Latest / Behind The Knife: The Surgery Podcast / Building the House of Surgical Education: The Legacy of Dr. Ajit Sachdeva
Transcript
- BTK Sachdeva v2 === [00:00:00] Hello, and welcome to this episode of Behind the Knife in Surgical Education. We are the general surgery education team from Cleveland Clinic. My name is Pooja Varman. I'm a general surgery resident and surgical education research fellow. I'm Judith French. I'm the PhD education scientist for the Department of General Surgery at Cleveland Clinic. And I'm Jeremy Lipman. I'm the DIO here. On today's episode, we sit down with one of the most consequential figures in surgical education for over the last two decades. Our guest recently concluded a 24-year tenure as the senior vice president for education at the American College of Surgeons, a role in which he built from the ground up an entire ecosystem of education, training, verification, and accreditation programs that have shaped how surgeons around the world learn and practice. Dr. Ajit Sachdeva did his me- medical training at the All India Institute of Medical Sciences in New Delhi. He completed his surgery residency at the Hospital of [00:01:00] the Medical College of Pennsylvania in Philadelphia, where he later became the vice chairman for educational affairs in the Department of Surgery. He also served as associate dean for medical education, director of the Academic Center for Educational Excellence, and chief of surgical services at the Philadelphia Veterans Affairs Medical Center for 10 years. He's adjunct professor of surgery at the Feinberg School of Medicine at Northwestern University. He has served as chair of the Committee on Surgical Education of the Society of University Surgeon and, and has published and presented widely on surgical and medical education across the world. He has received numerous prestigious awards over his career and has inspired generations of budding and practicing surgeons alike. We're honored to have him on Behind the Knife. Welcome, Dr. Sachdeva. Thank you very much. It really is an honor and privilege for me to be part of this podcast, and I look forward to our conversation, and thank you so much for the [00:02:00] very kind and generous introduction Thank you. So let's go ahead and get started with congratulations on concluding this defining chapter in surgical education with the ACS. As you reflect, can you tell us what stands out to you? I joined the American College of Surgeons in two thousand one when the college was getting reorganized into various divisions, and there was no division of education. So after a national search, I was selected as the founding director of the, uh, new division that I was charged to establish. And really, at that time, there was no script for me. The job description was very brief, and I had almost a clean slate to get things going. And what really attracted me to this opportunity was the fact that I could be a [00:03:00] leader on the national stage along with others, collaborate with other surgeon educators and surgical educators, and non-surgeons, uh, as well, to take surgical education to a different level, to work collaboratively with the Association for Surgical Education, the Association of Program Directors in Surgery, and other societies, both in general surgery and across the surgical specialties that were involved with surgical education, and to steer national directions and set standards in surgical education and training I wanted to focus on the whole continuum of education across our careers from the first year of medical school to the last day of surgical practice, and focus specifically on the transitions, which at that time were not getting much attention. And now everyone's talking about transitions such as the [00:04:00] transition from medical school to residency, the transitions during years of residency and fellowship training, then from residency and fellowship training to practice, and then the 20, 30, 40, 50 years of surgical practice. In addition to that, I was really focused on excellence and expertise. At that time, with the competency movement just taking hold, there was a lot of focus on the six core competencies that had just been announced by the ACGME and the ABMS. And my concern was that people would go to the level of competence and not really focus on excellence and expertise that really needs to be our aspirational goal. So those were some of the things that I wanted to establish and get started with, and that was the beginning of a very exciting journey for me. It's really fascinating that there are concerns about competency being a ceiling rather than sort of a [00:05:00] process. Can you say more about that and, and how your views on that evolved? I think quite often people use the word competence and competencies interchangeably, and that is the root cause of the problem. If you look at competencies as traits, as the various components of our skillset, then yes, they are traits. But those should not be considered interchangeably with competence. Competence is the basic level, which is the floor. Beyond that, in my mind, and, uh, I have published on this as well, comes proficiency, which is the level where we want all our trainees to graduate so that they are proficient and safe as surgeons. Then come the aspirational goals of expertise leading to mastery. And this is a little bit of a take on [00:06:00] the Dreyfus and Dreyfus model, but it's a simplified way of looking at things, and I think all of us as surgeons need to aspire to reach expertise, and also to achieve mastery and to maintain that across our lifetimes. And what really keeps me grounded is the knowledge that all of us have, and, uh, the feeling all of us have, and that is if we needed an operation or our family members needed an operation, we would not go to a competent surgeon. We would perhaps not even go to a proficient surgeon. We'd want an expert or a master to really operate on us. Yeah. Well said. So what structural changes from your tenure do you think genuinely moved the needle on how surgeons are trained? You know, during my tenure, as I mentioned right at the beginning, the six core