The surgical competence conundrum

Much attention has been focused on the changing times we are experiencing in the world of surgical practice and training. A growing chorus of voices, including some recorded in this section of Surgical Endoscopy, is telling us the days of "see one, do one, teach one" surgical apprenticeships are past [l]. We hear that surgeons must be held to more consistent and tangible measures of performance than have been expected of us to date [17). We are increasingly and correctly told of the need to provide objective measures of surgical competence to an ever more educated patient population, to more demanding third party payers, and to hospital credentialing boards. That such measures do not yet exist in any way that is meaningful or universally agreed upon remains a source of consternation for all involved. It has been suggested, again correctly, that new technology (e.g., mechanical and virtual simulators, robotics, telesurgery) must be harnessed to enable surgeons to acquire new skills and certify mastery of those skills. Yet at present, the medical community can neither define competence in new surgical procedures and technology nor agree on the best means of acquiring it. A survey of surgical education over the past century indicates that neither reassessment of surgical training nor the search for an objective measure of surgical performance is a new phenomenon, as Professor Peracchia made clear in his address to the European Surgical Association [14]. However, the most recent incarnation of minimally invasive surgery (MIS) in the late 1980s has again brought the issues of surgical training, competence, and credentialing to the fore [5, 6, 13]. Challenges raised by MIS have been enumerated by various authors [l, 2, 4, 7-10, 15-19, 21]; they include: