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The acquisition of surgical skills does not just happen. David O’Regan, on obtaining his primary FRCS, was given a knife and directed to an operating list with the instruction ‘you now know your anatomy, so off you go’. In two years as a senior house office his logbook registered over one thousand five hundred first operator cases across a wide spectrum of surgery and a further six hundred and twenty-seven in eighteen months as a general surgical registrar. This was the ‘old fashioned way’ of training – learning by volume; if a case went well, you got another. During his training, very few consultants explained how to hold or use a surgical instrument. Instead, instruction was often ‘not like that, like this!’ Much of ‘this’ is tacit knowledge to the expert surgeon but seldom does the trainer make it explicit. His instruction for his first solo coronary artery bypass graft was ‘just be quick!’

The nuances and skills of surgery are better explained today but the volume of surgery for the trainee has been lost and it is not appropriate to be ‘practicing’ on the patient. Boot camps, courses and wet labs do offer the opportunity for trainees to learn ‘why’ and ‘what’ we do in surgery, but none explain the ‘how’ or offer a framework for deliberate practice at home. Practice for a musician or a sports person is implicit in the development of skills, but this does not appear to be recognised in Surgery? Moreover, we have noted that many of these courses have trainees sitting at tables with the organ / model in question on the table. We believe this is akin to learning golf sitting down!