Friday, November 11, 2011

Surgical Residents Surveyed; Concerns about Experience & Confidence

A recent survey of general surgery residents was published online by the Journal of the American College of Surgeons yesterday. More than 4200 residents who took the 2008 American Board of Surgery In-ServiceTraining Exam (ABSITE) responded. This accounts for 82% of all categorical (five-year) general surgery trainees. The authors of the paper represented the American Board of Surgery, Yale University and Memorial Sloan Kettering Cancer Center.

Compared to those in university programs, residents in community hospital programs had more positive responses to questions about satisfaction with their operative experience, didactic teaching and support from their programs.

But a significant number (27%) 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. Almost half of all residents were not satisfied with the level of didactic teaching being offered.

Something is wrong if over 25% of surgical residents are uncertain that they will be able to operate independently when they finish training. And just how does one identify those surgeons? Don’t say, “Check to see if they’re board-certified.” The boards don’t test operative skill.

Not long ago, I blogged about the coming shortage of general surgeons. The paper discussed above would indicate that expanding existing general surgery residency programs may not be the answer. If a quarter of all residents feel they are not getting enough operative experience and are not confident in their skills, how can programs be expanded?


Anonymous said...

Were you confident to perform surgery when you graduated residency?

Skeptical Scalpel said...


Great question. The answer is yes. But after I started practice, there certainly were days when my confidence was shaky. I was fortunate to have some good mentors. Training was different back in the day. We operated independently a lot as residents. That does not happen much today.

Anonymous said...

Thanks for the response. And I think that there are still a lot of places that you can operate a lot as a resident. The place I am at (as a rotating student) has PGY-2 Gen Surg residents doing carotids from skin-to-skin (with the attending present, of course), patch and all. One of our chiefs did a thoracic outlet decompression unassisted. That's a tremendous operative experience. Our chiefs are confident to practice in a rural area and do it all, from colons to vascular to thoracotomies if need be.

I guess my point is (with the full admission of much, much less experience than you) that there is still good quality of training out there in the community, work-hour restrictions and all. And as a student, it really sucks (and is equally discouraging) to either be told that you're not going to be good when you're done due to the 80-hour rule, or that you're lazy because you have to follow a rule you didn't make.

Do I like the 80-hour rule? Honestly, I have mixed feelings. It's very good to know that when I (hopefully) head off to a neurosurgery residency, I'm less likely be abused like you guys were. And please don't call me "lazy" for saying that. It sucks to know that I might be forced to miss cases on some days. At least at our program, this isn't too much of an issue as no one takes weeknight call, so no one misses cases post call. That's huge. The 80 hour rule can be doable if your program makes an effort to schedule around it. In my mind, it's preferable to being in-house 120 hours a week, and spending 20 or so of those hours doing non-educational, scut-type things. I don't know if you ever considered that a problem in your training, but several attendings have said that is a positive in the transition to the work-hour restrictions.

Like I said, I think the new rules are quite the mixed bag, but I don't take quite the doom-and-gloom view that some of you guys do.

And as for mentorship--if there are guys like you out there, I am sure mentorship is still alive and well.

Anonymous said...

Do you feel like there is any difference in the variety of cases done/learned by current residents as opposed to "back in the day"?

Skeptical Scalpel said...

Well said. People like you give me hope. Let me clarify one thing. When I say we operated independently, I mean there was no attending in the OR at all. At night, the attendings weren't even in the hospital. Chief residents took the others through cases. When you were a chief, you made many independent decisions, from deciding who needs surgery, to what procedure to do, to the actual intra-operative conduct of the case. When you finished your chief year, you had the confidence that comes with that type of experience.

Skeptical Scalpel said...

There's a huge difference in the variety of cases. That's part of the problem. Certain open general surgery procedures are rarely done any more. Perhaps it won't be necessary to know how to do an open GB in the future, but don't bet on it.

Anonymous said...

Thanks for a constructive dialogue, SS. I appreciate not getting the "you're lazy" BS that I might get elsewhere with some of my comments (and yes, I do break the 80-hour rule on a weekly basis because as a student, I can). I guess my final thought would be (and I hope teaching attendings are reading this) simply this: even under an 80-hour limitation, if your program makes it a point to train you, and you put in the effort, you should be well trained. If your teaching attendings show little interest, it doesn't matter if you do 150 hours a week, you'll probably suck at the end.

We need to (instead of bickering about work hours we can't change) make a concerted effort to make sure we do everything we can to train our residents and medical students in the time we have available. I've rotated at places that show absolutely zero interest in teaching anyone--and it's an absolutely terrible place to be in. This is the big problem in medical education to me, not the 80 hour rule.


Skeptical Scalpel said...

I agree. I mentioned in the third paragraph of the blog that nearly half of the residents thought the didactic teaching in their programs was inadequate. Sounds like you've had that experience too.

Anonymous said...

Perhaps that 25% are just pessimists.

Skeptical Scalpel said...


Or realists.

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