Monday, March 12, 2012

Student and resident training needs radical change

If you’ve followed my blog, you know that I have been concerned about the state of surgical residency programs and other issues involving medical education. For more on these topics, browse the labels “surgical residency training” and "medical education" in my blog.

Here is more food for thought.

While the impending shortage of general surgeons has prompted calls for increases in the number of general surgery training programs and expansion of existing programs, there are some questions about quality.

Here is a paragraph from the Residency Review Committee for Surgery program requirements:

V.C.3. The performance of program graduates on the certification examination
should be used as one measure of evaluating program effectiveness. At
minimum, for the most recent five-year period, 65% of the graduates must
pass each of the qualifying and certifying examinations on the first

The American Board of Surgery publishes data on board passage rates by program. According to the 2011 figures, 82 (34.3%) of the 239 accredited general surgery residency programs in the US have first-attempt board passage rates of <65% for the most recent five years and 30 of those programs (12.6% of the 239 programs) have rates of 50% or less.

In the March, 2012 issue of Archives of Surgery, Dr. Leigh Neumayer cited a decline in the in the rate of individual residents passing their boards. In 2010, 75.1% passed the written and 76.8% passed the oral examinations. These percentages are remarkably consistent with the 25% of surveyed surgical residents who feel that they are not adequately prepared to practice independently. She mentioned the trend of graduating residents taking fellowships because they are not ready to practice by themselves.

She also discussed the need to change the way surgeons are trained, pointing out that the amount of knowledge to be acquired by trainees is increasing exponentially while the time available to learn is decreasing.

She said that every surgeon should not necessarily be trained to perform every procedure. This is actually sorting itself out with the volume and outcomes debate, which despite a few discrepancies, favors surgeons who perform large numbers of certain procedures.

She made some other interesting suggestions which, because they are sensible, are unlikely to be adopted by those in power. Others have called for reforms in medical education such as reducing the amount of useless material memorized in the first two years of medical school, also unlikely to change.

Now that a resident can carry a computer in her pocket and access everything there is to know instantly, why should she have to memorize formulas, chemical reactions and other minutia? With the exception of the rules limiting work hours, medical school and resident curricula have changed very little since I was a student and resident some 40 years ago.

To summarize: We are trying to cram much more information, which is also more complex, into less time using the same methods we did in the middle of the Twentieth Century.

My suggestion: Let’s teach them to think instead of memorize.

I wonder what it will take to get the people in charge of medical education [American Association of Medical Colleges, American Board of Medical Specialties, Accreditation Council for Graduate Medical Education (parent organization of the Residency Review Committee for Surgery) and others] to wake up and notice that the system is not working very well.


Unknown said...

Glad to see you revisiting this topic; when we were discussing it a month or two ago, Leigh was the personal discussion I cited.

The fact is that immersion cannot be expected to work with the external changes mandated in how we train residents and students, and continuing to do so is a paradigmatic placement of a round peg into a square hole. We must reinvent medical education as a whole, and surgical education in particular, if we're going to continue to produce quality physicians. It's that, or extend training to 10 years.

Skeptical Scalpel said...

Thanks for commenting. I vote for reinvention. I don't think extending to 10 years will be well received.

taraine said...

Will you be expanding on How you think we should teach residents to think rather than memorize? The problem occurs in all programs (I am an EM educator), but seems most acute in procedural specialties like yours ( not to minimize the non-procedure elements of GenSurg).

Stephen Zintsmaster said...

As a current 2nd year medical student getting through school and attempting to get ready for Step 1 I can sympathize with the idea that these first two years might not be designed for learning medicine today. I do not think I'm expected to memorize anymore than the medical student 50 years ago. However, I do think that I am exposed to so much more information that it makes it harder to figure out what is the "need to know" information and what I can use technology for.

Do you have any suggestions on how the first two years of medical school could be changed to fit how we learn and use technology today?

Skeptical Scalpel said...

Good question. I am working on that.

DocInKY said...

Maybe our residents need the "residency of the future" like John Raffensberger taught me in the late 80s at Children's Memorial:

1st year - Sequester in a library and read every text (now on Kindles I guess)
2nd year - spend all year reading CT and MRI and US scans for diagnosis acumen
3rd year - spend all year in the simulator labs.
4th year - Med-mal legal courses with enough business and taxes for an MBA
5th year - Managerial courses to manage everyone around you!

I guess I am showing my age...

Skeptical Scalpel said...

Sounds like a good plan. I think you may have something here.

SurgicAL said...

As a plain old general surgeon in practice in a community hospital, I would have to agree that a revised curriculum, and surgical simulators could greatly compress the learning time to create a competent General Surgeon. I will admit that my 140hr weeks in residency were low yield, and made even lower by poor retention and lack of sleep. It bothers me that my recently hired colleague, graduated from a residency with an 80hr work week, is an excellent surgeon.

Skeptical Scalpel said...


I'm glad you hired a competent one. I wrote in a previous blog that about 25% of all surgical residents are not confident in their skills. [See link above.] I'm not sure everyone could handle a shorter residency.

Anonymous said...

We didn't have these problems when we had a pyramidal though brutal system... That worked pretty well, but now generation Y will not allow it. You may say that system is anachronistic, but it still works out like this in law firms right now.

DOB 1970

Skeptical Scalpel said...

Pyramidal is not PC any longer and hasn't been for many years. Part of the problem is what becomes of those who spend 2 or 3 years in general surgery residency and don't make it through. But the truth is, a similar problem exists with preliminary trainees who don't secure a 5-year position.

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