Monday, July 16, 2012

Things that puzzle me about surgical education

When I was a surgical residency program director, I often wondered what the establishment, you know those guys who ran surgical education, were thinking. Some may remember the rule that a resident had to see at least 50% of the patients he operated on in the clinic or the private surgeon’s office in order to claim credit for having done the case.

There was the emphasis that still exists today on making sure every resident did research. At last, some are questioning the value of this for the average clinical surgeon. Contrary to the prevailing wisdom, there is no evidence that a resident who is dragged kicking and screaming through a clinical research project or who spent a year in someone’s lab really learns anything about research or how to read and understand a research paper. Then there is the obsession with a transplant rotation, recently noted in a published paper to be a waste of time in the opinion of surgical residency program directors.

And what’s with all the emphasis on basic science? Shouldn’t the residents have learned all the basic science they need (and more) in medical school? With all that is new in clinical surgery, why are residents forced to relearn basic science that they will not ever use in practice? When you stand at the bedside of a sick patient, do you ask yourself, “How is lactic acid formed”? Or do you simply order a lactate level?

Why do we teach surgery the same way we did 40 years ago? Instead of teaching residents how to think, we still force them to memorize large volumes of information that they can carry in their smart phones.

Now I am wondering what is going on with clinical training. A recent paper found that residents are concerned that their operative skills are inadequate.

Last year in a blog reviewing that paper, I wrote, “A significant number of all residents surveyed worried that they would not feel confident to perform surgery by themselves when they finished training. A similar number were not satisfied with their operative experience.”

Many graduates of residency take fellowships to gain extra experience. Especially interesting is the proliferation of so-called “advanced” laparoscopic fellowships. There was a time when we taught residents all they needed to know in five years. Why can’t residents learn advanced laparoscopy during a five-year surgical residency? Are they too busy memorizing the Glasgow Coma Scale?

I recently heard of a new proposal. Get this; there may be a plan to offer “open surgery” fellowships. Details are sketchy, but the idea would be to train surgeons to do old-fashioned laparotomies. It’s not yet clear which of the surgical disciplines (such as vascular, colorectal, hepatobiliary) would be involved or which hospitals have enough volume of open surgery to support such a fellowship.

Maybe we should skip most of general surgery residency altogether and just let them go to their fellowships after a year or two of basic training.


Dr Skeptic said...

I agree that making residents complete a research project misses the point. If we are aiming to improve their knowledge of the scientific method and their critical thinking skills, maybe we should teach those explicitly, rather than hoping that they will absorb it.
I am a researcher and surgeon, and I am responsible for making sure the residents in my specialty complete the research criteria to sit their final exam. I would much rather have them demonstrate a sounds understanding of the science that underpins research, and be able to critically appraise the information that they are constantly receiving, than spend a year in a lab counting cells under a microscope.

Skeptical Scalpel said...

Dr Skeptic,

Thanks for the comment supporting my position. As far as I know, a lot of the basic science research residents do is similar to counting cells. I agree that it does not teach them critical thinking.

Todd J. Scarbrough, M.D. said...

I graduated med school 1998. I remember being scrubbed in on a Whipple where the chief resident was doing most of the surgery. The attending was more or less assisting. The chief resident seemed imminently capable & confident. The anesthesiologist had to leave for some reason during the procedure for a while and the chief surgical resident ran the anesthesia equipment while he was absent! I'm afraid those days are gone. I think the idea of every training program, surgical or otherwise, should be to train a fully formed, fully ready physician to go forth and practice good, safe medicine on his or her own. Basic science is invaluable. Good research experience can make you a better clinician. But when it comes to medicine... there is simply no substitute for experience, experience, and experience.

"He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all."
-William Osler

Skeptical Scalpel said...

Todd, Nice comments and an interesting story that as you say, is not likely to happen again. When I was a chief resident in that dark ages of the mid-1970s, the attendings were not only not scrubbed, at night they were at home.

Anonymous said...

I agree that mandatory research time is a waste of valuable time. I always felt that it was just a means to build up the faculty members cv and publications. Why not just have a dedicated research fellowship for those residents interested in basic science research?

Skeptical Scalpel said...

Thanks, Anon. I agree. If a resident wants to do research, let her. Otherwise, teach them how to read a journal article.

Chris Porter said...

