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.

Amos said...

There is some truth..... Some residents are abit careless in the OR

Skeptical Scalpel said...

Jamal, except for some minor surgery cases, a third-year resident would probably not operate independently in the US. We do have the option for a chief resident to act as a teaching assistant taking a junior resident through a case in the OR.

Amos, so are some attendings.

rotator said...

This reminds me of the change in cardiology and radiology
a dozed yrs of so back where interventional qualifications needed another year or two of study. With such a variety of approaches (open/lap/robotic etc) it would seem another year or two of residency might be in order.

I am also reminded of an experience ~10 yrs ago when a newly minted comm hospital GS came on staff and for the first yr or so when on call he was calling in his partners for assistance on some cases. The senior partner was the only one in the group to do aortic vascular, the others did only peripheral vascular.

artiger said...

Rotator, that is not a bad practice for a newly minted surgeon.

Skeptical Scalpel said...

I would never criticize a surgeon who asks for help when needed. It's the ones who don't ask for help who are the problem.

Anonymous said...

Anonymous Europe: I am trainee in Europe, and what I can tell is, the problem lies at two points:
1. We are used for scut work. Filling out papers, running the outpatient unit, and organizing CT scans, US scans, whatever, which should be a secretary's job or a ward administrator's whatever. We do not get to relax between the operations,and this impedes our performance to...
2. The legal situation is so hostile, that if we are left alone in the OR, and something happens we get sued and all hell breaks lose.
I guess if a trainee were allowed to do nothing else through the day but to perform operations one after the other for 8 hours a day (not organising CT scans, and doing stupid paperwork) He/she would be one hell of a surgeon in two years.

Skeptical Scalpel said...

Regarding the last part of your #2 comment, what you say would be ideal, but in what hospital could every resident be operating 8 hours a day? None that I know of.

Anonymous said...

Anonymous Europe: I was talking about an ideal world..:). Unfortunately no such hospital exists...As from a trainee's point of view: I am hustling at the ward, my phone keeps ringing every minute, and the nurses keep harassing me with every possible nuisance. Then the call comes in that I need to go to the OR. By the time that call comes in I am already wasted psychically from the constant stress. And then I should calm down and should only concentrate on the intervention at hand, while my phone (it is the telefone system we use in the hospitals) keeps on ringing, even though I told the nurses at the ward, that I am in the OR.... By the time I get off of my shift I am too wasted to do anything... Not to mention the days when I need to cancel my operations because I have to play ward manager or run the outpatient unit....I do not mean to complain, I love what I do, just wanted to provide a picture from the trainee's point of view.What we would need is a ward secretary who would do the scuttle work so that the trainees could go into the OR more. We are used as coding nurses, administrators and it technicians and the least as doctors....

Skeptical Scalpel said...

Ah, yes. The ideal world. Your residency sounds a lot like a residency in the US.

Anonymous said...

Anonymous Europe: Yeah:):) We even have the burgers when I am on call( I order them).

Anonymous said...

Anonymous Europe: I learnt my work ethics in the US which gives me more than an edge in Europe.:)

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