward rounds, I think that's fairly high. Almost 80%, almost 60% there for the group in Switzerland and a bit higher of course for the groups in Canada. Although once again when we look at the trainees, 59%, 62% of the trainees in both these institutions thought that there was some informal teaching ward rounds. Median weekly duty hours, just to put that on the table. So for consultants in Switzerland 60%, 60% for the trainees, 60 hours I should say and 60 hours for the consultants in Queens and 80% mean weekly duty hours for the trainees in Canada. Median weekly formal structured surgical training hours. And there's a huge difference. There's really very little of it occurring. One and a quarter median weekly hours there and one according to the trainees much more structured. There's seven and a half, seven hours according to the consultants and trainees. And I think locally we would fall some way between these. The percentage of dedicated structured teaching time. Lots more, quite significant difference here between the Canadian and the Swiss groups. Is virtual reality as part of training important? I think throughout we see very high percentages here in virtual reality training in the era of reduced duty hours and not only the reduced duty hours. As we move towards a more fellowship based program where perhaps our normal trainees, postgraduate trainees don't get the operative experience because this has been driven by the fellows in sub-speciality training. Those do drive our numbers down as far as our registrars or trainees are concerned. And virtual reality would be one of the solutions to this problem, to get technical skills and we see quite a high, almost 80% and higher for all four of the groups. Anything that virtual reality simulation training is important. And now as far as the thoughts of the whole group is concerned towards training outside of the OR as a modality to improve patient safety and once again very high percentages that really I think everyone buys into the fact that training outside of the operating room can really improve patient safety. The same goes for this training outside of the OR to improve surgical skills. Everyone agrees with that and then training outside of the operating room to improve postoperative patient outcome. The numbers are a bit less but still the majority of people would feel that training outside of the OR can really improve patient outcomes as well. Now even though everyone feels that virtual reality simulation training is important the trainees in both institutions will ask whether they had experience with virtual reality training and less than 50% of the Swiss group and almost 90% of the Canadian group had some experience in this. Was there any training in surgical skills lab? Once again for only about half of the Swiss trainees versus almost 100% of the Canadian trainees had some surgical skills lab and it's something that we really are developing locally as well. Now trainees performing less surgery in this era of reduced hours 75% of consultants thought so in Switzerland but only half of the trainees thought really that they were performing less surgery. Very high percentage again of the consultants and a much lower percentage of the trainees. So really trainees feeling that they don't get less experience. Of course the consultants perhaps being they longer well I mean this article doesn't answer the question as to why these the consultants feel this way. Certainly this is not a quantitative article it didn't look at numbers but certainly the perception of the consultants that there really is a reduction in the performing for the trainees performing their surgery. As far as being reduced hours being acceptable 65% of the Basel consultants this reduced hours is an acceptable thing only half of the trainees in Switzerland the Queen's consultants in Canada only half of them feel that this is acceptable and less than half of the trainees in Queens feel that this is acceptable. So even though thoughts might lean the other way this being acceptable is only viewed by about half of the cohort here. So in conclusion very good interesting information here specifically for us or others looking into developing their own new curricula and to perhaps compare yourself against what is happening at these two institutions one in Canada and one in Switzerland and I really urge you to read the complete article it is available on the link that you see there I think it's worthwhile to keep in your file.