Otolaryngol Clin N Am

40 (2007) 1227–1235

The Evolution of Surgical Training:

Perspectives on Educational Models
from the Past to the Future
Christine B. Franzese, MD*, Scott P. Stringer, MD, MS
Department of Otolaryngology and Communicative Sciences, University of Mississippi
Medical Center, 2500 North State Street, Jackson, MS 39216, USA

The training of surgeons has undergone remarkable evolution in the mil-

lennia that have passed since the inception of the art of surgery. The path
that surgery has traveled has at times been rocky and has not always paral-
leled the course that ‘‘medicine’’ in general has taken. Surgeons and surgery,
in fact, have commonly been perceived as separate or apart from medicine
for ages, and the history of training of surgeons reflects this. The distinction
is apparent even in the ancient version of the Hippocratic Oath, which trans-
lates, ‘‘I will not use the knife, not even on sufferers from stone, but will
withdraw in favor of such men as are engaged in this work’’ [1]. This tradi-
tional divide persisted well into the Middle Ages and into even the modern
era. At times, it was highlighted by differences in titles: surgeons were (and
in some places still are) referred to as ‘‘Mister,’’ owing in many areas to the
trade of ‘‘barber-surgeon,’’ which required no formal training, qualification,
or degree, whereas physicians were referred to as ‘‘Doctor,’’ due to the rec-
ognition of the attainment of a medical education or university medical
degree.
Surgical training and education have indeed come a long way, but in
some fashion, they have also arrived very near where they began. Although
it is certainly not the only method of training and has undergone many ad-
aptations and variations, the apprenticeship model or apprenticeship
method of training is inarguably where the training of surgeons began
and, interestingly enough, has weathered passage of time well enough to
be the paradigm of surgical educational training for the present.

* Corresponding author.
E-mail address: cfranzese@ent.umsmed.edu (C.B. Franzese).

0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2007.07.004 oto.theclinics.com
1228 FRANZESE & STRINGER

Brief history of surgical training

Attempts at improving surgical education began almost a millennium
ago, the first tiny steps in a long process to advance training in the craft
of surgery and transform it from trade to profession. As medicine became
more defined as a field of its own, efforts were made to separate the aca-
demic surgeons from barber-surgeons with little or no training. The College
deSaint Come, established in Paris in about 1210 AD, was the first to do this
by identifying the academic surgeons, those who had training or had at-
tended the university, as surgeons of the long robe and the barber-surgeons
as surgeons of the short robe [2]. To systematically instruct barbers in sur-
gery, a school was set up in France in the middle of the thirteenth century by
the Brotherhoods of St. Cosmos and St. Domains [2].
However, the most common and well-established method of training sur-
geonsdif any training was obtaineddwas by the apprenticeship method.
Length of training and age when training began could vary, but a typical
apprenticeship in the mid-sixteenth century would last 5–7 years and could
start around the age of 12 or 13 [3–5]. Further training, in the form of jour-
neymanships, was available under the tutelage of the same or a different
master, but was not necessary for the practice of surgery. Initially, appren-
ticeships began as simple, unstructured arrangements, involving family or
friends, but as time passed, surgical apprenticeships progressed to more
organized arrangements with formal rules. For example, in Edinburgh dur-
ing the sixteenth century, the master was ‘‘obliged himself to teach and in-
struct’’ and ‘‘had the obligation not to transfer his Prentice to another
Master’’ [6].
As surgery slowly evolved from a trade into a profession, the apprentice-
ship model has been the surgical education standard. This time-honored ap-
proach has remained in practice to the present day, although not always in
its original form. In the most basic form of this model, surgery is taught by
the student directly observing and then imitating the actions of a skilled
mentor, both in the operating theater and in the clinical examination setting
[7]. In ways, this is the origin of the ‘‘see one, do one, teach one’’ mentality
that accompanies the instruction of individuals who are being taught a new
procedural skill [8]. Though it has undergone evolution and, at times, fallen
out of favor, the apprenticeship model is still viewed by many as the current
standard for surgical teaching [8].
The introduction of the apprenticeship model greatly improved surgical
education, as now an experienced mentor instructed the trainee, shared col-
lective knowledge, and taught surgical techniques by demonstration and
repetition. Surgical knowledge and techniques, though not scientifically
studied to determine their benefit (or harm) to the patient or their success,
were at least learned by instruction and example rather than trial and error
[9]. Still, there was absolutely no standardization or guidelines as to what
knowledge or skills were to be taught, who should be trained, when training
 THE EVOLUTION OF SURGICAL TRAINING 1229

