A
recent paper
in Annals of Surgery depicts the rate of resident remediation over a decade or
so at six general surgery programs in California. The authors reviewed the
records of 348 categorical general surgery residents and found that 107 (31%)
required mediation with knowledge deficits the primary reason in 74%. Other
issues, such as interpersonal and communication skills, patient care and
professionalism, were cited far less often.
Need
for remediation did not correlate with attrition. Remediated residents left
programs at a rate of 20% compared to 15% of non-remediated residents, p =
0.40.
On multivariate analysis, only two factors were associated with the need for remediation. One was USMLE Step 1 scores which were lower in the remediated group. But the median difference in scores between remediated and non-remediated residents was only 7 points with wide and overlapping interquartile ranges, and both median scores were above the average for all medical students over the years of the study.
The other factor was quite remarkable. Remediated residents were significantly more likely to have received a grade of "honors" for their medical school clerkship and surgery. How can this be?
The authors speculated, "One thought is that medical students start residency under-prepared for the rigors of surgical residency." Now where I heard that before? I have previously blogged (here) about the unrealistic third-year experiences of medical students on surgical rotations. While I agree that they likely are not ready for the workload, I'm not sure what it has to do with the primary reason for their poor performance—a perceived knowledge deficit. Does hard work cause them to forget everything they’ve learned or are they taught the wrong stuff in med school?
On multivariate analysis, only two factors were associated with the need for remediation. One was USMLE Step 1 scores which were lower in the remediated group. But the median difference in scores between remediated and non-remediated residents was only 7 points with wide and overlapping interquartile ranges, and both median scores were above the average for all medical students over the years of the study.
The other factor was quite remarkable. Remediated residents were significantly more likely to have received a grade of "honors" for their medical school clerkship and surgery. How can this be?
The authors speculated, "One thought is that medical students start residency under-prepared for the rigors of surgical residency." Now where I heard that before? I have previously blogged (here) about the unrealistic third-year experiences of medical students on surgical rotations. While I agree that they likely are not ready for the workload, I'm not sure what it has to do with the primary reason for their poor performance—a perceived knowledge deficit. Does hard work cause them to forget everything they’ve learned or are they taught the wrong stuff in med school?
I think not. The real reason may be found in the way medical
students are graded. A group from Harvard looked at medical school grading
systems and found that honors grades in third-year surgery clerkships are given
to an average of about 30% of students ranging from a low of 7% to an mind-boggling
high of 67%. I understand that those accepted to med school are smart, but how
is it that two-thirds of the class can achieve honors in surgery? Could it be
that some of the honors grades given to residents who eventually needed
remediation were not warranted?
If you would like to read more about this, you may read the
full text of the paper on medical school grades here
or a summary on my blog.
3 comments:
In my new job, I sat in as the attendings and residents gathered to assign grades to the recent students. The subjectivity and sway of opinions was remarkable. There was a strong favoritism toward students who acted like surgery interns, regardless of whether being a willing scut-monkey predicts success or correlates with knowledge base.
Wow, thank you for sharing these detailed information. The general surgery is very different from the modern surgery.
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