A new section named “Education, training, and methodology of research” has been launched in Updates of Surgery, with the aim of encouraging a scientific debate on how surgery should be taught and learned considering the relentless evolution that technology is facing before us. Addressing particular attention to young surgeons, this section will serve as a forum to stimulate continuous refinement of the standard of care in surgery.

To start, accreditation of surgeon and hospital in respect of volume outcome is the burning question in which we are stuck. In 2021, under the umbrella of the Italian Society of Surgery, we raised the question but unfortunately, it clearly appears as much of that claim has remained unheard [1]. The other authors have also tried, in different fields from oesophageal to hepatic surgery, to point out possible benchmark solutions [2,3,4,5] but no landing place we are able to see in the horizon. In 2016, Updates in Surgery had even published a collection of articles promoted by some of the Italian leaders in hepatobiliary, pancreatic, colorectal, and oesophageal surgery listing minimum hospitals and surgeons’ criteria to guide the credentialing process [6,7,8,9]. While those publications did not represent formal guidelines, they certainly offered a solid base for discussion between professionals and local or central regulatory agencies (Table 1). However, such discussion was never carried on in the institutional setting.

Table 1 Summary of requirements to be entitled to perform oncological surgery
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While it is generally accepted that higher is the surgeon’s volume activity better is the patient’s outcome, scientific societies, national organisations, and patient associations reasonably claim for minimum case volume thresholds to guide the surgeon accreditation, but so far there are still conflicting opinions among the involved stakeholders of this process [10]. Certainly, case volumes of a given specific complex procedure may serve only as a proxy measure of the quality of care which responds to many technical and nontechnical items that need to be uncovered in detail. Clearly, case volume reflects a complex interplay of multiple factors that cannot be simplistically synthesised by a threshold number. However, despite the opening debate by the Italian Society of Surgery towards setting rules by the government, 7 years after there is still a lack of national guidelines except some regional indications in Lombardia and Campania.

The Italian scenario is clear when reading the last report of the Piano Nazionale Esiti (PNE) published in December 2022 and covering the case volume of the previous year [11]. Taking the region Piemonte as an example, out of the 16 hospitals performing 346 liver resections, 12 (75%) hospitals performed fewer than 10 cases and 4 (25%) performed a single hepatectomy in 2021. The situation is not different for pancreatic surgery: among the 17 hospitals that recorded 197 pancreatic resections, 11 (65%) performed fewer than 10 cases and 8 (47%) hospitals fewer than 5 cases during 2021. If the reported 30-day mortality rate for liver surgery was acceptable overall, some hospitals recorded a double-digit 30-day mortality rate in pancreatic surgery requiring a time to change.

While a given threshold number of procedures may not be fully representative of a granted outcome in surgery, these numbers from PNE 2022 should represent an alert and should favour a complete discussion from the National Health Institutions on this topic. Overall, the situation is the same in most of the Italian regions: the centralisation process for complex procedures is far from being fully operational in Italy and alternatively, is also far from the hub-and-spoke model expected by the national health system. Formally defined, the hub-and-spoke is a model that arranges service delivery assets into a network consisting of a leading centre (hub) offering a full array of services, complemented by some secondary centres (spokes) that offer more limited services redirecting to the hub patients needing intensive care assistance. [12] Notably, this model is the one that is believed to be able to solve important disparities that limit patient access to specialised cures, such as those related to geographical territorial complexities, health professionals and technological resources which should contribute to limiting patient migration.

In 2018, a special committee from the European Surgical Association published a landmark paper [13] that listed 12 recommendations for the development of centralisation strategies (Table 2). To the best of our knowledge, these recommendations have not been yet fully considered neither applied by government agencies.

Table 2 European Surgical Association recommendations for centralisation
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While patient’s safety cannot be derogated, and it should be the main argument for the centralisation of high-risk complex procedures, the education and training of young surgeons raises another option in favour of a hub-and-spoke system. It is now time to rethink the postgraduate track in general surgery so far limited to offer a standard practice in general surgery over the 5 years of residency. Last year of residency as well the following year soon after could be structured into a specialty fellowship, allowing the young surgeon to achieve a complete training in more complex procedures in high-volume centres according to the trainee’s choice. We should also consider that the education and training process of young surgeons is now shortened and facilitated by the spreading offer of minimally invasive surgery, 3D vision, augmented reality, and mastering by the robotic console. This change in the postgraduate track in general surgery should be seen as an opportunity to establish, follow, and monitor a completely new surgeon credentialing process that the Italian Society of Surgery could contribute to design and oversee.

We think the time is ripe. Whoever the decision maker is, he will be obliged to consider all the figures: primary responsibility towards patients who deserve the best care and to the new surgeons who need to get full acquaintance of the most complex procedures to become the specialists of the incoming future. Surgeons’ associations should take these issues into their own hands to prevent the risk of leaving things as they are while the real-world data run fast ahead turning the tables under our eyes. Such opportunity for change could also give benefit against the dramatic contemporary surgical vocation crisis of new medical doctors. In the current academical year in Italy, there are 191 (29%) job vacancies with only 9 residency programs without vacancies, 2 programs with 100% of vacant positions, and most of the remaining programs with 30–50% of vacancies. If surgeons of the future deserve better education, and better training, we, surgeons of the present, should be the protagonist of that change.