should start, or how long training should last. The apprenticeship system
also promoted the ‘‘cult of the individual,’’ with the development of masters
who established competing ‘‘schools of surgery’’ [9].
The end of the nineteenth century and beginning of the twentieth marked
the first major shift from the previous apprenticeship training models to
more formalized and structured training. The method currently in practice
to train surgical residents in the United States is, in large part, due to the
influence of Dr. William Halstead [10]. Although not the first to propose
it for acceptance, he is often mistakenly credited for this method [11]. It
was, interestingly enough, proposed by his contemporary, Dr. William
Osler, in 1890, to the Board of Trustees at the Johns Hopkins Hospital; Hal-
stead immediately and enthusiastically adopted it [11].
Halsted established a school for surgeons that emphasized safety in sur-
gery and was characterized by the importance of meticulous hemostasis and
careful tissue handling [12]. He also was pivotal in popularizing the concept
of resident training in the United States. In 1904, Halstead delivered a land-
mark lecture at Yale on the training of surgeons, proposing the adoption of
a model of the German system of residency training, whereby trainees re-
ceived increasing responsibility with each advancing year [10,13]. The model
allowed for improved structure and standardization in training, but it also
introduced the ‘‘pyramid’’ structure in residency training, in which candi-
dates would be eliminated each year, until culminating in the graduation
of a single chief resident [10]. The idea gained support and, in 1928, the
American Medical Association House of Delegates approved the applica-
tion of the underlying principles promoted by Halstead to approve residency
programs and fellowships [9]. Thus appeared the surgical educational train-
ing programs and residency educational models that are known today.

Modern models of residency training

The residency system of training did not eliminate the apprenticeship
model for those who wished to learn the art of surgery; it was the catalyst
of evolution. Residency gave the apprenticeship model the structure, stan-
dardization, and stability it needed to train modern surgical residents. In
fact, the ideas introduced by Halstead still provide for the position of a mas-
ter or mentor who supervises and instructs his or her apprentices. The posi-
tion of mentor is so valuable and rewarding, not only to the trainee but the
mentor as well, that the apprenticeship model is still viewed as the current
gold standard in resident training [2,8,10]. However, with the advent of
this change in structure, it also opened the door to an alternative and com-
peting model of residency training. As these particular residency educational
training models have never been officially or formally recognized or de-
scribed elsewhere, the present authors have taken the liberty of naming
and briefly outlining each educational training model.
1230 FRANZESE & STRINGER

The ‘‘Osler’’ model of residency training

Referring to Dr. William Osler, very likely the greatest American clinical
teacher, this model is the most up-to-date or modern version of the appren-
ticeship model. Osler introduced medical education to the clinical clerkship
as it is known todaydthe backbone of the third year of medical schoold
and was one of the biggest advocates of mentoring, and thus, indirectly,
the apprenticeship method of training [7]. Osler emphasized that a closer re-
lationship between an instructor and student(s) was not only necessary but
vital, and portrayed professors as the ‘‘senior student anxious to help his ju-
niors. There is no appreciable interval between the teacher and the taughtd
both are in the same class, the one a little more advanced than the others’’
[7,14].
The Osler model consists of one or more residents of differing postgrad-
uate training levels (apprentices) closely working with one or more faculty
members (masters or mentors). Rotations may vary the exposure of resi-
dents to certain attending physicians, but the essence of this model of train-
ing is that faculty are invested, committed, and involved in nurturing the
education of their trainees. Staff physicians are not merely occasional lec-
turers or distant figures, but are actively involved in instructing residents
while seeing patients during clinics, on wards, and during operative proce-
dures. Residents are supervised, although the level and acuity of monitoring
will vary based on the experience level of the residents. In addition, by men-
toring and behavioral modeling, residents learn the art of practicing medi-
cine (not just surgical techniques), something difficult to learn from
textbooks or measure on examinations [8,15].
The model also allows for the practical marriage of science and tradition.
Evidence-based medicine is not something solely mentioned in lectures, but
is actively taught by faculty and observed and practiced by residents in the clin-
ical setting. Residents directly benefit and acquire medical knowledge and ex-
perience from their teaching faculty. Surgical procedures can and have been
studied systematically to evaluate almost all feasible aspects, from preopera-
tive skin preparation and antibiotics to methods of performing incisions
and techniques for dissection to complication rates and mortality. When
new surgical procedures are introduced, they can be studied and evaluated first
by the scientific community. In this way, a safe, effective, and validated oper-
ative procedure that has passed through the rigorous scrutiny of other physi-
cian-scientists can then be passed on to surgical trainees.
The apprenticeship model, and its various manifestations, has been used
for nearly the entire history of modern surgical practice. It is viewed as being
an effective method of training surgical residents, in that surgeons previ-
ously graduated from this system have practiced successfully [8]. Many sur-
geons practicing today are products of this type of system, but some, who
may believe they have been trained in an apprentice-style fashion, are actu-
ally graduates of a completely different model of training.
 THE EVOLUTION OF SURGICAL TRAINING 1231

