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May 13, 2020

Reflections of a Millennial Surgeon: The Changing Face of Medical Education

Author Affiliations
  • 1Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville
JAMA Surg. 2020;155(8):685-686. doi:10.1001/jamasurg.2020.0751

“Aren’t there any grown-ups here at all?”

“I don’t think so.”

The fair boy said this solemnly, but then the delight of a realized ambition overcame him.

-Sir William Golding, Lord of the Flies, 19541

Sir William Golding’s 1954 allegorical novel Lord of the Flies emphasizes the dangers of the autonomy of personal will at the expense of wisdom, and underscores the innate human longing for independence from determinate culpability.1 A group of children stranded on an island without oversight or governance is an unsettling premise, not only with respect to the safety of innocence, but also for the potential disastrous consequences of immature executors in impending life-or-death circumstances. Golding’s choice of vehicle to demonstrate this unhindered and undeserved independence through children is a powerful illustration of the growing pains of maturity, when naivety is exposed and the realities of life are recognized. This metaphor can be applied not only to the physical evolution of aging, but also to professional development in performance-based careers. The Dreyfus model of skill acquisition is a well-known scale of assessment of the transitional stages from novice to expert in a particular skill discipline and delineates patterns of behavior during these stages to gauge learner progression. This model has been applied to assessing progress in clinical and procedural skill development in medical education. However, a consideration that is not fully explored in this or other scales is the perceptions and emotional transitions of the learner during the process of stage shifting and how individual intrapersonal factors affect the rate of acceleration from novice to expert. It is not difficult to imagine that these factors are likely widely variable amidst the flux of cultural normality in different generational cohorts, especially with respect to interpersonal relationship standards between learners and teachers on opposing sides of the scale.

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    2 Comments for this article
    Surgery remains a craft
    Charles Dinerstein, MD MBA | American Council on Science and Health
    I greatly enjoyed your opinion piece, a topic that has occupied my thoughts since I too was a resident and fellow. I believe that surgery remains a craft, a bespoke practice, passed from practitioner to practitioner in the day-to-day workday. To my mind, surgical education has required some standardization, and rather than continue to submit to the subjective opinions of our trainers we have seized upon checklists of competencies and other quantitative measures. While that may be necessary, a emphasis on numeric values has two unintended consequences. First, numbers cannot capture the nuances of training requirements. What is the numeric value for persistent premature closure on a diagnosis? Second, the need for additional surgeons has increased the concept of scale, and numbers allow you to train more people, more quickly. But scale too robs us of the most valuable intrinsic portion of our training, the relationship with a mentor, to serve as model and guide.

    Surgery, despite all of the scientific advances, remains an applied art. The apprentice system produced craftmen and craft-women. In addition to the apprenticeship, there was a required period as a journeymen/women when you had greater autonomy and were made to work in a different city or environment. To become a fully autonomous master, you had to present your masterpiece to your intended peers. Perhaps there is room to bring this back in a new form.
    Moving From Reflection To Reflexivity - Listening Wisely As Medical Education Changes.
    Peter Shah, BSc MA FRCOphth FRCP Edin | University Hospitals Birmingham NHS Foundation Trust
    William Clifton provides us with outstanding reflections on his time in medicine, and in fact, illuminates perfectly the important transition from reflection to reflexivity. In this context one can view reflexivity as a conscious reflection on the role of self in the construction of meaning. Clifton critically evaluates what we learn, how we learn and why we learn, and incorporates reflection on both bias and heuristics.

    As clinicians on a long journey, we are continually acquiring knowledge, skills and a deep empathy for those we care for. We are constantly attending to a 'self-in-process' and Clifton asks bravely
    whether young specialists are fit for purpose in a world where 'medicine can be gritty and lonely'.

    The transition from trainee to specialist is a quantum leap, and as medicine and society change rapidly, we would do well to ask whether we could better nurture our young doctors. It may at first appear paradoxical that in order to strengthen young clinicians, we need to expose them to a harder and more intensive training - to anneal them. However, one only has to look at the pressures they will face on the first day as a specialist, to realise that the preparation for that must involve both mental and physical hardship during the years spent training.

    By listening more carefully to senior mentors within medicine and surgery, we will find the answers to the problems that young doctors face. We must be prepared to reconsider some of the modern teaching methods within a wider historical and inter-generational context, and using a reflexive approach, ask whether we are failing some of our bright young doctors, and could in fact do better.

    Clifton's erudite prose challenges us to re-evaluate, to be reflexive and to ensure that our younger colleagues are trained in a way that enables a smooth transition into the complex world of medicine. Only then will we achieve our primary goal - to care effectively and with empathy for the patients we serve.