2025 | Volume 26 | Issue 5
Supervision is the backbone of surgical education and training. But exactly how much is enough remains unclear. This question is central to a scoping review recently published by the Royal Australasian College of Surgeons (RACS). Undertaken by the team at ASERNIP–S, the review examined international evidence on the quantity of supervisor oversight for surgical Trainees and its impact on training outcomes.
FATES and the supervision challenge
The review forms part of the Flexible Approach to Training in Expanded Settings (FATES) program, an Australian Government initiative from the Department of Health, Disability and Ageing, designed to expand specialist training beyond metropolitan hospitals. The program seeks to broaden training opportunities so that the full potential of training in regional, rural and remote settings can be realised.
RACS is leading FATES 1: Rural accreditation, addressing barriers to rural specialist training in partnership with the Royal Australasian College of Medical Administrators (RACMA). This project examines how training-post accreditation standards, originally developed for large metropolitan teaching hospitals, can be adapted so regional, rural and remote centres are not disadvantaged.
The previous FATES 1 work identified the accreditation requirement for two to three FRACS supervisors per Trainee as a significant barrier for surgical units in regional, rural and remote settings with fewer surgeons. These hospitals may have fewer Fellows, but in many instances, they can provide similar or more hours of direct supervision compared to larger sites. Because current accreditation rules focus on headcount rather than supervision hours, this disconnect prompted the need to examine what the evidence actually shows about supervision during training.
The new report
The RACS review, Impact of the quantity of supervisor oversight on specialty training outcomes, synthesised studies from the US, UK and other international settings. It found that while supervision is consistently valued by Trainees and linked to better learning experiences, there is no clear evidence on the ‘right’ amount of supervision. Studies show wide variation in how oversight is delivered and reported. Interestingly, no study reported on the quantitative impact of any single aspect of training (e.g. number of supervisors) on the quality of the training program.
Findings
• Specialty training programs: Training varies widely across hospitals, with no agreed standards. Effective programs balance supervision, structured teaching and manageable workloads. International reforms highlight the value of simulation, competency-based assessments and regular review of training time and resources.
• Supervision: The supervisor–Trainee relationship is central to learning, with the quality of feedback and oversight more important than the number of supervisors. In some cases, smaller hospitals provided as much or more direct consultant oversight as larger centres.
• Observation and direct oversight: Supervisor presence in theatres and clinics, combined with real-time feedback, is associated with better Trainee learning and patient outcomes. Studies show uneven access to procedures across training sites.
• Autonomy and entrustment: Progress relies on supervisors’ decisions about when to grant greater responsibility, shaped by patient safety, Trainee competence and trust. Excessive oversight can reduce independence. Simulation and competency-based education were identified as tools that can support safe autonomy and readiness for practice.
Implications for accreditation
These findings align with the RACS Rural Health Equity Strategic Action Plan, which advocates measuring supervision by hours of direct oversight rather than by total headcount of available Fellows. Such an approach could enable smaller regional, rural and remote hospitals to achieve training-post accreditation without compromising training quality.
Why this matters
Expanding rural surgical training posts is one of the most effective strategies to address workforce maldistribution. Rural training not only provides a valuable educational experience; it also strongly correlates with future rural practice. Yet without flexible, evidence-based accreditation standards, many specialty training programs will be unable to expand training into more rural sites.
By shifting the conversation from ‘How many supervisors?’ to ‘How much supervision?’, the RACS review highlights the evidence gap and sets the agenda for future research in understanding appropriate accreditation pathways for rural settings.
The final report is available on the RACS website.
Acknowledgments
This project was supported by the Australian Government Department of Health, Disability and Ageing under the FATES 1 program. Other project activity is underway for FATES rounds 2 and 4, alongside consortium partners RACMA, the Royal Australian and New Zealand College of Ophthalmologists (RANZCO), the Royal Australasian College of Physicians (RACP) and the Australian and New Zealand College of Anaesthetists (ANZCA).