competencies were taking hold. They were about a year, year and a half old. [00:07:00] In addition to that, simulation was being focused on in a very, very basic way. In fact, we had a sim center that we had established in Philadelphia at a university hospital, as did many other institutions as the MIS movement took hold. And those centers were really driven by industry funding and had no standards. And that was a huge concern for me, even as I set up with our MIS chief-owned sim center, and, uh, we were talking about some of that in the VA as well And what I wanted to do was to really build on that, and I'll come back to that in a second. In addition to that, the science of education had evolved a fair amount since the early mid-'80s when I got involved in a very big way in surgical education. But still, the conceptual frameworks, the foundational theories were not [00:08:00] being adopted into our work as fully. In addition to that, surgical educators were not being recognized or advanced as much despite the landmark work that the Association for Surgical Education did. I had the privilege in the mid-late '90s to work with a task force of the Association for Surgical Education to create a four-level model of teacher, master teacher, educator, master educator. And some years down the line after I joined the college, that became the basis of our academy that we've established that I serve now as the senior vice president for. And even now, there is a huge amount that us surgeon educators need in the way of support. In addition to that, when I joined the college in that era, CME was being done. We had a clinical congress at the college. We had CSAP. But really, the science of CME and [00:09:00] continuous professional development were in their infancy, not just in surgery, but across all the medical and health professions. And of course, the college had three programs when I joined the college, the clinical congress that I was charged to redesign, which we made big headway with CSAP that we changed every three years across the many editions of CSAP that I had the privilege of leading with the chair of CSAP, John Weigelt, over the years. And the Surgeons as Educators course was the third course that I had the honor of getting off the ground for the college, along with four other well-known surgeon and surgical educators. And I say surgical educators because we had a PhD educator there as well. We got that going a couple of years before I joined the college. So those are the three programs that we established. Now, with that foundation, when I came to the college, the first thing was to look [00:10:00] at what was going on at the national level and what should be going on at the national level. So I engaged in dialogues with other leaders from surgical societies, especially the ones dealing with surgical education. And while we were looking at the whole waterfront on the national scene, my job was to create the structure of the Division of Education. So we started growing the division in a planned way. And one of the things I thought we should do is to engage the leadership of the college right away. We had many committees within the college. Even now we have. In fact, we have more committees now than we had at that time. And there were really basic committees in the education space that were dealing with some of the programs of the college at that time. So the first thing I did was to have four regions of the college take [00:11:00] on the four core competencies other than medical knowledge and patient care. At that time, patient care did not include technical skills. In fact, the procedural skills got added to the patient care competency. Some years later, when I was on the board of the ACGME at that time, uh, there was a big push made by the college and other constituents to add procedural skills to the mix. But at that time, those were the two, knowledge and patient care. And those were being done needed to be taken to the next level. But where there was a total vacuum, in a way, was structure in the area of interpersonal communication skills, professionalism, practice-based learning and improvement, and systems-based practice. So right off the bat, within a year of my joining the college, we got those four areas headed by a regent. I co-led those efforts, and we appointed a committee for each one of those, a task force, [00:12:00] and got an agenda going of a vision, what programs, educational programs, and curricula might be needed, and how we need to address these competencies. So that was a huge move to get the regents engaged in education in a very different way. And also, it had the benefit of crossing all surgical specialties because the college is indeed the house of surgery. So we started creating the space while we were redesigning the Clinical Congress, restructuring it completely from the bottom up, and redesigning CSAB Along with that, I also felt very early that we needed some specific focus on leadership. And a lot of people told me what we even hear now from people who are involved in surgery, that surgeons are natural leaders. That is true. We lead in the OR, we lead on the floors, we lead in various surgical environments. But really there's a science to leadership. So we got a group [00:13:00] together to conceive the model of the Surgeons as Leaders course that got off the ground very quickly. And the next thing we did was to start working on the simulation agenda, because as I mentioned before, there was very little structure there. So we got a group together to look at simulation in a different way and to create standards for accreditation of simulation centers. And I worked very closely with Dr. Carlos Pellegrini, who was then on the board of Regents, and we call it the effort to get the Education Institute program going, and we call them ACS Accredited Education Institutes because of their large footprint and their reach, not just in training individuals and teams, but also looking at systems of healthcare and safety So we got that program going in 2005. I joined in 2001. And [00:14:00] at the same time, we created a very unique and different program for patient