Very interesting point, how much our education emphasized basic science and research - neither of which scores high in my view of a good surgeon.

Can we require a non-clinical year to teach judgment, communication skills, cost-effectiveness, use of evidence over dogma, empathy, collaborative care, small-business management, public health economics, and industry ethics?

Skeptical Scalpel said...

Chris, good points. I think what you propose might take longer than a year.

chrisobgyn said...

In the discussion section of the article(MC Sullivan et al)you cite, the authors mention a survey in which <50% of the residents felt comfortable discussing intraoperative decision-making with their attendings(Coats & Burd). How the (reduced)hours in the OR could be better utilized is also a good direction to look in, isn't it?

Skeptical Scalpel said...

Chris, I agree that the reduced OR hours could be better utilized. It's a shame that residents feel they can't ask about intra operative decision-making. That's one of the most important things to learn in the OR.

Anonymous said...

"Open Surgery Fellowship" is another name for what is today called "Trauma and Acute Care Surgery Fellowship."

Skeptical Scalpel said...

Anon, Maybe. But I'll bet that most of the GBs and appendectomies are being done laparoscopically. In fact, I'll bet that unless there's high percentage of penetrating trauma, at least 75% of all abdominal surgery on the acute care service is not open surgery.

Anonymous said...

This is a TREMENDOUS article; I'm currently retired from general surgery and teach anatomy at a medical school. Recently, we asked a pharmacologist to talk to the students about the pharmacology, uses, contra-indications, etc. of aspirin, tylenol, and motrin. He said, "They don't NEED that. . .they need pharmacokinetics." He refused to speak about this and subsequently "turned" his lecture time over to a physiologist who spoke about "G"-proteins.

I usually get up behind them, when they pull this stunt (not uncommon by the way), and say, "Nurse! STAT! I need a bag of ribosomes and G-proteins, now! Don't shock this patient--the current may cause cellular apoptosis! And this this patient's saliva out for electrolyte testing--we MUST know the potassium content in his saliva before we can hang that bag of K+! And, don't forget to tell the physical therapist to work those damn sarcomeres!"

The class usually erupts with laughter. Of course, I'm not popular with my basic science colleagues.

Actually, I question the purpose of teaching the amount of minutiae students get from the basic scientists. I believe, now, more than ever, that most basic science should be taught by CLINICIANS (MD/DO's) and not by Ph.D. researchers for the first two years of medical school.

Skeptical Scalpel said...

Thanks for the comments and supporting my theory with some real-world observations. I've been saying this for about 25 years and of course, no one is listening.

BTW, I'm retiring soon. How did you get that anatomy teaching job?

Chris said...

Unfortunately this is not limited just to surgical training. Throughout my training, at least half (probably more like 80%) of research done by my cohort has been done to have a good CV for applying to the next step of training; thus, the students applying to more competitive specialties (derm, ENT, radiology) do more research--not because they're passionate about desmogleins and proper techniques of immunofluorescence staining, but because they want to run a procedural cosmetic dermatology clinic in 10 years.

Of course, this is reinforced by the prerogative of academic faculty who need a bulky CV to advance professionally, so they select trainees with demonstrated research productivity to be research mules during their training. So the paper chase has metastasized into the medical schools, worsening the problem of journals glutted with excessively technical, clinically irrelevant, for-its-own-sake research publications, with most of the actual work being done by medical students, residents/fellows, post-docs (who are at the mercy of their sponsoring faculty member most of all), and very junior faculty trying to get onto the tenure treadmill. Not to mention all of the gov't/NIH money spent on this. Of course medical science has revolutionized over the last 30 years, in large part due to diligent academic researchers; it's just that most researchers are motivated in large part (though not completely, I hope) by the carrot of tenure/job security, and eager trainees trying to become urologists or plastic surgeons or ENTs or whatever are willingly taken advantage of to make it happen, even when they harbor no personal career goals that would be served by any of the research experience they actually get.

Meanwhile for all practical purposes most of those trainees would've been better served spending that time reading UpToDate, talking to patients about their pets and grandchildren, and going to a well-run journal club on a regular basis.

Skeptical Scalpel said...

Chris, very well said. I agree, especially with your last paragraph.

Ryan Gray, MD said...

Chris, great comment! Agree 100%.

Skeptical Scalpel said...

Ryan, thanks for adding to the discussion.

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