Friday, January 10, 2014

Expanding surgical residency training programs—good idea?

One of my Physician's Weekly posts last month was on the subject of surgeons possibly losing proficiency for doing open cases because of the ever-increasing popularity of laparoscopic and other minimally invasive techniques resulting in declining numbers of open operations for residents during their training.

Although some suggested that knowing how to do open cases would be unnecessary in the future, to me that is wishful thinking.

Another commenter said, "We are seeing the result of this in one of our hospitals with a new surgeon. He frequently aborts cases when he cannot complete them laparoscopically because he does not know how to do the open procedure. Worse, instead of seeking the help of someone who does, he transfers the patient to a medical center."

A resident said, "Observing the big name academic center that I train at, it seems that the massive cadre of fellows has led to an extremely low and less interesting case load for the rest of the general surgery trainees. Overload of floor management onto the trainees seems to exacerbate the problem. Why not substitute some of the current residency training with more focused experience with mentors—maybe even community mentors outside of academic centers—who perform the cases they’re lacking?"

The presence of fellows is a huge problem that academic centers and both the Residency Review Committee and the American Board of Surgery have glossed over for years. Fellows are usually not present in large numbers at community hospital programs; therefore, the residents get to do more surgery. Last year, I wrote about the fact that community hospital residents are more satisfied and do more cases.

The suggestion about mentors from outside of academic centers seems logical. However, it assumes that there are large numbers of community hospital surgeons who are dying to have residents around. In my opinion, that simply is not so. This is also a concern regarding the new surgical residency programs that are being established. I think some of them have been the result of initiatives by hospital administrators (residency programs still bring in government cash) and not the surgeons themselves.

I find it hard to believe that a hospital that has previously not had a residency program and has private practice surgeons who do nothing but operate can turn itself into a setting where surgical education is important.

Who is going to let the residents operate? Who will give didactic lectures? Who will write the research papers that are required by the RRC to prove that the faculty engages in scholarly activity? And so on.

I don't think it will work very well. What's your opinion?


Anonymous said...

Seems to me that when faculty are writing their research papers, they are NOT teaching residents. The 2 activities need to be divorced.
Maybe the residents could just read scholarly research papers written elsewhere in an ivory tower.

Skeptical Scalpel said...

Nice try, but it doesn't work that way. Faculty have to do both. The residents are supposed to do research too. They need mentors. If an attending has never written a paper, how can she help a resident do it?

artiger said...

Residency has only followed the trend of overspecialization. Until an appreciation for a general surgeon or general internist is once again realized, the problem will only worsen. Still, I have to wonder about population shifts. Haven't people been moving toward the larger cities and suburbs for a while (places that favor superspecialization)? I did read something recently (I can't remember where exactly but will search for it) that there may be a shift back toward rural areas, with the idea being a lower cost of living and simpler lifestyle. If that is indeed the case, then the need for more general physicians will become apparent. It's hard to predict these things decades in's like trying to make a 90 degree turn with a Mississippi River barge.

No disrespect intended Scalpel, but medical education has lagged behind the real world for quite a while, as far as addressing needs.

Anonymous said...

So faculty and residents are supposed to do research -- meanwhile we have residents, after 5 years of training, unable to operate independently as surgeons. Seems to me, we should put first things first. Tell the RRC that we need competent surgeons, not researchers. (Those who are enthralled with research can still do it on the side.)

Skeptical Scalpel said...

I've been telling the RRC that we need competent surgeons, not researchers, for years. They don't listen.

Artiger, if you have read most of my posts, you know I have been complaining about the state of medical education since I started blogging.

Anonymous said...

A decade back, I was an intern/resident in a community-based general surgical residency in a large metropolitan area. At that time, I asked certain of my attendings why they wanted to be involved with the residency (versus just doing the cases themselves.) The answers were all similar. One pediatric surgeon basically said, I have been doing appy's and hernias for 30 years -- am getting bored stiff -- teaching a resident makes things interesting again. Others mentioned the intellectual stimulation -- residents teach me things -- they ask me questions I never thought of -- they help keep me up to date.
(Why would anyone want to be a parent? Isn't it easier just to throw the frisbee yourself, as opposed to teaching some clumsy 7 year old how to throw it? Can't you get the dishes washed better, quicker, and with less water on the floor/counters?)
There are some people out there who want to be mentors, teachers, "parents" to the young med students and residents. The issue is, such individuals may be scattered, even rural in location. I think the RRC needs to relax their firm grip, and stop insisting that a residency needs to be done exactly one way. Operating and clinical-based on-the-job training/teaching can occur in Podunc, WI for 6 months and then scholarly activity/lectures/research can occur for a 3 month rotation in Chicago. Flexibility is key.
That's the same problem with the rigid, stupid 80 hour/week straight-jacketed rules. Of course residents who have been up all night and are dropping asleep on their feet need to go take a nap, but that doesn't mean they can't then scrub the Whipple or lap spleen coming up this afternoon.

