Evidence in surgical training - a review.

The first residency programs for surgical training were introduced in Germany in the late 1880s and adopted in 1889 by William Halsted in the United States [Cameron JL. William Stewart Halsted. Our surgical heritage. Ann Surg 1997;225:445-58.]. Since then, surgical education has evolved from a sheer volume of exposure to structured curricula, and at the moment, due to work time restrictions, surgical education is discussed on an international level. The reported effect of limited working hours on operative case volume has been variable [McKendy KM, Watanabe Y, Lee L, Bilgic E, Enani G, Feldman LS, et al. Perioperative feedback in surgical training: a systematic review. Am J Surg 2017;214:117-26.]. Experienced surgeons fear that residents do not have sufficient exposure to standard procedures. This may reduce the residents' responsibility for the treatment of the patient and even lead to a reduced autonomy at the end of the residency. Surgical education does not only require learning the technical skills but also human factors as well as interdisciplinary and interprofessional handling. When analyzing international surgical curricula, major differences even between countries of the European Union with more or less strict curricula can be found. Thus far, there is no study that analyzes the educational program of different countries, so there is no evidence which educational system is superior. There is also little evidence to distinguish the good from the average surgeon or the junior surgeons' progress during his residency training. Although some evaluation tools are already available, the lack of resources of most teaching hospitals often results in not using these tools as long it is not mandatory by a governmental program. Because of decreased working hours, increasing hospital costs, and increasing jurisdictional restrictions, teaching hospitals and teachers will have to change their sentiments and focus on their way of surgical education before governmental regulations will emerge leading to more regulation in surgical education. Some learning tools such as simulation, electronic learning, augmented reality, or virtual reality for a timely, sufficient and up to date surgical education. However, research and evidence for existing and novel learning tools will have to increase in the next years to allow surgical education for the future generation of surgeons around the world.