Recent common practice is to evaluate residents or trainees at different levels, by different providers and through different tools. I think a combination of a socratic approach (test what you know) combined with a experienced based (kind of aristotelic). We often assume only to know and that where both faculty and trainees failed to approach truth. Practical abilities cannot disconnect from formal knowledge, besides, very skillfull person do not necessarily have the body of knowledge regarding a topic. They still happen to know and do it fast and correctly (observation, imitation, repetition, in a word ACCURACY and PRECISION?).

The introduction of simulation and evaluations of trainees by different providers are objective measures fo an otherwise difficult assessment. However, in a honest and well educated manner, we all know the trainees that are capable from those that barely are functional. In general we assume that anyone can do it, and in fact is very rare someone will be incapable. As well as few will be exceptional, but in general with proper training, but also POST training experience and self evaluation, we all reach the flat side of the curve. I agree that levels of different training requires different levels of self constructed situational experience, meaning, you have to do yourself. The senior specialist in that case could be an obstruction depending on 2 factors: the eagerness of the trainees to refer for advise (capacity of LISTENING), the interference of the faculty by intervening when not necessary (capacity of observing). But can the trainee also practice on his/her own license?

I personally think that a system like with multiple levels of trainees accountability (british?), junior, senior, pre-consultant, offers a good model. In many other countries this is replaced by fellowships or other types of postgraduate training. Even in the best programs where you are exposed to several procedures and activity, the difference between capable to do it, and really experienced to do it, that encompasses not only the skills but the ability of the situational awareness makes the difference. I do think we are making effort to educate about being actually a mature professional anesthesiologists, my only hope is that any attempt to reduce training lenght (justified by some by the smarter "kids") would be discouraged, while restructuring training to further develop the "wise" people we need.

Davide Cattano raises a number of interesting issues.

I would like to concentrate on the training issues raised – the process of assessment on my view should rest upon the intent of the training. Ultimately the latter should be to produce a safe, skilled independent practitioner, but I would like to be able to split that up into coherent goals.

I agree that academic knowledge and practical abilities should be developed together but it is not uncommon to see a mismatch of these in trainees (the academic genius whom you wouldn’t allow to anaesthetise a cat or the safe skilled resident who battles to pass exams).

I agree that we can identify the “barely functional” trainees, and this is to be expected of all trainees on day 1. But if we are seeing this in trainees further into the programme, does not this reflect failure of practical OR training? This can’t all be due to log stupidity on the part of the trainee; a large part has to be due to inadequacies of the training process. The use of mechanical teaching aids (airway dummies and the like) and increasing popularity of computerised simulators address not only the issue of the unacceptability of “practising” on patients but also the limitations of the OR as a training platform.

“With proper training” we all reach the flat portion of the learning curve – what I am trying to grasp is the “properness” of the training!

The structure of a training sequence, such as the cited multiple levels of trainee accountability or “general” versus “specialist” training, or “R1, R2, R3, R4” just create the landscape for training, they don’t address specific training needs of the trainee in relation to requirements of the programme. Specialist rotations create access to a diversity of experience and adequate training time ensures sufficient exposure to each experience, but neither ensures that the individual experiences are assimilated into a developing set of cognitive processes and skills. Given enough time and enough experiences, perhaps everyone would be able to undergo this process on their own, but surely the OR supervision should be guiding this process and oiling its wheels.

It is interesting that the idea of post-training experience and self-evaluation arises, and I think this is a very important point. It ties in with the concepts promulgated by Donald Schön (“The Reflective Practitioner, How Professionals Think in Action”. 1983. Basic Books. ISBN 0465068782), as part of reflective practice. This is the process of reflection on action to develop continuous learning. All humans (indeed, all primates) have the ability to apply prior learning from experience to a brand new set of circumstances. In new situations, particularly under pressure of time, the experienced practitioner will often figure out a solution without significant conscious processing of her knowledge from previous dissimilar circumstances (reflection in action). Unless we take time out to reflect on what has happened and how the problem was solved (reflection on action) we are not sufficiently integrating the experience and not truly learning from the event. Also, we need to analyse our perception of events to consider alternative ways of handling the situation, or even avoiding it altogether.

So I would hazard to say that a period of time spent reflecting on the events of the day in OR and discussing possible alternative courses of action with the supervisor (a kind of “debriefing” session if you like) should form part of effective OR supervision.

What else?