Docere – A forgotten priority

By Maile Wedgwood

Introduction

This essay is intended neither to scrutinise nor blindly praise, rather to serve as a reflection on how I was inspired and fell in love with orthopaedic surgery. But for you, as readers, to grasp what impact individuals can have and contemplate the etymological origin of the word ‘doctor’. It is from Latin, ‘docere’, meaning to teach. As holders of the GMC numbers, perhaps also on the specialist register, how often when you go to work does being a teacher come to mind?

Although orthopaedics is a surgical speciality, the foundations were built as being doctors, yet the original connotation of the word appears to have eroded over time. During work hours, do you take time to teach another individual? Or has docere, faded into the annals of history, overshadowed by the crumbling NHS bearing down on your shoulders¹. Perhaps docteur, coined in the Renaissance has also withered away from teacher, instructor; one skilled in a learned profession².

Through my junior eyes, a final year medical student, it is evident that the learning environment within the NHS has decayed^3,4. Not only at my level but also as one progresses through the stages of postgraduate training. The British medical education system has become a desperate sprint, rush to learn the NICE CKS guidelines, tick the boxes, log cases, pass exams and be minimally competent. Paralleling medical school curricula, postgraduates experience the push for rapid rotations to ensure ‘equality’ in exposure but at what cost. Is the system sacrificing humanity of trainees, leaving them bereft of opportunities to develop meaningful skills and relationships. This constant ‘pressure’ that the NHS has been under since the 1980s, push trainees aside as they are seen as hinderance of effectiveness and time⁵. Is the system genuinely built for educating and cultivating the next generation when opportunities for trainees to learn core surgical skills are robbed by new roles from the wider NHS workforce. Perhaps some may blame the dreaded C word - Coronavirus, for this trend of sidelining education in the surgical field.

The 2024 BOA Congress, themed ‘Recruit, Sustain, Retain’, focused on numbers: falling in trainee numbers, rising in patient numbers and financial metrics⁶. I walked away with a flurry of statistics but failed to ascertain the individuals behind each of those and a genuine cause to the decline. Despite the negativity I write within, this essay seeks to highlight the optimism rooted in the essence of docere - positivity that inspired and fostered my learning environment.

Pressurised priorities and historical philosophy

Amid the demands and pressures of the NHS, it is all too easy to prioritise clinical responsibilities and resonate with Mulholland et al.’s paper titled: “I’m a doctor, not a teacher…”⁷. It must be acknowledged that not all individuals are able to educate effectively, thus Harvard’s medical curricula implemented a course on teaching⁸. However not only is the origin of the definition of doctor, is to teach and to show, but it forms part of professional obligation outlined by the General Medical Council to be ‘prepared to contribute to teaching and training doctors and students’⁹.

Within the Hippocratic Oath, includes a commitment to teaching and sharing knowledge with students¹⁰:

- Share knowledge: “I will offer my skills to the young with the same generosity that they were given to me”

- Teach students: “I will teach them this art if they require to learn it, without fee or indenture”

This erosion of teaching and cultivation raises a difficult question: have clinicians simply abandoned these responsibilities, or has the system's unsustainably high workload, combined with the NHS's failure to ensure a safe and supportive educational environment, overwhelmed doctors^11,12?

Historically, the apprenticeship model was the cornerstone of medical education¹³. Students shadowed mentors over long periods, observing not just clinical techniques but also the values and ethos of their profession. The philosophy of mentorship emphasises the importance of learning as a continuous process, grounded in relationships that adapt over time¹⁴. In Greek literature, Odysseus entrusts Mentor with his son, Telemachus. Mentor acts as a teacher, advisor and friend to Telemachus, leading to the current definition of mentor; an experienced and trusted advisor. Long-term learning is not just about acquiring knowledge but about fostering critical thinking, emotional intelligence, safe learning environment, and the ability to navigate complex situations. Most importantly developing trust between the trainee and trainer is paramount^15,16. This allows for authentic engagement beyond numbers on a portfolio, where confidence of trainees allows for risks to be taken and creates assessment for learning¹⁷. As Kolb’s experiential learning theory suggests, learning is a cyclical process involving concrete experiences, reflective observation, abstract conceptualisation, and active experimentation¹⁸. Long-term mentorship facilitates this cycle by providing continuity, allowing trainees to apply new knowledge, reflect on their experiences, and gradually refine their skills. This approach fosters not only competency but also the confidence and adaptability needed for independent practice.