The Mall model of residency training

Referring to Franklin P. Mall, the Chief of Anatomy at Johns Hopkins
Medical School, this model could just as easily be named after William Hal-
stead. Mall and Halstead were not only contemporaries and friends, but also
seemed to share the same educational philosophy: that of the ‘‘inductive’’
approach to medical education, which is ‘‘to teach by not teaching’’
[11,16]. Mall is often credited as the father to the arguments supporting
this style of educationdthe antithesis of mentoring and the apprenticeship
modeldwhich proposes that mentoring is not needed if only the best are
recruited [7]. Mall would assign his students a part of the cadaver to study,
provide them with references, and leave. His staff would be present, but no
formal instruction was ever provided. He believed students were responsible
for their own learning. Although ‘‘brilliant students loved him,’’ [7] his
methods were found wanting by everyone else.
The Mall model consists of a group of residents of differing postgraduate
years who are provided with educational resources, such as textbooks, training
manuals, and surgical atlases, and who essentially instruct themselves and, at
times, each other. Faculty members may be completely absent from the picture,
or may have a loose association with the residents, but in no way does faculty
involvement approach the level of investment given by faculty in the first model.
Staff physicians may lecture to residents, but little or no outside clinical instruc-
tion is truly performed. If it is, it is usually sporadic and irregular, or it is lav-
ished on a select resident or favorite, whereas in Halstead fashion, the
remaining residents languish. In fact, those attending may even be physically
separated from their trainees, with the faculty member in one facility and the
resident in his or her own clinic or other location. The epitome of this model
is the scenario of one or more trainees in the operating room, looking at a sur-
gical atlas, struggling through a procedure while the faculty in charge are largely
absent, either briefly checking in at times to see how things are progressing or
never present. More senior residents may or may not attempt to fill the void
by providing the incomplete instruction that their limited experience allows.
Some may argue that this is not a separate or different model of surgical
training, but is still a version of the apprenticeship style of training, with se-
nior house staff serving the role of master. In fact, some have argued that
senior house staff can assume the mantle of mentoring [7]. This view is, at
best, naı̈ve and the position itself grossly flawed. Upper-level house staff
do not have the prerequisite surgical experience level, medical knowledge
base, or clinic expertise to serve in the role of ‘‘master’’ or ‘‘mentor,’’ espe-
cially given the responsibilities and expectations of these roles. Although
teaching more junior residents is certainly within the scope of responsibili-
ties placed on senior residents, it is in no way an adequate substitute for re-
placing an attending physician. If such were truly the case, academic
teaching surgeons would no longer be needed and a great many physicians
(the authors included) would no longer have a source of income.
1232 FRANZESE & STRINGER

The success of this model can be argued as there are certainly products of
this type of educational system who are or have been successfully practicing
surgeons. Yet, similar to medical students exposed to this type of ‘‘teaching
by not teaching,’’ brilliant trainees may flourish while less gifted residents
flounder. Though some may contest that skilled surgeons may come from
this educational training model, it begs the question if this method is truly
the most effective, efficient, or even responsible way to produce future sur-
geons. Fortunately, the Accreditation Council for Graduate Medical Educa-
tion (ACGME) has increased its vigilance in monitoring training programs
and toughened its program requirements, such that new mandates explicitly
state that ‘‘faculty schedules must be structured to provide residents with
continuous supervision and consultation’’ [17]. Though pockets of this
model of residency training may still persist, with the continuing focus of
the ACGME on ensuring adequate faculty involvement and supervision,
the current trends in medical education, and the increasing scrutiny by the
legal profession, it is highly likely this model will completely disappear.

Future evolution
Given the failure of the Mall model of residency training to fulfill the
demands and requirements of graduate medical education, apprenticeship-
style or Osler model residency training programs have quietly, without notice,
become the dominant standard for surgical training once again. With the on-
going requirements and monitoring of programs provided by the ACGME,
many of the flaws of the apprenticeship model, such as lack of standardization
and the ‘‘cult of the individual,’’ are eliminated, greatly reduced, or at least
tempered. However, modern medical practice has introduced new variables
into the training equation, and these new factors provide challenges to the ap-
prenticeship model that are becoming increasingly difficult to surmount.
The first of these new obstacles is resident work-hour restrictions, limited
to 58 hours per week in Europe (until August 2007, when it becomes 56
hours per week) and 80 hours per week in the United States [17,18]. Addi-
tionally, there are provisions restricting the amount of time a resident may
spend on call for one period, mandating a 24-hour rest period on average
every 7 days, and suggesting or requiring a 10-hour rest period between clin-
ical shifts, depending on the specialty. Although these changes may help
lessen or prevent resident fatigue, they have certainly had an impact on res-
ident education and the structure of training programs. Owing to restricted
duty hours, an operation previously seen 10 times by a resident may now be
observed only a few times [10]. There may be less continuity of care and less
exposure to more unusual diseases or surgeries that, although some may
argue most residents will not see or do in practice, it is vital that residents
be exposed to them for educational purposes.
Exotic diseases and surgeries aside, residents may struggle to perform
enough of certain larger or more major surgeries to feel competent enough
 THE EVOLUTION OF SURGICAL TRAINING 1233

