An historical context for medical training and selection practices identifies some historical influences on surgical training and selection.
Historical influences on surgical training and selection
Initially, European approaches to surgical practice and training were ad hoc and disorganised. Until the 1800s, changes in medical education occurred “slowly and almost imperceptibly” (Warren, 1951, p. 304). However, with the development of empirical methods, medical knowledge, and the ways in which it was imparted, advanced.
Prior to the Reformation in the 1500s, barbers performed bleeding and some surgical procedures as counterparts to clerics’ and apothecaries’ care of the sick. As barbers’ healing and surgical roles expanded they established the Barber-Surgeons’ Company in 1540, the Surgeons’ Company in 1745 and, ultimately, the Royal College of Surgeons in 1800 (Warren, 1951).
From the 1500s, to qualify to practise medicine, a proficiency in Greek and Latin, was “almost sufficient in itself” (Warren, 1951, p. 309), as classical scholars attained medical knowledge by studying Greek (Warren). By the mid-1600s medical training, through lectures, could be undertaken at some universities, although they were often lax in assessment.
According to Wittie (1651) as quoted by Warren: “in many Universities, although Physick be diligently taught in their publique Lectures, yet in conferring these degrees they are too carelesse, denying them to few or none” (Warren, p. 304).
During the 1700s multiple avenues—apprenticeship, university and hospital-based training, undertaken independently or together—could lead to medical practice. Warren, (1951) tells us that many an aspiring doctor “became an apprentice to his employer and a formal legal document was drawn up” (p. 305). On completing a five- to seven-year apprenticeship, the student received a certificate stating that “he had completed his training satisfactorily” (p. 305). Access to an apprenticeship was at least partly based on a capacity to pay. Abraham (1933), in Warren,describes Dr. John Fothergill’s (1712–1780) terms of indenture:
It was decreed that he ‘his master well and faithfully shall serve; his secrets shall keep; taverns he shall not haunt; at dice, cards, tables, bowls, or any other
unlawful game he shall not play.’ In return his master undertook to teach him ‘the art, trade, mystery or occupation of an apothecary,’ and provide him with
‘sufficient and enough of meat, drink, washing and lodging.’ Fothergill's father had to pay £50 for these considerations.
In the master’s absence the apprentice visited the patients and at other times helped his master by writing out the prescriptions and dispensing them. Meanwhile he was expected to read as many books as possible and generally acquire a thorough knowledge of medicine (p. 305).
According to Wall (1937), as cited in Warren, (1951), during the late 1700s apprentice surgeons also faced a plethora of examinations:
The Surgeons’ Company [precursor of the Royal College of Surgeons] help [sic] many different examinations. The surgeon’s apprentice had to pass a preliminary examination in Latin…before they could be bound to seven years’ servitude; on completion of which they were examined in surgery, the internal speculation of the natural causes and remedies of all manner of infirmities or diseases, etc. (p. 309).
At this time, British and European universities conferred medical degrees ostensibly via thesis, although in practice, verification continued to be slipshod. Warren (1951) tells us that while it was possible for a degree to be “bought for a few shillings” (p. 306), it was also the case that Fellows of the Royal College of Physicians were able “by influence to prevent persons of insufficient attainments from admission to degrees” (p. 306). Lectures and texts—the main forms of medical training—were mostly in Latin.
Although clinical teaching was part of neither Oxford nor Cambridge University medical training, surgery was taught in some hospitals through observation, practice and lectures, all of which were paid for by the apprentice students. Students completing surgical training were issued “a certificate signed by each surgeon … stating that they had worked diligently” (Warren, 1951, p. 308). Joseph Warner’s 1792 account of surgical teaching at Guy’s Hospital in London, as cited in Warren (1951), highlights the following:
‘Each surgeon was permitted to receive four pupils and four dressers at a time, inclusive of apprentices.’ The apprentices were the most superior, then the dressers and finally the pupils. The pupils originally had to bring certificates of their apprenticeship, ‘but now they only bring their money. … The pupils’ business is only to look on, and to make such an enquiry as he shall choose of the surgeon who is then attending. … it is the business of the surgery man to acquaint the pupils with the intention [to open a body for examination]. …It is the
business of the surgery man to make them acquainted with every accident immediately on its entry.’ … For these privileges the pupil paid 24 guineas per
annum or 18 for six months. This money was shared amongst the surgeons and apothecaries to the hospital. The dressers, who paid £50 per annum direct to one surgeon, became the responsibility of that surgeon and took a more active part than ‘looking on,’ as also did the apprentices who paid from £250 to £1,000 to their master….
