How do competencies for surgery and education for life compare?

Considerate, concerned, clinically competent, capable, collaborative, communicative, compassionate and comforting, careful with expert ‘cutting’ capabilities perhaps characterise the surgeon most patients would wish to have care for them. The purpose of this article is an attempt to bring to life a contemporary account of the nine competencies of the Royal Australasian College of Surgeons (RACS) to become a competent surgeon. The article also highlights that interestingly many of the descriptors of the competencies begin with the letter c. We think it is timely to reflect on these competencies, given they were first put into a framework in 2003, inspired by the seven of CanMeds. In secondary and tertiary institutions, there is understandably a continued focus on developing the traditional skill set necessary to perform well in a particular career. However, there is an increasing expectation that these traditional skills should be complemented by a set of competencies that enhance the performance of the individual. Worldwide, in many diverse professions, competencies are being developed. For example, groups that reference their own set of competencies include the Foundation for Young Australians, accounting firms and the collective of 36 countries, including Australia, who form the OECD. My interest in this broader development of competencies was further stimulated when visiting my alma mater in Melbourne, Carey Baptist Grammar School (CBGS), and learning of the CBGS partnership with world experts exploring both the teaching and measurement of competencies. All surgeons believe they know what constitutes a good surgeon, but some of the essential and important characteristics of the surgeon are not necessarily obvious. These features are not readily measured, and in the past may not have received the emphasis they deserve during medical school and surgical training. What then are the components and characteristics in aspiring surgeons that we need to select for, train and assess, and are they significantly different to those being taught and assessed in secondary and tertiary institutions? Surgery demands more than just the classic twodimensional construct of clinical competence and cutting capability. There is a clear parallel in secondary education where the traditional skills of numeracy and literacy have dominated assessments because of the difficulty of assessing other skills such as the individual’s ability to connect, communicate, collaborate and to adopt reflective practices. With these parallels, between the need for competencies beyond the traditional skill set seen at both RACS and CBGS, and their nine competencies and nine positive learner attributes, respectively, as an additional aim, we have endeavoured to align the competencies and attributes of both organisations to highlight some important similarities and strengths. CBGS has created three domains, each of which contains three positive learner attributes. Therefore, for the purpose of this article, we have considered the importance of the nine RACS competencies in the three domains CBGS has designated: Self-Management, Thinking and Relationships (Fig. 1). However, we recognise there is considerable overlap between the competencies and the attributes. Therefore, the alignment we have proposed may not be immediately intuitive and acknowledge other alignments could also be valid. In Self-Management, we have placed the RACS competency – Professionalism. It has many components, and is a collective term describing the conduct and combination of qualities seen in a highly trained and skilled surgeon. For RACS, there are four key categories – first, the trinity of emotional intelligence and selfawareness, situational awareness and insight. Second, the ability to observe ethics and probity – honesty, integrity, decency, trustworthiness and strong moral principles – and to respect and abide by the Code of Conduct of RACS. Third, to understand the issues of confidentiality. Fourth, to recognise coping mechanisms whilst maintaining one’s own health and well-being, and thereby being aware of, and considering the importance of mindfulness and resilience. At CBGS, this attribute is called Resilience, defined through the acronym, FOCUS. Resilience is the capacity of the individual to be Flexible, to remain Optimistic, to seek Connections with others, to embrace Uncertainty and to have the emotional intelligence to draw on personal Strengths to best embrace difficult decisions. It includes an ability and desire to learn from one’s mistakes, a heightened awareness of one’s capacity and grit when faced with duress in situations associated with vulnerability. The second RACS competency in the Self-Management domain is Judgement and Decision-Making. These are the cognitive characteristics describing the critical thinking necessary to resolve what may often be a complex constellation of information creating a challenging clinical situation. It is notable that since 2008, all Australian schools instruct in critical thinking from school entry through to year 10. Critical thinking is designated as one of the seven ‘General Capabilities’. At CBGS, this attribute of judgement and decision-making is called Knowledge. However, CBGS defines knowledge as the ability to extract information and to develop the capacity to move within and between areas of learning with a degree of fluidity. Therefore, this involves a higher level of learning and critical thinking, rather than just rote learning of factual material. Without this seamless movement or fluidity of thought, we as surgeons would not function effectively in situations such as multidisciplinary team meetings, audits and morbidity and mortality discussions. Hence, for surgeons this critical thinking involves an understanding of the breadth of clinical options, an