You might not think so but surgery actually combines both science and art, requiring certain skills that need to be combined with a knowledge of anatomy and physiology, as well as quick but calculated decision-making.
The tools used in surgery are also important, with surgeons having to be intimately familiar with the devices they need to get certain procedures done. Therefore, all surgeons have to keep abreast with the latest tools and technologies that can help them provide a better outcome for their patients.
“Every day, we do procedures on the human body and that requires the use of equipment, which in the past, was limited to just a scalpel, scissors or sutures,” says Professor Dr April Camilla Roslani, president of the College of Surgeons, Academy of Medicine of Malaysia (CSAMM).
“As technology has progressed, we are now increasingly using more advanced medical devices in order to execute our operations. These devices are more complex and require specific training for the surgeon to perform effectively and safely. Added to that is also the complexity of each patient, who has different issues.
“What the public may not realise is that even though every doctor goes through medical school, followed by training for their speciality, developments (in medicine and surgery) are continuously going on.
“So what you learnt in medical school 20 years ago has now changed – even what we learnt in our surgical training programme five years ago has moved on, so it is important for surgeons to be properly (and continuously) trained.
“With skills, you need to practise to improve, but you first need to understand what you’re doing. If I gave everyone a scissors, most people can use it. But if you try to perform procedures without being properly trained in the device, chances are that complications will arise.
“So our focus is on safe practices to ensure that patients are not compromised,” she says.
Prof April, who is University Malaya’s Faculty of Medicine Department of Surgery head, reveals that CSAMM recognised that there would be this problem of inadequate training back in 2013, so it started work on a curriculum for upskilling surgeons.
She adds: “Training people is a skill. A good surgeon may not necessarily be a good trainer, so we had to spend time identifying suitable surgical consultants in the country, and also in the region, and then put together a series of training courses.”
This evolved into the Science of Tissue Management (SoTM) workshop, which is run in collaboration with Johnson & Johnson Malaysia.
The workshop exposes surgeons to the latest surgical technologies, providing them with hands-on experience using better-designed equipment that is less invasive, promotes enhanced recovery and reduces post-surgery pain.
It has been so successful that CSAMM recently signed a third memorandum of understanding (MOU) with Johnson & Johnson Malaysia to extend the workshop collaboration for another three years.
The workshops are primarily intended to train both medical officers in surgical departments and junior surgeons on how to understand interactions between medical devices and tissues. Some-times, senior surgeons join in too.
Learning the tools
Each workshop is divided into four modules. One module focuses on the use of the latest energy devices to cut or stop bleeding.
Prof April explains, “Methods back then were extremely primitive, but now devices can both cut and seal. In fact, they can even sense when the tissue is already sealed because of their technology. The device provides feedback and the surgeon knows when to stop.
“Imagine that you have a chunk of tissue, along with blood vessels, muscles, etc. The newer energy devices can sense a certain temperature and current will not run through the area if the temperature is too high or low. This is really a targeted way of delivering energy.
“The newer technologies will not make much difference if you’re just removing a mole, for example, but with complex operations like paediatric liver transplants, it makes a difference between life and death.”
Another device surgeons learn to use in the workshops is the surgical stapler. Much like the stationery staplers we are familiar with, surgical staplers join two pieces of tissue together.
This can be applied in many circumstances, such as stapling the bowels, lung or stomach during surgery. Current staplers can also help stop bleeding more quickly.
Prof April gives an example of cutting a tumour from the bowel. In the past, once the tumour was removed, the surgeon would join the two ends of the bowel by using sutures to sew it together.
“There’s some skill and judgement involved because you must know how tightly to join the ends together. The problem is that it tends to leak in between the stitches if the closure is too tight or too loose. In the hands of a good surgeon, the leak rate is lower, but it’s not zero,” she explains.
“However, this sewing process takes time as each stitch is subject to a different procedure, depending on the thickness of the tissue in that area. Patient safety can be compromised and life is at risk, so we had to find better way of doing this – a way that is more predictable and teachable.
“This is where the staplers came in, and now, almost all operations use stapling to join many parts. It saves time and lessens the problems of bleeds and leaks.”
The current generation of staplers are so sophisticated that they will not function if they are not used at the right tissue thickness. In such cases, the surgeon would then have to adjust the height of the stapler.
Prof April points out though that surgeons still need to have suturing skills for other simpler procedures that are not life-threatening.
Another module involves abdominal wall closure. She says, “Many operations are done in this area, yet the skill of properly closing the abdomen is perhaps not uniformly delivered, so we want to have a structured approach to enable the task to be carried out in a standardised manner.
“Traditionally, surgeons were trained on a one-to-one apprenticeship basis, but since the trainer-trainee ratio has changed, this is no longer possible. We have, at any one time, 200 trainees, and we don’t have 200 trainers, so we have to make sure that everyone is being taught the same way in all locations.
“Locally, it has been estimated that there is only one general surgeon per 100,000 population, and that’s a very small number in public service. Even if you add the private sector, it only goes up to about to two per 100,000. What we’re aiming for is somewhere in the region of four to 10 per 100,000.”
The aim of the course is not learning how to do a specific type of operation, but being trained in how to use surgical tools properly. The skills learned can be applied to many specialities because the principles are the same. All the tools the surgeons are trained in are available in public hospitals with surgical services.
“We have experts in almost every surgical field; we just don’t have enough numbers, so we are stretched. Once we’ve trained a medical officer to do a simple procedure, we allow him to do that, but he’s always going to be under the supervision of a consultant,” says Prof April, noting that this practice might be different from other countries.
Since the SoTM workshops were introduced in 2016, Prof April has noticed a reduction in death and complications in her workplace. On whether surgeons are overworked, she admits that cognitive skills like attention and decision-making, are affected by fatigue, and while the industry does pay attention to this problem, the regulations are perhaps not as strict as those for pilots.
She says, “We certainly look at the working hours and we send consultants home if we know they’re working beyond certain hours. In the aviation industry, pilots are responsible for a few hundred people, so the rules are slightly different.”
When asked what the mark of a good surgeon is, she says it all boils down to surgical professionalism.
“Patients obviously don’t see when someone does a procedure on them, so it’s about how we communicate with a patient, how we conduct our professional life – are we respectful, do we conduct ourselves ethically, are we seen as being altruistic, do we have the patient’s interest at heart as opposed to pushing procedures for financial outcome, etc.
“A good surgeon might not have anything to do with actual technical skill, although you need to have done some surgeries. You cannot become an expert if you have only done one or two surgeries. It takes time to get over the learning curve, so you wouldn’t expect someone who is young to reach that level yet.”
However, she quickly clarifies that that doesn’t mean older surgeons or those with more cases under their belt are better as they may have done several surgeries for various reasons.
“As we age, cognitive and technical skills start to drop off, just like athletes. Once you reach the peak, there is a gradual decline and this age is not the same for every person. Some surgeons are best at 60 because of their experience and wisdom,” she explains.