Recent research has shown that trainees in both in the United States and the United Kingdom do not feel confident in their abilities to operate or care for critically ill patients. I have commented on this (here and here) but haven’t discussed the possible causes.
Of course, we surgeons have been complaining about the work hours limitations for years, feeling that the education of residents will suffer. There may be some validity to this as expressed in the article about graduates of medical training in the UK, where the work hour limit is now at 48 hours per week.
Regarding surgical training, more than 25% of recent residents are worried that they will not be able to operate by themselves when they begin practice.
Numbers collected by the American Board of Surgery and the Residency Review Committee for Surgery and published in Annals of Surgery show that for many operations the operative experience of residents is ominously low. For example of the 121 types of cases considered by program directors to be absolutely essential, the mode (most common number) reported by graduating residents for 63 of those case types was none.
This may not strictly be due to work hours limitations. There are conflicting studies on the impact of those restrictions on case volumes.
Resident insecurity is related to a number of factors. To me, the most important of these is that residents almost never operate independently in the 21st century. There is much more supervision than there was in the past. This may be because of increased regulatory scrutiny, medicolegal considerations and patient demand.
For those who like the pilot/surgeon analogy [I don’t but use it when it supports my biases], would you like to fly with a pilot who had never soloed before? Better for a young surgeon to solo during residency when help is readily available than when she is in practice, don’t you think?
11 comments:
SS, I'm a fourth year medical student at a large academic medical center who is currently applying for a general surgery residency and, Match-permitting, will be a surgical intern in July. I couldn't agree more with your statements about the current state of surgical education. There are multiple (modifiable) factors that contribute to residents' feelings of insecurity about their operating skills. As you stated, there is little to no independent operating anymore. I hear my mentors who trained as early as the late 60s and 70s talk about their residency and am jealous. They worked hard and made a lot of sacrifices, but in the end they learned more and were trained better. They were able to make decisions based on medicine, and not "medicolegal" rationale. In addition, I think it's ironic and appalling that at many of this country's "teaching hospitals" the attending surgeons are disinterested in teaching residents. This speaks to the different sentiment that residents at community hospital programs have regarding their operative experiences. I've been lucky that I've been able to work with some of the better teaching attendings at my institution, but have also interacted with some who have no interest in teaching. Finally, I think that if the ACGME intends to keep the
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I think if the ACGME also keeps the outrageous 80 hour rule, or worse - if Rey decide to further limit work hours - individual hospitals and residency programs need to make an effort to limit residents from having to do unnecessary tasks. These include following up on orders written in the morning to make sure they wee done, doing their own phlebotomy, transporting patients at times, social work, etc. These tasks abound at many programs and, while they usually fall onto the intern, I would argue that even the intern should get some additional OR time that was used to be the norm if so much time is being restricted.
I think if you polled most people applying for CATEGORICAL general surgery spots in the United States, a vast majority would be agains the work hour restrictions. They've made things more difficult and have created more problems than they've solved. If you're at a teaching institution, I'm sure you've sat in on more than a couple M&Ms where the complication rested in an inadequate sign-off between the "day shift" and "night shift" resident.
I'm glad you bring this up because I think you are absolutely right. While a lot of attention is paid to the work hours changes of the last decade, this has happened alongside more stringent supervision requirements and attitudes that have had just as big (if not bigger) impact on resident training. Yet this is hardly discussed at all compared to the impact of work hours.
Would this lack of ability determine what treatments are available in the future? The scary fact is that these are the surgeons who would be operating on me and/or you in 15 to 20 years time when we need our bypass .
Thanks for your comments. This is a big problem that no one is talking about. Many surgeons here in the US share your concern, Dr. Briffa.
That's disheartening to hear. Medicine has become too political. I am a medical student likely to enter a surgical specialty, and even in medical school I feel we are not getting adequate training. An older surgeon recently commented on how this generation of medical students is not "allowed" to do much during training, and they're right. I had hoped this would get better in residency - my last chance to refine my skills before I get to practice on my own. Like others here, I am jealous of our medical predecessors. I love free time and sleep as much as the next person, but my priority during residency is to learn to be not only a competent, but great physician - something that I believe will take far more than 80 hours a week in the OR with someone constantly holding my hand. Thank you so much for this post.
Interesting comment. I agree that med students suffer from the same smothering supervision that afflicts residents. Also, one of the many unintended consequences of the electronic medical record is that student H&Ps are becoming extinct in many hospitals.
Clearly 2 of the major components of learning are time and opportunity. Leave the body of work to be learned the same and cut time-->you don't learn as much. Not have exposure to many procedures you're expected to know-->same result. You have commented on the latter several times. As regards opportunity, perhaps it's time for general surgery to prune itself again, as it did with, for example, Ob/Gyn. So, is it better to limit the specialty at the specialty level, or leave it to hospitals to limit privileges based on resident case experience? As regards time, is there really any hope of reversing the 'humane' ACGME changes already made? If not, longer residency or a smaller chunk of knowledge to be learned seem to be the only alternatives.
RDL
RobertL39,
Thanks for commenting. You have a point. Why am I the only one talking about this? And why aren't the board and/or the RRC doing something?
The difference in surgical training across the atlantic is significant. there are many levels beyond independent operating that trainees should achieve in training in the UK before independent practice. even that latter phrase is contentious in that, it is hoped, that for new Consultants in the UK undertaking major cases are supported by senior colleagues. Surgical teams have better outcomes than individuals, in my experience.
Yes, it's nice to have senior colleagues around, but in many areas of the US, surgeons practice alone or with only one or two others. There may not be available help at times. Ideally, a surgeon should be able to handle almost everything by herself.
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