Thursday, April 18, 2013

What? American College of Surgeons establishes "Transition to Practice" fellowships

The finding that more than 25% of general surgery residents are not confident that they can practice independently after finishing their residency training has prompted the American College of Surgeons (ACS) to create "Transition to Practice" fellowships.A pilot program at five medical schools and one rural community teaching hospital will place newly graduated residents with community hospital surgeons who will serve as mentors.

The program was introduced in an article in the February 2013 issue of the ACS Bulletin. It says, "current fifth-year residents often lack confidence in their capabilities and may be ill-prepared to enter practice due to a lack of general surgery mentorship and limited exposure to open surgical procedures."

The article goes on to say that the deterioration in training is due to "a number of factors, including reduced work hours, fewer hands-on experiences, and reduced volume of cases, especially emergency cases. Of particular concern is the lack of continuity of care and supervision."

But one of the members of the committee that planned the program said, "The transition from being a chief resident on June 30 to a surgeon in independent practice on July 1 is a daunting step. They haven’t done an operation without an attending across the table."

So which is it—not enough supervision or too much?

It seems to me the ACS feels that general surgery residency training is inadequate.

This confirms what I have said in previous blogs. Last July, I suggested that open surgery fellowships might be necessary to train residents who lacked sufficient exposure to open cases during their residencies. In January of 2012, I pointed out that residents who have never operated alone (the situation in most training programs—confirmed by the ACS) are analogous to pilots who have never soloed before. Would you want to fly with such a pilot? Back in November of 2011, I reviewed the paper that reported the lack of confidence expressed by 27% of residents who were surveyed. I have heard that in a paper about to appear in a major surgery journal, that number is approaching 40%.

If we can't produce confident graduates, why not simply change the way we train them instead of adding another year to the already long process (4 years of college, 4 years of med school, 5 years of surgery residency)?

I have discussed several areas of the curriculum that could be reduced or eliminated, such as insisting that all residents do research whether they want to or not, the heavy emphasis on basic science and the needless transplant rotation.

With a little thought, I am sure more changes could be made so that graduating residents will not feel the need to "transition to practice."

What do you think about "Transition to Practice" fellowships?

This post originally ran on General Surgery News in early March.


NeuroTrumpet said...

This betrays my ignorance of surgical residencies, but is it common practice to have an attending present in the OR to supervise right up until graduation? I would have thought that in PGY5 there would be some sort of taper so that by year's end the resident would be flying solo (with some attending nearby should he/she be needed). Is this highly variable between programs? Are there any data out there regarding factors that increase resident confidence at graduation?

Henna said...

I could say the same about nursing school. Why are there suddenly nurse residencies and nurse fellowships? Because there is too little clinical time while in school. My nursing school has a name that you would recognize. Our med-surg clinical days were one half-day per week spent at the hospital, about 26 in total over 2 semesters. Peds and maternity, about 5 half-days each. I was lucky because I was on a general medicine unit and got to see a variety of patients. We all complained that our clinical time was inadequate. The preceptorship in the last semester consists of working eight shifts one-to-one with a staff RN. No wonder, then, that hospitals are not confident in the capability of new nurses to practice safely and effectively.

Anonymous said...

I believe attendings can not bill for what they do not cut or at least pretend to cut while scrubbed in.

artiger said...

In order to bill for the procedure, the attending has to be scrubbed in (Scalpel, correct me if I'm wrong), otherwise it's considered fraud. I don't know if there is a specific portion of the case that requires being scrubbed in to make it kosher. I did my residency in the mid 1990's, and we were often unsupervised from PGY3 and on. Attendings would scrub for Whipples, esophagectomies, some AAA's, and things like that, but usually they would come in, ask if everything was OK, sign something, and go back to wherever. They would be available to come back at anytime during the day (at night, it depended which one was on call).

The Libby Zion case and the threats of fraudulent billing changed all that, and got us to where we are today. I am not advocating overworking and undersupervising residents, but like so many outcry reactions, the pendulum swung way too far in the opposite direction.

