‘See One, Do One, Teach One’ in the Globalization Era

1. Main Test

“See One, Do One, Teach One” [1]: this has been our mantra in training, and not just ours.

See not just one, but many, if you can; perform one when the opportunity arises (often in an emergency setting on a Saturday night, relying on the goodwill of a more senior colleague who ‘concedes’ you the case); and teach not just one, but in every possible situation. That depends on you, on your personality, on your attitude, and on your willingness. Before going further, allow us to offer a few preliminary remarks.

From a more scientific standpoint, it is not easy to discuss training for young surgeons. Without delving into the ‘academic’ responsibilities of university education—both theoretical and practical—there is a certain Italian penchant and an ‘interest’ in anything that comes from abroad. Nevertheless, if we read the literature carefully, we know full well that ‘all that glitters is not gold’. The lack of organization, the abdication of responsibility regarding training (for both teachers and students), and the demotivation stemming in part from the prospects facing future doctors affect all areas of university education.

The revolution brought about by laparoscopy, for example, now over 30 years old, has been a case in point. We have moved from a solitary view, of the single first operator, to a view of the entire operating theatre team (anesthetists, scrub nurses, trainees and junior surgeons), thereby removing the excuse of simply doing things as they had always been done, but instead imposing a more scientific and equitable review of surgical knowledge [2,3,4,5]. This means that given ‘the grass is not always greener on the other side’, as we have already said, those who are more experienced must themselves be responsible for teaching or learning, and can no longer afford to rest on their laurels, but must therefore also become skilled at ‘explaining’ and teaching the reasoning behind certain choices. An old family saying advises us to learn from and imitate those who are better than us, rather than seeking comparisons that justify our shortcomings.

Sometimes it is useful to undertake a scientific project and acquire or deepen one’s knowledge through experience. We must push beyond our limits, initially adopting a practical approach without forgetting the theoretical one and, in doing so, set an example for young people. As anticipated, it is a thorny and difficult topic to address because training should never end. One’s skills should always be improved, refined, and perfected, and one should never fall into the error of feeling they have ‘arrived’. That would be, and is, in our opinion, a serious problem. ‘Nature is beautiful because it is varied’ (as someone said), and since we are dealing with the most beautiful form of nature of all—the human body—its variability, unpredictability, diversity, and pathological alterations mean that we are always learning, often whilst we are training our younger colleagues. Having concluded these, perhaps not entirely tedious, preliminaries, let us delve into ‘seeing, doing, teaching’.

2. See One

Seeing: This is fundamental. It cannot and must not be quantified (one, a hundred, a thousand: there is no limit; indeed, we should not impose one). Seeing and observing, with a view to learning, means comparing, including with what we ourselves have done—perhaps alongside someone more experienced, who may have been our mentor [6]. Seeing and observing means, first and foremost, comparison. And this is ethical [7].

Especially when we believe our actions are correct. ‘A well-conceived speech becomes a good speech to read and listen to if the intonation and punctuation are right’ (as an Italian teacher used to say). Training therefore requires the humility to engage in dialogue—to listen—whilst still knowing how to apply one’s own intonation and punctuation. Of course, the strictly educational aspects (courses, meetings, conferences) are crucial for growth in the various disciplines, but sharing, even at in our daily practice, both with those who should already be trained and with those still in training, contributes to that poem we wish to write. If we reflect on ‘seeing one’, perhaps the ‘one’ should be replaced with ‘let us see together’, and let us share because, as the Latins teach us, ‘cum-dividere’ is the lifeblood of growth, training and teaching.

This is undoubtedly true today: ‘Modern training is based on multi-centre specialisation programmes. It offers trainees the opportunity to observe numerous experienced surgeons at work and to learn from them. This enables them to acquire knowledge of various surgical techniques and to develop a multidimensional way of thinking’ [8]. Multidimensional and multimedia thinking is what guides us today. But ‘seeing/seeing together’ is only the beginning.

This could be the added value, not only for surgeons but also for other scientists. Sharing knowledge and discussing with others could be a good example of medicine and research.

Everyone sitting at this table goes home with a broader view of the world.

3. Do One

It seems obvious: Do it, and do it as much as possible! But it is not just a matter of quantity and numbers. ‘Whatever you do, do it well. Do it so well that when people see you do it, they will want to come back and see you do it again, and they will want to bring other people to show them how good you are at what you do’ (Cit. Walt Disney).

