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.