I commented on that article last month, specifically remembering that when work hour limits started, some program directors (especially in surgical fields) wondered aloud if post graduate training would need to be lengthened. I wondered aloud if this "fellowship" was simply a way of doing just that. If I were going through today, I sure wouldn't want to do it.

I would suggest weeding out the residents who are heading to plastics and breast after the third year, and the CV, vascular, laparoscopic, and transplant after the fourth (not sure about colorectal, maybe after the fourth for them too). And yes, get rid of the stupid transplant rotations. Everyone hates it except for those who want to do it after training. Then, allow the fourth and fifth year residents to work slightly longer hours (maybe 90-100 per week), and let them operate solo in the last half of the fifth year (or maybe with the attending in the room but not scrubbed). I know this would require major changes from several governing bodies (ACGME, Medicare, IRS, probably even the ACLU), but it would have the effect of offering the senior resident a larger caseload and a little more of a real practice feel with increased hours and call. This would eliminate the need for a silly fellowship in the same field in which one spent the previous five years.

Skeptical Scalpel said...

Thanks for all the comments.

In order to bill for a procedure, the attending surgeon must be present inside the operating room for the key portions of the case. She cannot "supervise" from her office or "supervise" two cases at the same time. Medicare cracked down on many teaching hospitals to the tune of several millions of dollars a few years ago.

Henna, I have a post about nursing that is complete but is pretty inflammatory even for me. I'll publish it very soon. It touches on some of the great points you have made. Thanks for confirming my impressions.

Anonymous said...

This is just another sign of subpar educational system, I believe they way the ACS wants to break down training into multiple trackmaybe helpful. But the real issue here falls on the new group the graduate joins They need to scrub with the new partner , first assist and support and mold the partner not just throw them to the wolves. Worse new graduate should not be hired as solo providers. I believe the first 2 years in practice has a huge learning curve and with the right partners the surgeon will do well , with the lack of partners they may make many mistakes. PROTECT OUR YOUNG but i believe we rather feed of our young. I have seen to many new graduates have bad expereinces due to older surgeons protecting their turf.

Charlotte said...

There is a big difference between feeling inadequate and actually being inadequate. Many people perform at a high level, but they may never get over some feelings of inadequacy -- regardless of their profession. Overconfidence can be as bad as underconfidence.

artiger said...

Anonymous, that is a great point. I was fortunate to join a fairly large group (6-8 other surgeons) at a fairly large hospital right after residency. It wasn't a good fit for me (I'm a small town guy), and I left less than 2 years after signing on, but that experience was quite valuable for me later on, specifically learning my limitations.

Skeptical Scalpel said...

Anon, good points. Charlotte, I agree that overconfidence can be bad too. But surgeons need confidence to make decisions in the middle of the night and to believe they can do the operation that a patient needs. They cannot have doubts or they will not act decisively.

Some people do not understand that anyone can make a decision when they read a chart 3 weeks after an event occurs and when the outcome is known. To me that is a big problem.

Anonymous said...

Dr. S, If a resident knows he's going to do the whole operation solo, does he introduce himself as the surgeon when he meets the patient in pre op? And does he dictate and sign his name to the operating report afterwards?

Thanks, Emily

Anonymous said...

I'd like to see innovative programs move away from time-based advancement to competence-based advancement.

artiger said...

Emily, if a resident is going to do the whole operation solo, I would certainly hope that he/she has already met the patient prior to the day of surgery.

Yes, dictating and signing/e-signing the report is part of that responsibility, although it has to be cosigned by the attending as well.

Josh said...

I hate this idea. I actually think our specialty's leadership should be embarrassed by it because of what its existence implies: "Our general surgery residencies aren't successful at training general surgeons." If that is the case, they should back up and reevaluate our training programs from the ground up, as you are advocating. Adding a year like this seems like a lazy solution ("Just add another year..."). The obvious solution to me is moving to a 2+3 or 3+2 early specialization system.

Skeptical Scalpel said...

Josh, I agree that the problem lies with the way residents are being trained (or not trained). If you go to separate shorter tracks, how do you know that the residents will not simply be just as under trained since it is still five years? My solution is to eliminate unnecessary parts of the training such as transplant and research for starters.

Anonymous said...