Today, precisely considering the laparoscopic revolution, already mentioned in the introduction, and the fact that ‘everyone can see everything,’ one can no longer become a surgeon without a solid foundation. Furthermore, the laparoscopic revolution remains a relevant development and should not be underestimated, particularly considering new minimally invasive techniques [9]. Surgical background alone and the ‘surgical school’ to which one belongs to are no longer sufficient; they can no longer serve as an alibi. Training—multidimensional and multidisciplinary—requires simulation and virtual reality [10,11,12,13]. This is right and necessary: it hones manual skills, giving equal importance to both hands, just as musicians do to achieve harmony. Yet, simulation remains virtual—devoid of personal and group experience, and devoid of those sensations necessary for the success of the operation. ‘Simulation’, therefore, is necessary, especially during academic years, to lay those foundations that are all too often overlooked, thus limiting time, costs, and patience.

This should be the responsibility of academic institutions. In addition to this—particularly where significant technological innovations exist (robotics, for example)—scientific societies, ideally in collaboration with industry, should take on this responsibility. It is a cultural, not just economic, joint venture. ‘Simulation’ is therefore necessary but not sufficient. One must ‘get stuck in,’ step by step [14], starting with parts of procedures, guided by a mentor [6]. A clear example of this is the Paralympics. For instance, in running, visually impaired runners are guided by a partner to whom they are tied by a rope. The guide provides directions, but the performance depends entirely on the athlete. Similarly, the mentor must guide, instil confidence, and enable the trainee to give their best [6]. And in this race, continuity is essential. Training cannot be sporadic. In emergencies, if one has not been trained in elective settings, it is unrealistic to expect competence in urgent scenarios [15]. As stated in the literature [16,17,18], advanced laparoscopic procedures in emergencies require prior and progressive skills.

Our personal philosophy is as follows: whenever possible, even in an emergency, insert a trocar and an endoscope, then proceed laparoscopically if it is safe to do so. This allows for continuous learning and teaching. Skills are transferred between different procedures [19,20]. This is, in our opinion, a major gap in training, especially in Italy today. The almost total absence of training in emergencies, often becomes the situation in which young people will most often find themselves at the completion of their studies. This clinical situation is essential in training because it makes us reflect even more on the fact that surgery is not just the procedure itself. Surgery is not just the intraoperative phase. What really matters is to focus on the preoperative phase (the preliminary assessment, the indications, and the correct evaluation of the patient) and on the postoperative phase (the management of the patient on the ward, the empathetic and global interaction with the patient and their family and, last but certainly not least, the management of complications). Indeed, indications are too often overlooked and complications are too often ignored, and both are too often not taught and considered.

4. Teach One

Teaching—even just once—requires competence. But competence, unfortunately, is still difficult to define, and all too often reduced to mere numbers or qualifications.

A better definition is as follows: competence means acting, knowing how to act, enabling others to grow, allowing others to act, and dedicating oneself to research. Research is a daily commitment, not just an exceptional one, and not necessarily worthy of a Nobel Prize, but aimed at improving oneself, the team, and the learners—refining techniques and making them more understandable for both colleagues and patients. While we are teaching, we are always continuing to learn. At times we must embrace what has been termed ‘productive stupidity’: the willingness to be ignorant in order to learn, to explore the unknown, to make discoveries [21].

Teaching means not only transmitting the technical aspects of the surgical procedure and the reasoning behind it, but also placing the right emphasis on non-technical skills, which are now essential for achieving the expected and desired outcomes in the surgical field. Teamwork, given the pressures to which the medical profession in general, and surgeons in particular, are increasingly subjected to, must be encouraged; and to do so, it is necessary to take these skills into account (‘professionalism, fulfillment of the roles of researcher and teacher, safeguarding health, management and leadership, collaboration, communication, medical, clinical, and technical competence’) [6,21,22].

All this should be done without forgetting the patients. True learning does not take place in simulators, but in real, unique, and unrepeatable situations, while also taking into account the emotional aspect of such situations. As Benjamin Franklin said ‘Tell me and I forget, teach me and I may remember, involve me and I learn’, and nothing could be truer.

In the age of globalization, we must also remember that the training process should be equitable, not egalitarian, just as innovation in surgery and technology should be. We should strive to overcome disparities and share knowledge regarding surgery and innovation even with low- and middle-income countries, involving people from all over the world. Knowledge, just like science, should be shared beyond borders and limitations.

In short, training never ends—‘Exams never end!’ as the famous play by Eduardo De Filippo says. Surgeons are always in training, even in non-surgical contexts such as the COVID-19 pandemic, which influence decision-making [23,24].

Finally, as William Stewart Halsted wrote, ‘We need a system—and we will certainly have one—that produces not just surgeons, but Surgeons: individuals who inspire young people to study surgery and to dedicate their lives to advancing the standards of surgical science’.

He was right. But once you have become Surgeons, never stop improving, day after day. And always remember—‘If you are the smartest person in the room, then you are in the wrong room’ (Cit. Confucius).