Skeptical Scalpel said...

Anon, thoughtful and interesting comments. I think finding the truly motivated private practicing surgeons would be very difficult. Even more difficult would be getting the RRC and the ABS to allow the flexibility that would be needed to accomplish what you suggest. Of course, I agree with you about the rigidity of the 80-hour work week.

Anonymous said...

I am a general surgeon 20 years into a practice in a formerly rural, now more of an ex-urban community. I didn't go into academia in part because I like doing the cases and I didn't want anyone else doing "my" cases. Now I'm so busy, I can't afford to have anyone slow me down.

On the other hand, part of the reason I'm busy is because the hospital is turning the physicians into unit clerks, with all the extra computer work we are having to do now. I still haven't found anyone who can tell me how slowing my productivity even more is going to help the hospital. Now if I had a resident, maybe he could do the keyboard work....

Just kidding, but I'm sure that is part of the problem with medical education these days. But it's not all of the problem. I occasionally get 3rd and 4th yr medical students shadowing me around. When I pimp them on BASIC anatomy and physiology, I am absolutely appalled at how little they know. It makes me very afraid for the future.

Speaking of the future of general surgery: It's a multifactorial problem. Part of the problem is that patients want superspecialists. I get asked at least once a week what kind of surgery I do. When I tell the person I'm a General Surgeon, I invariably get the response "Oh, you're just a General Surgeon." And I invariably tell that person, "Yes, I'm JUST a General Surgeon." I think we are thought of kind of like plumbers--no one wants to be around us unless they need us. If only WE could get paid double after hours!

Furthermore, since we are operating on more and more obese, morbidly obese and supermorbidly obese patients, and it is much harder and more time and resource consuming to do so, our reimbursements ought to be adjusted commensurately. I propose increasing the reimbursement by 25% for a patient with a BMI> 30, by 50% for a BMI > 40 and 100% for a BMI > 50. This is something the ACS should advocate for.

That's my stream of consciousness for today.

Anonymous said...

"... When I pimp them on BASIC anatomy and physiology, I am absolutely appalled at how little they know...."

Maybe they should just pick their specialty carefully.

A very good and smart orthopedic surgeon of my acquaintance told me his story:
As a 3rd year rotating thru Ortho at a Big-Name med school, he got quizzed by his attending:

Orthopod: What is this, Smythe?

Student: Ummm, an elbow, sir?

Orthopod; Very good, very good. Now what is this?

Student: The other elbow?

Orthopod: Very good indeed. You should go into orthopedics, Smythe.

Student: Yes, sir.

Skeptical Scalpel said...

Anon, thanks for commenting. I agree with everything you said. I've been explaining what a general is for 40-some years. I've been revealing my thoughts about medical and surgical education in this blog for 3.5 years.

RuggerMD said...

I get the just general comment all the time.
I do more general surgery then trauma surgery, but most of the general surgery is emergency general I say I am an emergency surgeon...sometime I get oh, you an ER doc. Ughh.

I do all gallbladders and appys and colons laparoscopically on young healthy people. In my semi-rural area with a ton of retirees over 60 with multiple medical problems, I do all belly surgery open. Mostly because everything has already popped, but as a trauma surgeon, I am used to getting things out fast, and I truly believe an 85 y/o does better with a sigmoidectomy done open in 45 minutes, then done laparoscopically in two hours. I really believe the less time under anesthesia for the geriatric population leads to less morbidity, most of which is volume, pulmonary, or cardiac related. Anyone else agree?
so send your residents this way...we got open surgery galore.

Skeptical Scalpel said...

Rugger, thanks for commenting. I think you are going to have a hard time convincing people that open surgery results in fewer complications in elderly people. Maybe you need have a chat with your anesthesia colleagues.

Anonymous said...

Research and residency should have an amicable divorce.
I resent the hours I spent as a scribe of a worthless document, published in some open-access rag. I would have much preferred to actually learn my craft with that time.

The extension of residency positions is a semi-transparent way to destroy physician leverage via oversupply. Pathology has been in these doldrums for years. Radiology is getting there. Surgery might be next if what you're saying is true.

Skeptical Scalpel said...

Anon, thanks. Of course, I agree that research should not be mandatory for residents.

