Cutting for a career; a discussion of the domains of surgical competence using expert bespoke tailoring as a metaphor for surgical practice.

Competency based surgical training uses proficiency of technical skills to quantify surgical competency. We believe this is an over simplification of what is required to be a competent surgeon. This work aims to illuminate the attributes of a mature, competent, thinking surgeon. A bespoke (or custom) tailor is highly trained craftsman who produces unique items of clothing to the customers' requirements. This paper uses the practice of expert bespoke tailoring as a metaphor for illuminating surgical training and practice. A sustained and evolving dialogue with a single eminent tailor identified a number of emergent themes. A three-year iterative process included wide reading, interviews, observation, discussion and reflection. These emergent themes have produced a provisional working framework for exploring non-technical domains of surgical competence. Surgical practice is a complex process, which interweaves non-technical and technical elements in a seamless harmonious marriage of physical and mental processes. These processes need to be more clearly defined to allow the most effective training of future surgeons in the limited time now available. We discuss the benefits of illuminating these hidden facets of surgical practice, pointing out the limitations of defining competency in terms of knowledge acquisition and technical skills. If we are to train balanced, thinking surgeons for future surgical practice, and the training of future surgeons, has to be viewed as a complex integrated process rather than a collection of isolated domains.