Tuesday, June 20, 2017

Some general surgery residency graduates may not be competent to operate

A new study says 84% of general surgery residents in their last six months of training were rated as competent to perform the five most common general surgery core procedures—appendectomy, cholecystectomy, ventral hernia repair, groin hernia repair, and partial colectomy. However the percentage of those judged competent varied from a high of 96% for appendectomy to a low of 71% for partial colectomy.

When analyzing the other 127 core operations of general surgery, the investigators found that 26% of residents in their last six months of training were felt to not be competent to perform at least some of those procedures.

The study was presented at the annual meeting of the American Surgical Association in April 2017 and reported in ACS Surgery News.

Data were compiled from ratings of 522 residents by 437 faculty yielding 8526 different observations.

For all of the procedures rated, maximum resident autonomy was observed for 33% of cases, and the more complex the case, the less ready the residents were to perform it on their own.

The lead author of the study, Dr. Brian George of the University of Michigan, was asked whether the duration of surgery training should be increased. He answered, “The 20,000 hours of surgical residency should be enough to train a general surgeon to competence—it's up to us to figure out how.”

As currently constructed, the 20,000 hours isn't enough. This 2011 post I wrote explains why. Much of the residents' time is taken up by tasks other than operating such as electronic charting, conferences, scut work, activities of daily living, sleep, and more.

I was surprised the residents had maximum autonomy one-third of the time because I have blogged about autonomy and pointed out that some graduating residents have never done a single case by themselves.

If the one-third number is reproducible, it is encouraging but clearly inadequate because except for some simple cases, over 25% of residents are not proficient enough to perform complex cases alone.

Past surveys corroborate these findings. A 2011 survey of residents found one quarter did not feel confident to operate by themselves, and another reported fellowship program directors felt about the same number of residency graduates were unprepared to operate independently.

Fixing this will not be easy. I agree with Dr. George that increasing the length of general surgery training is not the answer. More resident autonomy and less scut work might help, but both may be difficult to accomplish.

The current study’s findings should worry the leaders of general surgery training—the Residency Review Committee for Surgery and the American Board of Surgery—and the general public who has no way of knowing which 1 of 4 recent graduates of general surgery training might not be competent to operate on them.


lp said...

The solution is easy but there is no political will to do so. Bring back county and charity hospitals for the uninsured. Several problems solved at once!!

Skeptical Scalpel said...

Ip, good idea. It would solve the problem for some residency programs. It will never happen.

Anonymous said...

Just finished residency last year from a "community" program where my attendings rarely scrubbed and frequently didn't sit in OR unless asked to do so for chief cases (obviously some exceptions existed). I felt nervous but very ready to be done with training. My questions to those who have been on both sides of the training OR table.

Is the lack of competency due to:
-Larger institutions with more attendings not knowing their residents as well and therefore not trusting them to do cases?
-The larger number of ways procedures are done now vs. 15-25 years ago (i.e. open vs. lap vs. robot vs. endoscopic...). I.e. you've seen a hundred colectomies, but you've seen it done 50 different ways.
-A generational gap in confidence

Or a little bit of all 3?

Do you think the "apprenticeship" model some programs are adopting will help?


artiger said...

If I was a medical student today, there's no way I'd choose surgery for my residency. Then again, I'm not sure I'd even be in medical school today.

Skeptical Scalpel said...

Anon, I am partial to community hospital programs.

The problem may be due to all three things anon listed but I think the first one is probably the most important. Others include medicolegal and regulatory concerns and patients not wanting to be operated on by trainees.

Artiger, I understand. I'm glad I'm not trying to run a residency program right now.

Antonio said...

hello Dr. im from venezuela, im in the second year of residency in general surgery, i find really interesting your article. as a resident, i feel uncomfortable at the OR sometimes. even more if im going to make a procedure i have never done before, but sometimes it depends on who you have in front of you, the attending attitude towards the student is really important. i believe that the confidence comes with the time, and its probably normal that some percentage of residents might feel odd when doing a procedure themselves, tho i believe that "not competent to operate" its kind of hard... im a big fan of your TL in twitter! cheers!!!

Skeptical Scalpel said...

Antonio, thank you for reading my blog and following me on Twitter.

I agree that as a resident the information may be difficult to accept. I hope you understand that it was the study that said some residents are not competent to operate. I merely reported and discussed its results.

Jamal said...

I think the situation is better in Canada. I've seen lots of 3rd year residents independently operating (smaller cases though).

I also think residents are used for scut work and as bus boys. They should get more OR time under supervision.

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