The projected need for surgeons in the future is all over the place. I have no idea whether there will be too many or not enough, nor does anyone else. So we will produce more surgeons of unknown quality and see what happens.

Anonymous said...

"I am used to getting things out fast, and I truly believe an 85 y/o does better with a sigmoidectomy done open in 45 minutes, then done laparoscopically in two hours. I really believe the less time under anesthesia for the geriatric population leads to less morbidity, most of which is volume, pulmonary, or cardiac related. Anyone else agree?"

I absolutely agree. I think the perioperative complications are more likely related to the patient's co-morbidities than the approach to the procedure. I've seen significant complications from advanced laparoscopic procedures, such as colon resections, in the elderly. I've had elderly open colon resections go home in 3-4 days. Obviously, this is anecdotal, but it is hard to argue that a lap approach can lead to a better outcome than discharge home in 3-4 days.

Skeptical Scalpel said...

Much as I would like to agree with you, I can't. Here are links to two recent papers which suggest that complications are at least no worse when the laparoscopic approach is used for colon surgery or abdominal surgery. and

Anonymous said...

My compliments on staying up-to-date with the literature that isn't even in print yet!

So, if I am reading and interpreting these abstracts correctly, I get the conclusions that operations take longer in obese patients, but obese patients don't have increased morbidity or length of stay in the lap colectomy patients.

The statistically significant difference in operative time increased by 25 minutes, from 157 to 182 minutes. This is no surprise to any surgeon in the world. The postoperative LOS was 6 days, and morbidity was around 23%.

However, an average of over 2.5 hours for a partial colectomy seems long to any experienced surgeon. My most recent open resection of a large rectosigmoid cancer in a 71 y/o man with a BMI of 33 and mild COPD and HTN took 67 minutes (about average for me), and is discharged home today 3 days postop with (+) BM's, good ambulation and pain control. I'm not saying I don't have LOS's of 6 days, but those are more the exception than the rule, and when you look at those patients, they seem to have more co-morbidities of all types (including pre-existing general debilitation and poor mobility, and prior abdominal surgery, rather than just obesity or CHF). They also may have had longer operative times, but I haven't taken the time to tease this out.

The second article seems to be subject to patient selection bias in that the laparoscopic approach seems safe in the "appropriately selected" patient with worsening or new CHF. Those who were apparently sicker (more urgent and emergent cases), were more often done open, rather than laparoscopically. This implies to me that the surgeons expected that the patient would benefit from a shorter operative time, although I didn't see that comparison in the abstract.

Obviously, I am a community surgeon rather than an academic one, but according to my limited intellectual capabilities, a possible explanation for the above disparate lengths of stay could be that anesthesia time greater than a certain threshold could lead to more problems with all body systems. I don't think that either of the above studies prove or disprove that hypothesis. Almost certainly, though, there are many more factors than just obesity and worsening CHF that contribute to the possiblity of perioperative complications.

Skeptical Scalpel said...

I assume you are operating without residents. That may account for some of your decreased operative times.

The CHF paper did not mention operative durations. They would have been nice to know.

If your experience is that patients do better with open surgery, then I can see why you would want to do it that way. Maybe you should write a paper of your own. It would be interesting to see your data.

Anonymous said...

I'm just a rookie in this field, I'm an intern. I've read all the comment above. One thing I have noticed in the program i am at, the attending who are heavily involved in research really love just pumping out research papers on material we already know with a slight twist. It's like they find any small reason to write a paper and try to get it published. Sometimes they will have students write BS on research work already done and then present it. I'm regretting joining a program that is affiliated with a university that loves research. It has really taken us away from being great surgeons in training. In terms of what is written above about so many fellowships people taking away procedures from gen surg residents. I would say this is variable. My location is overwhelmed with pt's, the program/univ cannot keep up. Residents need to take initiative, there are plenty of procedures. Second, I do feel after observing some senior residents graduate and some first yr fellow's that even after a 5 yr residency, they seem to struggle independently. They really need that attending looking over there shoulder. My question to all of you is why in your generation did your group become so independent and confident. I feel people are doing fellowships because they know they are not ready to be alone. Very sad.

Skeptical Scalpel said...

Anon, thanks for the very interesting comments. I appreciate your honesty in being worried about operating independently. About 25% of graduating residents lack confidence. I have blogged about this. In the "Labels" field above above, click on surgical residency training for links to my other posts.

In the old days, residents had many more opportunities to operate without an attending present. That's why we were more confident when we finished. Due to medicolegal and regulatory concerns, it's no longer possible for residents to operate by themselves.

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