The Latin root docere reminds us that teaching is not a luxury but a fundamental aspect of our profession. Yet, teaching is often sidelined, risking the NHS as a system that prioritises short-term efficiency over long-term excellence.

Transactional rather than transformative

British medical training is prolonged and broad, yet paradoxically structured around short, rapid-fire rotations. This design aimed to ensuring equitable exposure for both trusts and trainees, often leave little time for substantive teaching and mentorship. Whilst this model offers breadth and equity, it often sacrifices community and continuity, resulting in significant challenges for trainers, trainees and ultimately, patients. Furthermore, the unspecialised nature of many rotations serves as a mask for service provision, with trainees shouldering responsibilities of the hospital maintenance rather than advancing meaningfully through their speciality training. Trust is fundamental and necessity to all social interactions, in a study by Towers Watson indicated that on average it takes seven months to develop professional trust¹⁹. However, students like myself rotate every six weeks, as a FY1 every four months and in speciality training every six months. This raises an important question: does the current training environment allow sufficient time for meaningful trust to form? As trainers, when do you begin to trust your trainee? Unlike rapport building with patients, the propensity to trust varies between professionals and the transient nature of these rotations forces trainees into superficial relationships^15,19. This dynamic prevents the development of mentorships that could unlock the full potential of trainees, leading to downstream effects for patients, who may encounter less prepared doctors as a result²⁰. Perhaps by adopting elements of the training models in other countries, where trainees are afforded stability to focus on honing their expertise and education, rather than balancing the dual roles of learner and service provider, we could create a more effective learning environment and ultimately improve patient care.

The rapid pace of rotations also disrupts continuity in learning. Whilst many medical school curricula often describe their 'spiral' structure, which thrives on continuity, the reality at both undergraduate and postgraduate levels is disjointed. Longitudinal care of patients improves their outcomes, yet trainees are rarely afforded the opportunity to observe and learn this holistic approach²¹. Paralleling approach to patient care, continuity in mentorship significantly improves decision-making and long-term skill retention compared to fragmented training models²⁰. Whilst discussing 'equality', EDI must be also considered, which long-term relationships with supervisors can have a profound effect. By fostering meaningful connections, it creates opportunities for underrepresented individuals to gain access to networks, confidence and guidance. Not only does a mentor guide and support their mentee, but the next generation of surgeons often has the potential to motivate and influence their mentors in return, fostering a dynamic and collaborative exchange of inspiration.

By failing to account for the human element of trainees in such short rotations, the system risks fostering a perception of education as transactional rather than transformative. Does this experience leave the next generation trapped in a model that stifles inspiration and fails to nurture the trainees and students who follow?

The NHS: Place of service and learning

The NHS is one of the largest training grounds for healthcare professionals in the world. However, under the strain of rising patient demand, staff shortages, and limited resources, its role as a place of learning is faltering. Overwhelmed by service demands, the learning environment is eroding and, at times, becoming toxic. Opportunities to reflect meaningfully, ask questions, and develop core skills are increasingly scarce.

Anecdotally between my peers, we have felt guilty being on our clinical rotations for seeking teaching or learning opportunities. Whether it be asking to scrub into procedures and practicing surgical skills. Thoughts that we are an added burden to the overwhelmed NHS where time is a precious commodity. Beyond stifling curiosity and diminishing the educational experience, the introduction of new roles in the wider NHS workforce, such as Surgical First Assistants (SFAs) and Physician Associates (PAs), threatens to limit trainees’ hands-on learning opportunities²². Rather than upskilling these new roles in areas such as theatres, where trainees already face stiff competition for experience, why not focus their scope of practice to day-to-day administrative tasks? By assisting doctors with these responsibilities, they could create more opportunities for trainees to focus on their surgical skills. This raises the question: is the NHS moving towards a 'see none, do some, teach none' model, where short-term efficiency is prioritised over the long-term goal of training future surgeons?

