Wednesday, August 17, 2011

More on whether 10,000 hours makes an expert surgeon

Last week I blogged that I didn’t think 10,000 hours of residency training would make one an expert surgeon [or any other type of physician]. As I explained, and someone who commented on the post explained even more clearly, residency training is not like practicing the piano or swimming. Residency is an amalgam of many skills as well as significant hours of non-productive work that does not approach 10,000 hours of doing only one task.

The concept of the so-called “10,000” hour rule as espoused by Malcolm Gladwell is also open to debate. Another commenter shared a link to a sports science blog that totally debunks Gladwell’s premise, at least as it pertains to athletic ability.

In my previous blog, I pointed out that despite surgical residency training lasting over 19,000 hours, many residents feel the need to take fellowships. The extra year of training not only gives them an edge in the job market, it also helps bolster their confidence.

Three days after that blog was posted, a paper was published in Archives of Surgery confirming what I had suggested. The authors, from Yale University and the American Board of Surgery, surveyed all surgery residents in 2008 and 4136 (77% of all residents) replied, an excellent percentage of response for any survey.

The most interesting finding was that 26% of all respondents were concerned that their operating skills were not appropriate for their level of training and that they would not be confident enough to operate independently upon completion of their residency training.

More residents in university hospitals and those in large programs felt less prepared than residents from community hospital and smaller programs. [Disclosure: I was a community hospital residency program director for 24 years. This paper confirms my longstanding bias that community hospitals produce surgeons with more experience and skills.] Women trainees were somewhat less confident in their abilities than men.

Of course the paper has limitations common to most self-reported surveys. The residents were assured that the survey would be anonymous, but it is possible that the number of residents lacking confidence in their skills may have been under-reported. Confidence is difficult to measure and too much confidence can be as bad or worse than too little. But a distressing finding of the survey was that the residents who were less confident were also less likely to ask an attending surgeon for help in the operating room or when managing a patient.

It is disconcerting to learn that 26% of all surgery residents are uneasy about operating independently.

I hope this paper is read by all surgical program directors and the people who run the American Board of Surgery and the Residency Review Committee for Surgery. I wonder what they will do about it?

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