to perform them after graduation. By being willing to limit duty hours, prac-
ticing physicians, residents, and future trainees must also be willing to
consider lengthening the period of surgical training in order to produce
well-trained and competent surgeons. This is not an unreasonable consider-
ationdand is not without precedent. In Sweden, where a 40-hour work
week for surgical trainees has been the fashion for a long time and thus,
the number of surgeries performed by trainees is small, an additional 6 to
8 years as junior specialist is required upon graduation for residency training
[18]. It is during this additional time period that these new surgeons ‘‘will
acquire the experience necessary to become autonomous as professionals’’
[18]. In the United Kingdom, new surgeons also may not have the prerequi-
site experience to practice independently and are supervised by more
experienced colleagues [18].
The duty-hour regulations have occasionally necessitated ‘‘structural’’
changes in some residency training programs to prevent violations but still
continue to provide acceptable instruction. Some programs have had to
change the format of their teaching programs, changing times, days, and
numbers of lectures or lectures of laboratory sessions, to accommodate
the new hour restrictions and yet still strive to maintain excellence in educa-
tion [19]. Other changes include adding ‘‘day-float’’ or ‘‘night-float’’ cover-
ages, changing the number of residents on call at a time, and in some
instances, having faculty take call without resident coverage [19,20]. Others
have made more ambitious adaptations to the apprenticeship model and
have reworked training programs so that, in one general surgery program,
one resident follows one to three surgeons in a practice, in essence being
their apprentice [19].
Another of the obstacles faced is the realities and legalities of the business
of medicine. Because of changes in reimbursement and other insurance and
medico-legal issues, there is less opportunity for ‘‘teachers to teach’’ [18].
Specific issues impacting academic physicians, but certainly not all, include
productivity constraints, need for timely completion of the surgical proce-
dure, and patient safety concerns [8]. Decreases in reimbursement increase
pressures on academic physicians to be clinically productive, leaving little
time for resident education. Traditionally, until recently by a few major in-
stitutions, actual teaching time or ability was not recognized or supported
with a dollar amount or career advancement. Merely having enough masters
or mentors present does little good if they are mostly unavailable to train
their apprentices.
It may be that a new model for surgical education is needed. There is one
valuable point to take from the defunct Mall model and apply it to present
and future educational endeavors: students must be responsible for their
learning. Residents are responsible for their own education. Residents
must take an active learning role if they are to achieve true competency in
surgery. Although the ACGME intends to portray this message to residents
and training programs, it is easily lost in a swamp of administrative
1234 FRANZESE & STRINGER

paperwork, electronic or otherwise. Requiring residents to review goals and

objectives, complete surgical case logs, and other menial tasks is meant to
remind trainees that they need to participate to learn; however, it fails to in-
spire and merely generates additional burdensome documentation for the
program director or coordinator. This message is an important one and it
needs more emphasis: the master is not here to spoon-feed the apprentice.
Whether we change education models or not for the future, the appren-
ticeship models had served well through the ages. One thing that seems cer-
tain is that if the apprenticeship model is to continue to serve the needs of
surgical training programs, some changes need to be made. Reimbursement
procedures need to be changed to account for teaching time and expertise,
or salaries will need to be amended to include support for participation in
academic teaching responsibilities. Faculty who participate strongly in
teaching need to be acknowledged, not only with dollars but also with rec-
ognition and promotion. After all, good teaching takes time away not only
from clinical practice but also research time, grant preparation, and publi-
cation. Teachers also need to be taughtdtraining programs need to educate
attending surgeons on how to effectively use adult education learning theo-
ries and strategies [10]. One thing there will not be more of is time, so con-
certed efforts need to be aimed at making surgical teaching practices both
effective and efficient. Finally, if further restrictions on duty hours are
passed, or graduate case numbers decline, serious consideration needs to
be given to the uncomfortable suggestion that residency training be ex-
tended. Academic surgeons and training programs have a duty to their
trainees and an obligation to society to graduate competent and indepen-
dently functioning surgeons. A 40-hour work week sounds great, but if
‘‘graduates’’ of such programs require over half a decade more in further su-
pervised training before they are fully competent, what has anybody gained?

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