Most physicians, not just surgeons, will have a period of adjustment moving into independent practice. The most useful adjunct is having senior partners who are willing to offer advice - and scrub in - as needed without imposing his techniques and practices.

I don't know about the hate for transplants. I am not a surgeon, but don't the residents learn surgical techniques and critical-care skills even on the transplant rotation?

For surgeons who go into breast or plastics, I agree that 5 years of general surgery is overkill. Especially since I have known perfectly skillful breast surgeons who trained in OB, and plastic surgeons who spend a year training past ENT. The problem is that few areas can support a full-time breast surgeon who cannot do other surgery.

Skeptical Scalpel said...

Anon, thanks for the comments. It's not about hating transplants. I don't know about all transplant rotations but my residents did not get to do much on the service because of the brevity of the rotation and the fact that the staff barely got to know them. It's not just me. A recent survey of program directors agreed that it was not a useful rotation.

We all agree that mentors are of great value. Maybe that is the answer. The problem is how to formalize that sort of thing. The transition to practice fellowship is one way. On the other hand, we never had to do that before. Why is it deemed necessary now?

artiger said...

Anon, I remember my transplant rotation years ago, and it pretty much resembled 3 months on an internal medicine service more than a surgical one. What I mean by that was that I was seeing post transplant patients in clinic and managing their immunosuppressive meds, as well as refilling their Percocets or whatnot. There was a minimal amount of time scrubbed in on the actual transplant procedures. While I won't discount the value of learning a bit of knowledge about cyclosporine and azathioprine, it certainly didn't feel anything like a surgical rotation, and to this day it has had zero value for my day to day practice. So perhaps that is where the transplant hate comes from, if my experience is close to that of most other surgical trainees.

Anonymous said...

Artiger, thank you for responding. I should have explained my story a little further. I had initially met with a surgeon ahead of time, but he was not the surgeon who met me in pre-op. A much younger doctor met and talked to me, asking if I had any questions, etc. I never saw the original surgeon again, only this much younger one for follow ups after the surgery (which by the way went well). So, after reading this post, it made me think that the younger doctor might actually have been a resident allowed to solo on me. I don't mean to be provocative, but if hypothetically this was the case, does a patient have the right to know ahead of time if there will be a switch to a surgeon in training, and that the operation will be unsupervised? Or because this was a teaching hospital, there was no obligation to do so?


Skeptical Scalpel said...

Anon, this is a very prickly subject, which has been hotly debated for years.

When you say you never saw the original surgeon again, do you mean you did not see him even in the operating room? If he was in the OR, he would have been supervising. If he wasn't there, that might be a problem. What did the consent form say? If the original surgeon's name was in the blank for "surgeon," then he should have been there. If the resident's name is the only one on the form, then you certainly had the right to know that the resident was going to be doing the procedure. Another issue is who sent a bill?

The gray area, which is the subject of much discussion, is how explicitly do you need to know that a resident may do a part of even all of your operation under the supervision of the attending surgeon?

Ewen said...

In the 3200 most recent tweets from the ACS, the words train/trainee/training occured in 24 (0.75%), residence/residency/residencies in 31 (0.97%), and resident/residents in 56 (1.75%).

I'm struck by how low these numbers are.

Anonymous said...

Dr. SS,

I don't know if the original surgeon was in the operating room as I lost consciousness when being wheeled down the hallway to the OR. This operation was 6 years ago, so don't know whose name was on the consent form or who dictated the operating report. And my insurance paid all the hospital bills directly. But I do remember that I only saw the surgeon I thought was doing my operation once when I met him during my initial visit. Then met the second much younger doctor just before the surgery, once again during my hospital stay, plus 2 outpatient visits.

As I stated, I had no problems with my care, everything went well, but from your post saying that residents can or should operate solo without supervision made me curious if that was the case with me. If this gray area you mention is whether to inform the patient ahead of time that they are being handed over to a trainee for the operation, I can understand the reluctance to do so. Probably more than not the patient would be upset. And if there's nothing the patient can do about it, short of going to a non-teaching hospital, then maybe it's best to keep the patient in the dark.


p.s. I appreciate your blog being welcoming to patients.

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