“Supervised” is the most abused word in surgical training, so this page states exactly which version of it is meant.

Direct supervision means the consultant is scrubbed, at the table, watching the field, and able to take the instrument out of your hand inside a second. Not in the next theatre. Not in the coffee room. Not reachable by phone. Supervised surgical training in this module uses the term in its strict sense, because the loose sense is how trainees end up doing things nobody senior actually saw.

However, the other arrangements deserve naming honestly. Indirect supervision means the consultant is in the hospital and immediately available, which is reasonable for a wound review and unreasonable for a critical operative step. Distant availability means a name on the notes and a phone switched on, which is governance rather than teaching. In the operative skills workshop, every operative step a trainee performs happens under consultant supervised operating in the strict sense, and the alternative is not a lesser version of it, the alternative is that you watch.

• Direct supervision here means scrubbed, at the table, watching the field, and able to take over immediately, with no looser version substituted.
• Supervision levels move step by step and case type by case type as you earn them, and they move backwards for a difficult case without it being a punishment.
• Patients consent to the arrangement, and a trainee’s learning never outranks a patient’s safety at any point in the operation.
• Correction happens in real time, in short specific instructions, with the reason stated briefly so it carries to the next case.
• Cases are logged with the role you actually held, countersigned by the consultant, since an inflated logbook is worse than a thin one.

Progress is described in surgical training supervision levels, deliberately narrow ones. You observe. You assist with retraction and exposure. You perform one defined step under direct supervision, then a sequence, then the closure. Then, for straightforward cases only, you lead with the consultant scrubbed throughout. Each level is granted for a named step in a named case type, which is why graded operative steps are recorded per step rather than as an overall rank.

Furthermore, movement is not one-directional. A trainee doing the dissection in routine gallbladders goes back to assisting when the next case has dense inflammation, an unclear duct or a previous operation in the way. That is not a demotion. In addition to that, nothing here is time-based: two trainees who start together can sit at different levels after three months, because the record justifies different things.

A postgraduate trainee in Dhaka, in his late twenties, arrived expecting to operate within a fortnight and spent considerably longer on exposure and retraction.

He was frustrated, and said so. What changed things was not more time, it was two habits: handling tissue as though it would be there tomorrow, and describing the anatomy out loud as he exposed it. Once both were consistent, the gallbladder dissection came to him in pieces, with the consultant scrubbed beside him and the instrument changing hands twice in the first case. He now defends the waiting he resented. No case numbers were promised to him, and none are promised here. Sessions ran in Dhanmondi, and identifying details have been removed.

Direct supervision is not a substitute for preparation, and a trainee who arrives without having done the reading gets less out of the case, not more. Before scrubbing, you are expected to have opened the imaging yourself rather than somebody’s summary of it, to have the blood results in your head, and to state the plan in a sentence or two including the step you expect to perform.

In addition to that, you are expected to say what you would do if the anatomy is not what the scan suggested. Not in detail, and not correctly every time, but with an answer. Furthermore, the consultant will ask which structure you intend to identify first and why, because that question separates a plan from an expectation that things will be pointed out to you as you go. The same discipline is drilled away from theatre in the decision-making drills.

A trainee’s learning never outranks a patient’s safety, and that is not a slogan on a wall, it is a set of hard rules that decide who holds the instrument.

If bleeding is not controlled within a short, stated interval, the consultant takes over. If the anatomy is unclear, the trainee stops rather than proceeding on a guess. If the physiology is deteriorating, teaching pauses and the case is done by whoever can do it fastest and safest. If the operation turns out to be a different one from the plan, the granted step does not carry across, because permission was given for a defined step in a defined situation. Emergency and unstable cases are consultant-led.

However, none of this is hidden from the patient. Patients are told before consenting that a trainee will take part, what he will do, and that the consultant is present throughout and performs any part that requires it. A patient who does not want a trainee involved says so, and that is recorded and respected without argument.

Correction under direct supervision is immediate, short and specific, and it comes while your hand is still in the wrong position rather than in a debrief an hour later. The instruction is what to do, not an essay: change the angle, take smaller bites, stop pulling. A brief reason follows, one clause, so it carries to the next case.

Furthermore, correction and takeover are different, and both are normal. Correction means you continue with an adjustment. Takeover means the instrument changes hands, without discussion in the moment. What is not acceptable is a consultant who watches a trainee do something unsafe to make a teaching point of the consequences. In addition, a trainee hands over cleanly when told, without a second attempt, and asks about it afterwards.

Supervision is usually described as something the consultant does to the trainee, which misses half of it. A trainee is expected to escalate, out loud, at the moment of doubt: I am not sure what this structure is, I think this should be your hand rather than mine. That sentence is the most useful thing a trainee learns to say, and it is treated as competence rather than weakness.