education because, uh, when I was in Philadelphia, it was very clear to me as a practicing surgeon, very active in practice, that our patients were going home with all kinds of tubes, drains, uh, gadgets, and they didn't know how to take care of them. That problem is even worse now because of the fact that people have even shorter lengths of stay in the hospital, we all know that, and still people go away with gaps in their skillset. But we got a program going for patient education with the right educational underpinnings, and I recruited a nurse who was at that time at the master's level. She got a PhD while she was with us, and she headed a lot of the research and development in patient education, looking at it very differently. I should mention that the philosophy that guided my thinking, and the one that [00:15:00] I proposed to the regents was something called the Blue Ocean Strategy, which was described in the Harvard Business Reviews around the time I joined the college. And that strategy or that philosophy articulates the fact that we should not be competing for the same piece of the pie. We need uncontested space that we need to create through our vision, through our leadership, that has really no competition, uh, that is unique and different. So all the stuff that I was involved with in creating the division, we used that philosophy. We did not want to replicate or duplicate what others were doing. We needed to collaborate with them, but yet we needed to create our own space that would be very unique and that the college could really foster, support, and advance. Thank you for sharing all of that. That sounds like a very impressive series of accomplishments and a very important agenda. We wanna shift gears a [00:16:00] little bit and talk about some of the challenges that you faced in your role. Are there any directions that the field of surgical education has taken that, looking back, you feel may have been misguided? Any initiatives that seemed promising but didn't pan out exactly how you thought it would? Let me start by mentioning that I try not to have any regrets. Uh, we all learn from our experiences when we are breaking new ground, when we are doing innovations. We have to think about things outside the box, and sometimes those will work, and sometimes the time isn't right, and we have to revisit them, or perhaps even the concept isn't quite there. One of the challenges that we faced very early was the work hours restriction. Actually, I was on the board of the ACGME at that time when the work hours issue came up, and we immediately created a task force that involved people and leaders from all the surgical [00:17:00] specialties. It was led by Dr. L.D. Britt. I co-led the task force with him, and Dr. Gerald Healy, another past president of the college, played a huge role in that, and we had a complete focus on work hours as they would be viewed through the lens of surgery. And we testified before the ACGME. I had dual hats. I was in the board of the ACGME, and I was co-leading this task force, and that was a very worthwhile exercise, and certainly the work hours are being looked at even now, as all of you know. And we are determining what the best model is, how much flexibility we need at the senior levels, how we can really train the next generation to be the greatest surgeons they can be. But that was one big area that impacted us right away. The other item I would mention is that we got very heavily [00:18:00] into the area of competency-based education even before it was a household term. And we got into collaboration with the Association for Surgical Education and the Association of Program Directors in Surgery, and we created iconic educational programs for medical students, for residents, and we also then started creating similar ones for practicing surgeons. Now, those curricula are still on our website. They have gone through a lot of change. And one of the challenges there has been adoption of them or adaption of them into the local environments, and that is because some of them are resource heavy, and we all know, uh, resources for education are limited, and they're getting more and more challenging as we speak In addition to that, uh, I had the real privilege of negotiating [00:19:00] with SAGES, our collaboration, and our partnership with FLS, another iconic competency-based education program, and we went into partnership with them, and we are co-owners of FLS, which is dually branded with SAGES. In the practicing surgeon area, we have focused on competency-based education, and that has had its own challenges because we can create skills courses for our clinical congress program and for our accredited education institutes working together with them. But the issue is: how do we pay for that? We cannot charge thousands and thousands of dollars for each practicing surgeon to come and avail of those resources, get verified for us to provide the certificate. And then the challenge comes up: how do we provide structured preceptoring? Now, one of the areas, as we all know, that has [00:20:00] really been quite prevalent has been the training of surgeons in robotics, where they go through an industry-sponsored course generally, and then they go through something called proctoring, which is unstructured by and large, and it is really ad hoc. But more than that, the terminology is not correct. This is something I'm very passionate about, and I've written about and, uh, I've distinguished between preceptoring and proctoring. We need preceptoring first, and then we need proctors to assess the skill. There are two elements that are kind of wrapped into one, and that has still remained a challenge for us at the national level as educators, not only in the robotics field, but in other areas. And some of that is truly limited because of the resources and the fact that all these courses and the verification programs and the preceptorship, all that requires funding, [00:21:00] and who pays for it? And what is the value proposition? Which I think is the question we are going to have to answer as educators and as leaders and administrators to move the field forward. The