At the same time as this clinical teaching was carried on lectures were given. … ‘The fee for [anatomy] lectures and for the dissecting room is twelve guineas. There are lectures read every morning at half-past seven on Midwifery. …At ten o'clock Mr. Babington the apothecary, gives a lecture in Chymistry. Those mornings that pass without the lecture in Chymistry, Dr. Saunders supplys with one on the Practice of Physic. The anatomical lectures are every day from one o'clock until three o'clock.’ The fee for each course of lectures except the anatomical was 10 guineas (pp. 307–308).
During the 19th century medical education became more stable and uniform, and “the classical works assumed their proper importance as companions of medicine, rather than the masters” (Warren, 1951, p. 310). Hospital outpatient teaching was introduced early in the 19th century.
In northern America at this time there was no formal training—all surgeons were either self–trained or they apprenticed themselves to a ‘master’ (Cameron, 1997). This changed in the late 19th century when Sir William Halsted championed a German model of university-
sponsored, hospital-based residency training which emphasised learning with graded
responsibility (Cameron, 1997). Training comprised “an initial a stage of observation, followed by increased participation in surgical procedures under close supervision” (Wanzel, Ward & Reznick, 2002, p. 604) and focussed attention on the student (or resident) rather than on a particular professor. (Wanzel et al., 2002) report on the pervasiveness of this system, that “was adopted widely at that time and remains the cornerstone of surgical training programs today” (p. 597).
Critics of the Halstedian model of residency training have commented on its ‘pyramidal’ nature, for although several residents commenced training each year, “half were only permitted to train for 1 year, and few completed a full course of training” (Bell, Banker, Rhodes, Biester & Lewis, 2007, p. 811). In addition, the pre-eminence of the Halstedian model has been challenged by Rutkow (2013) who proposes that simultaneously, in New York, “a curious breed of medical schools [arose with] surgical-oriented curricula” (p. 1130) and that these postgraduate medical schools strongly influenced surgical training by offering short, practical courses for medical graduates who wanted to specialise in particular branches of medicine. Both the Halstedian and postgraduate models influenced surgical training in America in the early 20th century, concurrent with similar changes elsewhere in the world.
Geffen (2014) suggests that by the 1950s, medical education in the UK had evolved from “a chaotic mix of institutions and practices” (p. S19) to a two–phased system combining academic and clinical components. Students were initially trained in university-based medical schools and subsequently in academic departments in teaching hospitals. Australian medical training also followed this model with medical students being selected on the basis of their secondary school performance (Geffen, 2014). It was generally assumed that high marks were an indication of likely success in the medical professions.
Although at Australia’s Federation—in 1901—there was little or no Australian postgraduate medical study or specialisation, by the 1920s, as Storey recounts, “there was general agreement that both training and accreditation were haphazard and required both clarity and uniformity” (Storey, 2014, p. S26), with calls for “extended study, additional hospital experience and the selective influence of a stiff test” (Storey, 2014, p. S26)
RACS was established in 1927 (Beasley, 2002; Geffen, 2014) “to promote the art and science of surgery” (Syme, 1928, p. 488) admitted candidates to Fellowship, by examination. By the mid 1940s RACS “required a candidate to possess a Primary examination, to undergo a formal period of training and then to pass a Final examination” (Beasley, 2002, p. 85).
prepared to submit to formal examination [to gain RACS Fellowship]” (Beasley, 2002, p. 88). The examination interview was perceived by some as discriminatory; Miller (n.d.), as quoted by Beasley (2002) criticised the examination interview as:
a rather unpleasant and unsatisfactory procedure, in which the candidate confronted the whole Court [of Examiners] across a table and could be
bombarded with questions which were not always appropriate, and [which] were at times unsympathetic (p. 88).
The level of interest and consequent changes to surgical training and assessment were such that between 1926 and 1958 “there had been fourteen ways of becoming a FRACS” (Beasley, 2002, p. 89). In the late 1970s “basic surgical training programmes” were again restructured and a “register of basic trainees” was discussed, however in the early 1980s it was felt that “to place the name of a would-be basic trainee on a register … would confer on that person a status which might be misinterpreted as an obligation on the part of the College … [for] concession or recognition” (p. 139).