Moreover, escalation is required rather than permitted. A trainee who continues while unsure, hoping it resolves, has broken the arrangement even if the case ends well. The consultant states his own escalation openly: I am taking this because the plane is wrong. The step is handed back once the difficulty passes, where that is safe, and the case is debriefed with the decision separated from the outcome.

Every case is logged with the role you actually held, in the categories used above: observed, assisted, performed a defined step under direct supervision, performed a sequence, closed, or led with the consultant scrubbed. Complications are recorded, and the consultant countersigns. There is no category for supervised in the loose sense, because that is exactly the ambiguity this module exists to remove.

However, the strictness is not administrative tidiness. An inflated logbook is worse than a thin one, because somebody later reads it and assumes you can do what it says. A trainee who has performed the dissection in twelve routine gallbladders and written it accurately is better placed than one who wrote twelve gallbladders and assisted in all of them. A thin honest record tells you what to work on next, which is what the exit assessment compares against the baseline assessment. Records are kept to the standards expected by the Bangladesh Medical and Dental Council and the Bangladesh College of Physicians and Surgeons.

Supervision decisions in this module are informed by published assessment of surgical risk before liver resection, and that literature is quoted accurately rather than stretched.

In a prospective observational study of 70 adults undergoing liver resection at the Department of Hepatobiliary, Pancreatic and Liver Transplant Surgery, BSMMU, Dhaka, between August 2023 and July 2024, 30 of 70 patients (42.9%) had postoperative complications. Post-hepatectomy liver failure occurred in 0.0% of ALBI-1 patients, 38.5% of ALBI-2 and 100% of ALBI-3. The ALBI score gave an AUC of 0.659, with sensitivity 70.0% and specificity 62.5% at a cutoff of -2.67. Age and ALBI score were independently associated with complications, while MELD did not differ significantly between groups. The authors concluded that ALBI has weak to moderate discriminatory ability and is a possible adjunct rather than a replacement for clinical judgement or established scores, and that larger multicentre validation is needed.

Dr. Murshidul Arefin is a co-author of that study, not its first author, and it is single-centre work. The paper is published in Cureus, 2026; 18(6): e111661, and the indexed record can be found on PubMed.

Furthermore, note what this study is not. It assesses liver function before resection and says nothing about supervision or trainee performance. Its relevance here is narrow: an AUC of 0.659 is weak to moderate, so a score cannot carry a decision on its own, and a trainee who treats a number as a verdict has learned the wrong lesson.

“Surgery is the branch of medicine that deals with the physical manipulation of a bodily structure to diagnose, prevent, or cure an ailment.”

Source: Surgery, Wikipedia

The module runs inside a working hepatobiliary service at Popular Medical College Hospital in Dhanmondi, Dhaka, so the case mix is whatever comes through the door that week rather than a curated teaching list. The same consultant supervises throughout, so corrections carry from one case to the next.

Dr. Arefin holds MBBS, FCPS and an MS in Hepatobiliary Surgery from BSMMU, with more than seven years focused on hepatobiliary work, over 1,500 surgeries including 800+ laparoscopic cases, and three peer-reviewed Cureus papers. In addition, no guaranteed number of cases or operative steps is offered, because that would depend on the theatre list rather than on any promise made in advance.

Research-based practice: what Dr. Arefin has published

Dr. Murshidul Arefin is a research-active hepatobiliary surgeon, not only an operating one. He is a co-author of peer-reviewed, open-access Cureus work on the preoperative albumin-bilirubin score before liver resection, on the mean platelet volume to platelet ratio in pancreatic cancer and chronic pancreatitis, and on a case report of neuroendocrine tumour of the ampulla of Vater. Trainees read those papers with their limitations, which is the habit this module is trying to build.

Send a current CV, your present post and registration details, and an honest account of what you have assisted with and what you have actually performed. Then say what you want to be able to do by the end. Vague applications get vague placements, so specifics help.

You can arrange a discussion in Dhanmondi or call +880 1311 487 592. The conversation covers your record, the level you would start at, and the parts of the module that would not apply to you yet.

Will I definitely operate during the module?

You will hold the instrument for defined steps once the record supports it, under direct supervision. No specific number of cases or steps is promised, because the theatre list decides that, not a brochure.

Does the consultant ever leave the theatre while I operate?

No. Direct supervision here means scrubbed and at the table for every step a trainee performs. If that is not possible on a given day, the case goes ahead consultant-led and you assist.

Do patients know a trainee is involved?

Yes, before they consent. They are told what the trainee will do and that the consultant is present throughout. A patient who declines that arrangement has it recorded and respected.

Is this a fellowship or a licence to operate independently?

No. The module is supervised training within a hepatobiliary service. It confers no licence, no fellowship and no independent operating rights, and any registration or certification remains a matter for BMDC and BCPS.

Written by Dr. Murshidul Arefin, MBBS, FCPS, MS in Hepatobiliary Surgery (BSMMU), hepatobiliary and liver surgeon at Popular Medical College Hospital, Dhanmondi, Dhaka.