other challenge that I find is that our system, which is wonderful, we have the best education system in the world, and I have no doubt about that, it's still compartmentalized. The first piece is medical students, residents and fellows, and practicing surgeons. Three different sets of accrediting organizations nationally, quite often handled by different faculty members and different staff within surgery departments and within institutions. And with different standards. That is an issue we need to continue to work on bridging, and bridging more effectively. And some of that is happening where communication is getting better [00:22:00] between medical schools and residency programs with bi-directional flow of information, but learners, some of that is beginning to happen at the end of training into practice, but there's still a lot that still needs to be done. And the other thing is, of course, there hasn't been a clear demarcation of the roles of all the national organizations involved with various activities, so there is a certain crossover of activities from assessment into education, or vice versa. And what we need to do is look at this in a real planned way, and some of the surgical specialties have begun to do that, and figure out what the role of each national organization is so we're not losing time and wasting effort, especially when resources are so scarce. We need to complement each other and work towards common [00:23:00] goals. So those are some of the challenges I find, but one of the big, big challenges that remains, as I mentioned before, are the resources which, hopefully, we can get a little more into if you'd like during this conversation. Yeah, I would like to talk more about that, but I'm, I'm fascinated by this idea that, like you said, we have all these different organizations that are doing bits and pieces of education here and there. What do you see as the ideal state, going back to that blue ocean, blue sky concept? How should that be organized to make it most efficient and effective for surgical education nationally and internationally? Great question. I think we need, within each one of our specialties, surgical specialties, as you know, have their own review committees, they have their own certifying boards, and they have their own academies or colleges. What we need to do is get the leaders of all the groups together, [00:24:00] and each one of the specialties needs to decide, okay, there's room for all of us. We all have a role, but how do we deal with this issue, and what does each party do? And do it for the learner, do it for the profession, do it for the patient, ultimately, so that we have the products we need coming out of our training programs and our certification and verification activities. So that's the first thing. Then we need to stay within our lanes and complement each other and have ongoing conversation that is very meaningful In addition to that, one other element that gets lost quite often when we're talking about these national endeavors is the role of the local educators and the universities and the medical schools and the surgery departments. And that is where I believe we [00:25:00] need a lot more action and coordination as well. I'm so delighted that there are surgery departments now that are collaborating and pursuing original research, getting funding. We have a lot of collaboration that's going on across the simulation centers, our AEIs, as I mentioned before. But we really need much more done at the local level, and the local activities need to complement the national standard setting. National organizations, regardless of which one it is, cannot do everything that the local folks can do and should be doing and are doing. So I think what we need to do is really leverage that strength, the expertise that lies within universities. And that is beginning to happen with individuals being appointed in leadership roles within surgery departments, in the dean's offices supporting some of that, the hospital systems [00:26:00] putting some money. But I believe a lot of the action, uh, in the future is going to be local and regional, especially as the hospital networks continue to expand and they begin to offer their own training to their own people. I think the national organizations have a big role, but the local organizations need more emphasis. And the two sets of folks, both nationally and locally/regionally, need to work together for the betterment of surgical education, most importantly the learners and then the patients. Uh, otherwise we will not be using our resources appropriately. So that is my vision. I think there's a role for everyone I wanna go off something you said there. You know, as you said, many of the big hospital systems are expanding, small hospitals are contracting or going away. [00:27:00] There are organizations, like you said, some for-profit organizations that are starting to initiate their own training, and there's even talk of their own accreditation programs. And so what do you think about that balance between the need and the drive for productivity and taking care of patients? Because there's a lot more patients that are a lot more complicated than they've ever been, and yet still, uh, providing some focus on training. Where does that balance lie and, and whose responsibility is it? Another very good question. I think the pressures on the faculty members are gonna continue. There is no solution in sight because people have to bring in the revenues to keep the local institutions going and have to continue to, uh, produce the RVUs. What I think we need to do is, first of all, we need to [00:28:00] train, recognize, reward, and advance surgeon educators. That is absolutely key, and they need to be complemented by professional educators locally and regionally within systems. If you have expertise, you can do a better job with education. You know, it's like a surgeon. We were talking earlier about surgical expertise. There's educational expertise. We would get better results in a shorter time if we had expert surgeons who have expertise in education and are educational leaders. So there needs to be a huge, huge