In 1969 “there was broad [College Council] agreement on the need for planned programmes in specialist surgical training under the supervision of an appropriate authority” (Beasley, 2002, p. 149). This manifested in the 1970s as a two–phase training program culminating in an exit Fellowship examination. This two–phase system of basic surgical training (BST) and ‘advanced’ specialty training (AST) necessitated two selection processes, as success in BST did not guarantee entry to AST. Surgical specialties devised their own selection methods, which reflected specialty priorities and varied in rigour:
In New Zealand prospective orthopaedic trainees were ‘vetted’ at a weekend retreat.... This worked well. Trainees were judged on something more than a brief interview, and in turn came to know some of the older surgeons.... I can recall commending the idea to a general surgical colleague of mine who was involved in his own selection process. ‘I see,’ he commented, ‘you fellows judge
your trainees on how they hold their glass in the evenings, as well as on their reports’ (Beasley, p. 152).
Geffen (2014) reports that in the late 1990s, revisions to curriculum content and expanded admission procedures, “elicited considerable controversy … particularly among surgeons” (p. S20) who considered that such revisions eroded admission standards and neglected scientific knowledge. Presumably, these surgeons felt that success in training was predicated on trainees’ ‘scientific knowledge’ at selection. However, these changes were at least in part a response to new influences such as the Canadian CanMEDS Physician Competency Framework, which described the knowledge, skills and abilities of specialists in seven domains—as medical experts, communicators, collaborators, managers, health advocates, scholars and professionals (“Royal College of Physicians and Surgeons of Canada: CanMEDS Framework”, 2016). Wanzel et al. (2002) summarise some of the changes, identifying that “medicine as a profession has become more systematized in the recent past” (p. 649). Iobst, Sherbino, ten Cate,
Richardson, Dath, and Swing, (2010) concur: “with the introduction of Tomorrow’s Doctors
[UK Medical Council standards for medical education] in 1993, medical education began the transition from a time- and process-based system to a competency-based training framework” (p. 651). The competency-based training model has, to varying degrees, become adopted in specialty medical education in many countries through the early part of the 21st century with ensuing changes to selection methods.
It is implicit—when the onus was on an aspiring surgeon to find a master and to pay to become their apprentice—that deep pockets and an existing relationship with the master would stand an aspirant in good stead when the master was choosing whom to accept. With the systematisation of medical training, and selection being controlled by organisations placing increasing emphasis on objective methods, selection instruments such as letters of
recommendation and referee reports—proxies for personal ‘introductions’—may be seen as remnants of arbitrary arrangements when ‘who you knew’ could sway selectors’ judgement and secure your appointment. In a similar vein, applicants seeking opportunities to ‘introduce’
themselves by presenting themselves in their best light, showing what they can do, and interacting with selectors (Burgess, Roberts, Clark & Mossman, 2014) nowadays rely on instruments like the CV and the interview to convey this personal information where once they would have made representations to a master or their associates.
Conceptual frameworks
To contextualise selection to surgical training in Au and NZ, to provide foci for
understanding this study’s results and to inform discussions regarding practical applications of the findings, I have identified three conceptual frameworks. Literature regarding surgical selection tends to concentrate on functional aspects and implications for practice in specific environments, resulting in a lack of theoretical models for selection to surgical training. Conceptual frameworks describe the main phenomena studied—the key factors, constructs or variables—and the presumed relationships among them (Miles & Huberman, 1994). For the purposes of this review, three identified frameworks have been gleaned from the fields of human resources and education. The three conceptual frameworks presented are: person– environment fit theory; procedural justice theory, and Blooms taxonomy.
Person–environment fit theory
Medical training does not occur in a vacuum; it is influenced by prevailing social norms—as these evolve, so does the content and presentation of training. Consequent on changes to training, are changes to selection principles and processes—the nature of training influences selection methods. Some selection processes will be more attuned to the
idiosyncrasies of ensuing training programs than others. Aligning selection with training—to rank highest those candidates most suited to a specific training program—is a challenge. Mismatches may result in the “appointment of trainees who struggle with a particular curriculum or training culture” (Bell, Fann, Morrison & Lisk, 2012, p. 23).. Kelz, Mullen, Kaiser, Pray, Shai and Drebin (2010), from their study of resident attrition, suggest that “it is
plausible that to reduce attrition, programs need to work to ‘match’ trainees that have characteristics that are compatible with their type of program” (p. 537).