Most of us can likely recall a moment in the past couple days where we prioritised immediate demands over educating someone eager to learn and perhaps the negativity that may have unintentionally inflicted on that individual. Similarly, senior clinicians often feel overwhelmed, leaving them with limited capacity to dedicate time to mentorship and ‘create time’ in procedures for trainees. Without structured opportunities for teaching, the potential for meaningful mentor-mentee relationships dwindles.

The power of long-term mentorship

Building trust and fostering a sustained learning environment allows for personalised guidance and advocacy. Trainers can understand the unique strength, aspirations and challenges of their trainees which enables guidance from navigating complex clinical cases to planning career trajectories. In such rich relationships, there is room for advocacy, ensuring trainees are not pushed aside during busy shifts but instead given opportunities to develop themselves. Without such practice, how can you expect trainees to be confident once they are consultants. A long-term mentor not only provides clinical guidance but also emotional support, helping mentees build resilience and coping strategies for adverse events²². This support is particularly crucial during career transitions, such as preparing for exams or applying for specialty training and fellowships.

Mentors inspire more than competence; they inspire a love for learning. By sharing their passion for their specialty, mentors can ignite similar enthusiasm in their mentees. An example in surgery would be demonstrating surgical skill and precision alongside a commitment to holist patient care. Mentors have a responsibility to role-model both surgical and non-surgical skills which transcend any single procedure. There’s an element of legacy in building such long-term mentorship with a ripple effect of teaching and learning. This culture of docere cycles and strengthen the profession as it passes from one individual to the next. Having had such positive experiences in orthopaedics, this has formed part of my mission and practice, whereby I offer support and guidance to fellow students.

Integrating teaching and mentorship to practice

Whilst the benefits of long-term mentorship are clear, implementing it in the NHS is not without challenges. On an individual level, one may feel that they are not qualified to teach and constrained by time. On an institutional level, it must be recognised that students and trainees are people and must be given the time to be nurtured. The key lies in finding creative solutions to integrate mentorship into the realities of modern healthcare.

It must be acknowledged that teaching in itself is a skill, which perhaps should be integrated in the grassroots of medical school curricula⁸. Some individuals incorporate teaching into their daily practice seamlessly and exploit learning opportunities that arise during clinical activities (e.g. handover, ward round, clinics). Simply verbalising actions and thought processes also enables learners to understand and develop clinical reasoning skills. In orthopaedics, I have witnessed several excellent examples of mentorship, such as guiding trainees through techniques, discussing the underlying theories, highlighting potential pitfalls and teaching them how to manage adverse event when they arise. Within the apprenticeship model, mentors take a structured approach: demonstrating procedures, breaking them down into steps, guiding trainees as they master each step, and providing repeated opportunities for hands-on practice. This approach not only helps trainees master core surgical skills but also enable them to confidently perform complete procedures with competence and precision. On an interpersonal level, I have also seen many trainers and trainees genuinely enjoying their profession, sharing inspiring discussion about new surgical innovations, exchanging ideas, and engaging in light-hearted conversation that build camaraderie and foster a positive, supportive working environment. This continuity reinforces the idea that teaching is not an inconvenience but a core responsibility.

Trainees and students should also take responsibility for seeking mentorship and advocating for their educational needs. A shift in mindset that teaching is not a privilege but as a right and as a shared duty.

Personal experiences mentorship in orthopaedics

February 2024 was an ordinary timetabled orthopaedic teaching clinic. It wasn’t just the impactful consultant led teaching, but more so the invitation to join him in theatre the next day. In that moment, I felt wanted by the NHS. As a student there is an element of guilt on placement, that we are in the way but this feeling – that I deserved to come and learn – was transformative. Over the course of the year, eight rotations and over 16 supervisors, this consultant made a sincere effort to be a mentor. Without such long-term mentorship I would have struggled to grow, gain confidence, and build the portfolio needed to pursue orthopaedics. Reflecting, I doubt I would have been prepared nor wanted to apply for the Trauma and Orthopaedics (T&O) Specialty Foundation Programme, which I am proud to have been offered in my local deanery.