emphasis on training and advancing surgical educators, which would be one solution. We would certainly see efficiencies in that regard Secondly, I think the local networks and the hospital [00:29:00] systems and the dean's offices and the practice plans, they all need to recognize that there is a value to education, and that is not reflected in quarterly profit and loss statements or the revenues generated and the expenses incurred. They are accrued in the longer term, and there's no question that the impact of education is long-term. So we need to work with those leaders to change their thinking. Now, how do we change their thinking? Uh, because they obviously have to balance the sheets and report to their boards and other governing bodies. What we need to do is to change the language. Quite often, we use education and training, and that goes only so far It's standard terminology but only goes so far. We need to change the terminology to learning organizations [00:30:00] that are fulfilling the mission of the organization in terms of providing the best patient care. And if you have a learning organization in a system, in a network, within a whole conglomerate of institutions that are linked together and tethered together in some way, then we have a very complex learning organization which will accrue benefits faster than any other organizational structure. So we need to continue to work with those items. We need to align our thinking as educators with the thinking of the administrative leaders to see what their goals are, what their objectives are, what they are held to when their positions are being looked at, and link what we are doing with them and talk the same language that needs to be common. And we need to show the value, both short-term and long-term. And some of it is [00:31:00] not tangible in the traditional way. Some of it is, um, the reputation of the organization, the kinds of people we recruit for faculty, the staff we recruit and retain. The faculty that we mentioned earlier recruit but also retain and advance. In addition to that, what kinds of residents and fellows do we attract? What kinds of medical students and other health professionals do we attract? For example, if we have, um, great teamwork training programs and they involve surgeons, residents, nurses, et cetera, whether it's in the OR setting or it's at the bedside, and that teamwork leads to less of a turnover of nursing staff, isn't that an obvious advantage to the healthcare leaders in seeing that there's a tangible benefit to them, which is financial?[00:32:00] So I think we need to change our language and our approach. And at the same time, it is our responsibility as surgeon educators to make sure that the waste is limited. There is a lot of downtime in education. Education is not as efficient as it could be, and it is absolutely imperative for us as educators to make sure that we tighten our belts and provide the best education at the lowest cost. And also we have some cost accounting so that it's not just, um, a general value, it is also value that is associated with cost and benefit both. So I think it has to be a multi-pronged ground level up approach, and a lot of this will be driven at the local and regional levels, I believe. So i- back in November of 2025, you passed the torch off to Dr. Kyla Terhune. [00:33:00] She's the new senior vice president for education at the ACS. What advice did you have for her? What did you tell her? What are you hoping that she is able to accomplish in her tenure there? I'll be perfectly candid with you that I really don't have any advice for her. She is an accomplished surgeon educator. She has a lot of experience, and she has her own vision to take the division and the educational enterprise of the college to the next level. What I have done is to hand over to her what I think are magnificent staff members who we've been very fortunate to recruit. When I came to the college, we had three staff people. I handed over the division to her with over 50 staff people. We've got iconic programs, the Academy of Master Surgeon Educators, the AEI program, the Leaders Course, Educators [00:34:00] Course, iconic curricula and so on. So there are these programs, there are these staff members, and I have been available to Dr. Terhune. I have had regular meetings with her to answer her questions, give her some historic information, and also tell her about what we have done if there was a need to fill in some of the gaps. But our staff members have really carried the ball in terms of the transition, and I know she has a great vision for the future, and I wish her well, and I think she's gonna do a brilliant job. I look forward to continuing to be active in some way in surgical education, especially as it is growing so rapidly. And with technology and AI and other things coming into play, I think it's gonna look very different years down the line. And the thing that I hope to continue to do during the years ahead [00:35:00] is to continue to push forward with the expertise agenda and to help young surgeon educators grow, whether they are at the resident level, fellow level, in fellowships, or young faculty members because now there is a clear path to reaching the highest levels based on education as the academic ticket. When I got started with surgical education in the '80s, there was no path. We had to create a path. Now there's a path. And I think that's gonna need leadership in, uh, surgical education. And I believe, as Collins has mentioned in the Harvard Business Reviews and other publications, that good leadership or transformational leadership comes from a combination of humility and firm resolve. And I'm going to continue to work with the young people to inculcate them with that level of thinking, and to emphasize to them [00:36:00] that there will be challenges despite all the resources. And the important thing is to never, never, never, never give up, as Sir Winston Churchill had said. Thank you. It's been a real privilege chatting with you. Saj, thank you so much. Great conversation, and again, thanks for everything you've done for the college and education. Thank you.