In organisational behaviour research, person–environment fit describes the “congruence, match, or similarity between the person and environment” (Edwards, 2008, p. 168). This theory underscores the notion that the better the fit between the attributes of an individual and the characteristics of a vocation—between the needs and abilities of the individual and
organisational demands and rewards—the greater the job satisfaction and the more likely that the individual will meet the required performance standards and be retained. When this is extrapolated to the realm of specialty training, it suggests that the greater the concordance between a trainee and a training program, the more likely that the trainee will complete training.
Go, Klaassen and Chamberlain (2012) reflect on how this may influence selection, suggesting that candidates’ “non-academic qualities and ‘fit’ within a programme are playing increasingly significant roles in recruitment” (p. 498). This is a two–way process in which organisations identify and assess candidate attributes and candidates are able to identify features of training programs. Kelz et al. (2010) recommend that recruitment information clearly identifies both positive and negative aspects of a program’s educational style and culture— addressing “the realities of the surgical training environment” (p. 537). In their study of
German, UK and Swiss surgical training, von Websky, Oberkofler, Rufibach, Raptis, Lehmann, Hahnloser and Clavien (2012) similarly identify that the management of trainee expectations contributes to trainee satisfaction and retention—they recommend clarifying expectations through documented and structured training curricula to increase trainee satisfaction. The selection process itself contributes to expectation management and exchange of information. Burgess et al. (2014), in their study of selection into general practice training, argue that “properly conducted selection systems are in the best interest of both the candidate and the organization” (p. 3) and that components of the selection process ought to provide “insight and understanding of what is required to work in general practice” (p. 4). A novel example is cited by Seabott, Smith, Alseidi and Thirlby (2012), who describe a “candidate-centered” (p. 803)
approach to interviewing, in which applicants each individually spend a day observing and interacting with trainers and residents as they undertake their normal clinical and surgical activities. This “working interview” (p. 805) explicitly encourages open disclosure of information about the program and offers both ‘interviewers’ and candidates opportunities to observe and interact in authentic clinical environments.
Singletary (2010) questions whether a lack of awareness of “the challenges of a surgical residency” (p. 365) contributes to trainee attrition; he puts the onus on candidates to inform themselves and accurately judge their fitness for surgical training before applying, “It is hard to believe that students interested in a surgical residency are not aware of the challenges that await them. …It is certainly possible that some students opting for a surgical residency may
overestimate their ability to adapt to the demanding schedule” (p. 365). A counter view is presented by Buhr, Gröne and Ritz (2012), who highlight the importance of two–way interactions between trainees and trainers, suggesting that “good training in surgery always depends on two people: a motivated trainer and a resident who wants to be trained. Personal commitment is always required on both sides” (p. 808). The quality of people’s interactions and extent of their commitment may reflect the affinity between the culture of the organisation and the individuals functioning within it.
The expectations that employers and employees have of each other have been described as a ‘psychological contract’, or set of beliefs that are held to be important by each party. These expectations and assumptions, often unarticulated, can be crucial to the person–environment fit (Armstrong, 2006; Rousseau & Greller, 1994; Sims, 1994). Sims (1994) proposes that “a balanced psychological contract is necessary for a continuing, harmonious relationship between the employee and the organization. However, the violation of the psychological contract can signal to the participants that the parties no longer share (or never shared) a common set of values or goals” (p. 375). Armstrong (2006) recommends that it is incumbent on managers to “manage expectations [by] clarifying what they believe employees should achieve, the
competencies they should possess and the values they should uphold” (p. 227). This viewpoint has great resonance with surgical training.
The importance of a harmonious person–environment fit intensifies when pressures are brought to bear on organisations and individuals. Armstrong (2006) observes that “leaner organizations may make greater demands on employees and are less likely to tolerate people who no longer precisely fit their requirements” (p. 231). Constraints such as a shorter working week are placing pressures on surgical training—in effect making training ‘leaner’. If
Armstrong (2006) is correct, the precision of the fit between trainees and training programs becomes increasingly important.
Awareness of the person–environment fit framework as it applies to selection to surgical