The opportunities provided through this mentorship are unparalleled. I am forever grateful for this consultant taking me under his wing. The irony of all this, the medical school didn't even hire him to be a supervisor for the block, instead this was out of his goodwill and embodiment of docere. By integrating me into his team and the orthopaedic department, I gained countless invaluable moments. Whether the team illustrated diagrams of knee biomechanics on scrap paper, spending extra time with patients to prepare me for exams, or explaining surgical techniques in detail. These are things that a lecture slide or a fleeting clinic experience could never teach. However, what I valued the most, is the personal connections I have made with so many individuals throughout this mentorship, whether it be the scrub nurses, trainees or researchers beyond this team.

Mentorship does not stop at the immediate relationship between mentor and mentee; it extends into every interaction it influences. During the 2024 Congress, I was fortunate to meet surgeons who embodied docere, again an event I wouldn’t have attended without encouragement. Nervously walking around the conference floor, I inserted myself into conversations, which led to incredible moments of inspiration, learning and opportunities.

One particular hand surgeon, who shared how he teaches his own students, set me a challenge: suture a satsuma. Sheepishly, I brought my sutured satsuma (in fact it was an easy peeler) the next day, unsure if it would even amuse him. To my surprise, he took over one of the mini tables at the DePuy stand to demonstrate suturing techniques, offering me further challenges and follow-up images for months afterward. On the last day of the Congress, during the Hunterian talks, he turned to me and said, “You better win that”, sparking a long discussion about how I could one day stand on that stage. Which has had a lasting impact of inspiration and aspiration to pursue orthopaedics.

Symbiotic relationship with confidence

Such mentorships are rare. Anecdotally, I am the only student in my 200-person year group who has had such guidance and opportunities. Peers often ask, “How did you do it?” or “Gosh, you’re so lucky”. Yes, I am lucky to have met surgeons who embrace docere, but relationships are two-way. Utilising my free time to foster long-term mentorships has allowed me to gain confidence in my clinical practice and propel a passion for orthopaedic surgery.

Confidence, or the belief in one’s abilities, is a cornerstone of professional growth. However, students and trainees often face barriers that erode their confidence: perfectionism, comparison culture, past negative experiences, and the rapid pace of change in medical education. These insecurities are compounded by negative self-talk, fear of judgment, imposter syndrome, and dependence on external validation. Long-term mentorship is uniquely positioned to counteract these barriers. My own journey is a testament to this. The consultant who mentored me did more than teach; he created a safe environment where I could learn without fear. He offered constructive feedback, modelled resilience, and empowered me to take on challenges.

This mentorship allowed me to grow not only as a student but as a person. When my personal life was in turmoil, I found support in the team of consultants and registrars at my DGH. The value of this human connection cannot be overstated. Medicine is a field that thrives on relationships, yet why has this connection been robbed from so many trainees and students? Without this support, I would have struggled to navigate the challenges of medical school and life beyond it.

Reclaiming docere

The Latin root of 'doctor', docere, reminds us that teaching is an inseparable part of our identity as medical professionals. In a healthcare system under immense strain, the teaching ethos must not be lost. Long-term mentorship offers a powerful means of reclaiming this ethos, inspiring trainees, and fostering confidence that enables them to thrive. We must evolve the profession to prioritise training opportunities rather than service providers by leveraging the wider NHS workforce to create a more focussed learning and enriching environment for trainees.

Reflecting on my medical school journey, I am reminded of the mentors who shaped it, not just through what they taught me but through how they made me feel valued and capable. To those who hold GMC numbers, I pose this question: When you walk into work tomorrow, will you take a moment to teach? To inspire? Because in that moment, you are not just a clinician; you are a teacher, carrying forward the legacy of docere.

Acknowledgements

One quick note of to my mentors; I’m sure the individuals know who they are, thank you. Thank you to South Warwickshire University NHS Foundation Trust for providing me with such invaluable experience throughout my degree.

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