Background: The topic of discrimination, bullying and sexual harassment in surgery was raised in the Australian media earlier in 2015. This led the Royal Australasian College of Surgeons (RACS) to commission an Expert Advisory Group to investigate and advise the College on their prevalence in surgery in Australia and New Zealand. This paper reports the findings with respect to prevalence of these inappropriate behaviours. Methods: The data in this paper were drawn from the published results of two quantitative surveys. One was an online survey sent to all RACS members. The other was an invited survey of hospitals, medical institutions and other related professional organizations including surgical societies. Results: The prevalence survey achieved a 47.8% response rate, representing 3516 individuals. Almost half of the respondents 1516 (49.2%) indicated that they had experienced one or more of the behaviours. This proportion was consistent across every specialty. Male surgical consultants were identified as the most likely perpetrators. More than 70% of the hospitals reported that they had instances in their organization of discrimination, bullying or sexual harassment by a surgeon within the last 5 years. Surgical directors or surgical consultants were by far the most frequently reported perpetrators (in 50% of hospitals). Conclusions: Discrimination, bullying and sexual harassment are common in surgical practice and training in Australia and New Zealand. RACS needs to urgently address these behaviours in surgery. This will involve a change in culture, more education for fellows and trainees, and better processes around complaints including support for those who have suffered.

Clinical decision making is a core competency of surgical practice. It involves two distinct types of mental process best considered as the ends of a continuum, ranging from intuitive and subconscious to analytical and conscious. In practice, individual decisions are usually reached by a combination of each, according to the complexity of the situation and the experience/expertise of the surgeon. An expert moves effortlessly along this continuum, according to need, able to apply learned rules or algorithms to specific presentations, choosing these as a result of either pattern recognition or analytical thinking. The expert recognizes and responds quickly to any mismatch between what is observed and what was expected, coping with gaps in information and making decisions even where critical data may be uncertain or unknown. Even for experts, the cognitive processes involved are difficult to articulate as they tend to be very complex. However, if surgeons are to assist trainees in developing their decisionmaking skills, the processes need to be identified and defined, and the competency needs to be measurable. This paper examines the processes of clinical decision making in three contexts: making a decision about how to manage a patient; preparing for an operative procedure; and reviewing progress during an operative procedure. The models represented here are an exploration of the complexity of the processes, designed to assist surgeons understand how expert clinical decision making occurs and to highlight the challenge of teaching these skills to surgical trainees.

A predefined philosophy of surgical education may serve as a useful reference point when choices arise during the development of surgical training.

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