Graduated surgical skills training: time for a new paradigm? 

'Mastery is the continual attention to and maintenance of basic techniques.’e last Royal College Charter was amended in the early 1970s. Since then, there have been many changes to the membership of the College – and to society itself. Since 1505, the College has constantly evolved and modernised to keep at the forefront of surgical education, training, examinations, assessment and the maintenance of standards (its founding values). Regenerating regularly, a little like Doctor Who! The key objectives in the governance review include transforming the College structure, increasing transparency and enhancing engagement with the College Members (in this context including Fellows and Members).. 

Deliberate purposeful practice with attention to detail is fundamental to the acquisition of any motor skill. Fundamentals, including posture, instrument handling and visual special alignment, are vital to developing these skills. Historical teaching of ‘see one, do one, teach one’ ignores these precepts and, in the UK, is generally limited to ‘on the job’/‘train as you go’. There has been a fall in operative exposure in surgical training with an increasing need to include meaningful simulation. At present, the only mandatory requirement in early years training is that a trainee shows evidence of skills training, which may include basic surgical skills courses run by the colleges, supplemented by a patchwork of skills sessions and courses from a network of regional and national organisations. Whilst they have a role, many trainees leave these courses not knowing how to continue to refine their skills and there is little guidance on the need to perfect the fundamentals, practice and develop skills outside the operating theatre. There are no other requirements to receive formal training or be formally assessed with respect to basic skills, other than as a mention in a small part of the various global ratings and OSAT undertaken around index operative procedures.

Any practical skill takes time to develop. This applies to surgical operative skills as much as it does to playing a musical instrument or participating in a sport. There are very few individuals who are naturally gifted in sport or surgery, and developing the techniques takes many hours of practice. Much has been made of the reduction in surgical operative training hours compared with ‘the good old days’ but these changes began almost 30 years ago and challenges remain. 

In any new activity, the first steps are the introduction of basics, (posture/handling the instrument, tools/weapon) followed by specific movements honed through increasingly complex tasks or exercises. Previously, operative skills were developed by spending long hours in the operating theatre and through experience. Changes in working patterns require us to think how to practise skills. The evidence is pointing us to simulation and out-of-theatre practice.

The Black Belt Academy of Surgical Skills (BBASS) was developed, teaching operative skills through the lens of teaching traditional Japanese martial arts. Surgery has been described at various times as a ‘contact sport’ so why not teach it as such? Both disciplines require mastery and maintenance to become an art of movement and fluidity, where technique trumps power and speed. The principles of BBASS focus on teaching a graduated practical skills syllabus across several domains, using a series of exercises employing easily available low-fidelity models. These exercises are designed to give immediate feedback, which enables trainees to ‘hone’ their skills, but this cannot be done in isolation and needs be supplemented at intervals by instruction or assessment by a skilled teacher/sensei. 

Martial arts training (and training in most practical skills) deconstructs techniques into their elemental parts with measurable graduated learning goals reinforced by a rank or belt system. Skills can be generally divided into three areas with tasks increasing in complexity as an individual advances through the grades. It is through this lens that the BBASS curriculum was developed.

1. Kihon – basics. This is teaching the very building blocks of skill: how to stand, walk, move. From a martial viewpoint, all these are learned, not innate skills. Beginners often struggle for many weeks or months with basic stances or positions, movements, how to hold and manipulate weapons. Surgical skills are no different. One of the fundamental skills is correct posture as musculoskeletal disorders of the spine are a significant issue in surgeons. Other basic skills include how to correctly hold and use instruments, economy and precision of movement and correct tissue handling, emphasising lightness of touch. These are not widely taught, even on formal courses, but form the foundation of our everyday operative skills across all specialties.

2. Kata – formal exercise. Most traditional eastern martial arts are taught through a number of set ‘forms’ of increasing complexity. These forms use sequences of basic movements and techniques, which have been likened to fighting an imaginary opponent(s). These can be practised almost anywhere, using minimal resources to develop both technique and a ‘muscle memory’. With practise, these movements become fluid and effortless, almost second nature. From here, these movements can be adapted and applied to different situations without thought. Surgical trainees tend to limit their training to the work environment, however, there are many easily accessible models which can be used at home to practise both hand and instrument skills. This practise should be regular, using simple accessible equipment, and models should be low fidelity but designed in a way to offer immediate feedback without the need for an instructor to be present. The BBASS syllabus has developed several models and exercises using items such as bananas or baked potatoes, which fit these criteria and are sustainable.

3. Kumite – fighting. The end point, taking what you have learned and using it in a ‘fight’. Even in a martial arts environment, the application of basic technique is fundamental to ‘winning’. Pure force rarely prevails and frequently the more technically adept fighter will come out on top. To a surgical trainee, this arena would be a theatre session, using their developed surgical skills in learning and performing an operative procedure, being focused on learning the steps of the procedure itself and not their own basic surgical skills. 

The BBASS syllabus is modelled on the traditional martial arts belt model with increasingly complex tasks at each level. The skills are grouped into domains, including suturing, knotting, use of scissors, knife skills assisting, use of the nondominant hand and assisting skills. Using this approach then allows trainees to develop skills away from the workplace and, with regular practice, the skills become second nature with the trainee refining and developing their own technique but adhering to fundamental safe principles.

Martial arts and surgery share an intrinsic blend of precision and artistry, both requiring mastery of movement, control and execution. Every movement must be executed with precision as too much force or deviation from form can lead to inefficiency or vulnerability. Similarly, in surgery, each incision, suture and manoeuvre demands meticulous accuracy, where even the slightest miscalculation can have significant consequences. Surgical skills take time to develop and the current programme of skills training in the UK lacks a focus on longitudinal development. Perhaps a programme of graduated surgical skill training, where trainees are encouraged to achieve the next level in an accessible and safe environment out of the clinical arena, offers an alternative training paradigm. It also taps into a surgeon’s natural competitive tendency. We also mustn’t lose sight of the fun element. After all, who doesn’t like the sight of a perfectly sutured banana?

Ultimately, both martial arts and surgery are testaments to discipline and mastery. Whether in the operating room or the dojo, the pursuit of excellence is defined not just by mechanical skill but by an artistic sensibility that turns precision into an elegant expression of expertise.

The authors would like to acknowledge the contributions of the other
‘Black Belt’ instructors Mr Chris Caddy, Dr Melvin Maklin, Professor
Zaleha Mahdy and the Academy team.