Thursday, January 29, 2015

Now I'm really worried about surgical education

Here's why.

A friend told me that a new attending on his staff was having some problems. Although the young surgeon was a graduate of five years of general surgery training plus two years of fellowship, he was unable to do an inguinal hernia or a laparoscopic cholecystectomy by himself.

This is just an anecdote, but the issue has been identified by others. Remember the paper from Annals of Surgery in September of 2013 that described a survey of fellowship directors? It stated that 66% of graduates of five-year general surgery training programs could not conduct a major case unsupervised for 30 minutes, and 30% could not independently perform a laparoscopic cholecystectomy

A study published online in JAMA Surgery last month looked at 20 years of ACGME surgical resident case logs and found that although minimally invasive surgery is being done much more frequently, it is currently performed in more than 50% of cases for only five procedures—cholecystectomy, appendectomy, adult anti-reflex surgery, partial gastric resection, and thoracic wedge resection.

In 2007, the Residency Review Committee for Surgery increased the required number of basic laparoscopic surgery cases from a minimum of 34 to 60 and from 0 to 25 for advanced . The authors expressed concern that there might not be enough minimally invasive cases for all of the residents to do. They also pointed out that there was still in need for residents to learn open surgery since all but five operation procedures are still predominantly performed that way. However, as laparoscopic cases increase, the number of open cases will decrease because the total number of cases done by graduating chief residents has not changed significantly in 20 years.

A year ago, I blogged about some potential problems that might occur when surgical residencies are expanded and new programs are begun. Specifically, I wondered if there would be enough teaching cases to go around. It is interesting to see my speculation bolstered by data.

A program director recently told me that there may be a movement afoot to start a Fundamentals of Open Surgery course.

What is going on here? There is already a Fundamentals of Laparoscopic Surgery course. Do we really need to have a separate course to teach residents open surgery? Isn't that what a "residency" is supposed to do?

How did surgeons of my generation ever learn how to operate without courses in the fundamentals of laparoscopic and open surgery?

The visionary surgeon Leo Gordon saw it coming in 2002. He predicted the need for a "macrolaparotomy" course, and it can be run by the newly created American Board of Open Surgery.


Matthew said...

Really insightful take on this! Thanks for sharing.

Henry Woo said...

It's a problem faced by other surgical specialties as well. We now have a number of urologists who have never performed an open radical prostatectomy as they have only ever been exposed to robotic surgery. Open pelvic surgery can be difficult and experience makes a huge difference. I fear the time when complications during robotic surgery necessitating open conversion will create a situation where the only ones able to bail out the situation will be sub specialised open macro surgeons - not even urologists will be able to help because the art of open prostatectomy will have been long been lost.

lucidlyexpressed said...

This is certainly a concern I have in choosing a surgical residency. The programs I am looking very seriously at have fantastic case volumes in basic and complex open/laparoscopic procedures. In that same vein, I believe that adequate exposure to complex cases enables one to apply technical skills to a situation where one may not be fully versed. This is simply my opinion as I will only begin residency this summer, but I have contemplated this issue quite extensively in my quest to find a home to train in.

Anonymous said...

I think it's also worth considering how policies attempt to inform practices in the OR in training programs as well.

As a junior resident, my favorite example to illustrate this point of a teaching disconnect is the lap chole at our 'bread and butter' community affiliate. Multiple choles happen each day and occasionally overnight for those on call. But it's a private hopsital, so the attendings are trying to get stay on schedule.

When does a junior resident get to touch anything beyond the camera or maybe a retractor? Taking the gallbladder of the liver bed. But we've been standing there for the first part of the case, not manipulating any instruments, and and slow to get acclimated once we're actually doing something. And I'll tell you what happens in too many cases, the attending gets impatient and the resident doesn't even get to finish dissecting the GB off the liver bed. The resident gets maybe a few minutes of operative time that's cut short because they're not fast enough.

I sincerely hope that changes by the end of my training. This is just an example but I use it broaden the discussion beyond the residents themselves. It seems (from stories) the generation of surgeons who are near the end of their careers pretty much all operated autonomously in their chief year...running their own rooms and trying never to call an attending. That would never happen now.

There's no doubt I'll get to "see" all required cases with many complex cases. The question is will I get to meaningfully participate in many of them.

Anonymous said...

As a 4th year medical student who will be submitting his Genreal Surgery rank list in less than a month, I wish you'd name names. Seriously though, that could be a way for surgeons of your generation to hold these programs accountable. Let everyone know about the programs you've seen that have consistently skilled and confident graduates and the ones who don't.

artiger said...

First Anon, don't fret. Even though I finished still in the era of chief year autonomy, I found that my real skills developed in my first several years of practice. Even if you feel short changed coming out of residency, the real learning starts after that (only my opinion).

Still, I am tempted to get an ultrasound on myself tomorrow; if I have gallstones, I think I'll get it removed while there is still someone around who can do it independently. I'll probably ask them to take my appendix while they're in there.

Anonymous said...

Anonymous Europe: I hail from Europe again.:) What I can say today, Europe is yet again different. A lot of people in a lot of countries here envy you guys overseas for the numbers you get to operate there. It is funny to read that someone in the US has difficulties with these basic operations....
In Eastern Europe every patients are operated on by the chiefs because of the so-called "gratitude money", that is tax-free money they receive directly from the families of the patients.
Where I work in Western Europe we have ideal training conditions as we get to operate everything and are closely monitored and tutored through appointed supervisors. The trainees do at least 3 operations a day and that is the minimum, we even get more!

What if the problem in these surgical programs lies not in the working hours but what the trainees get to do with it? If you have to do too much administrative work it gets you away from the OR....
What I think would be good and ideal is that trainees would not have to do any administration except for operations reports they did. I know I sound radical, but think this through guys.
At least in Europe 20 years ago life was waas slower and there was waay less administration. In my opinion with the increase of hospital administration, training suffers. I find it way harder to learn where to write what, as what the next step is during an operation....

PGYx said...

Although some will blame the reduction in duty hours, another factor is the increase in resident administrative duties (both absolutely and relative to total training hours). The increase in attending administrative duties and reduction in reimbursements further worsens pressure on the attending to just do the procedure himself.

Medicolegal concerns have also caused a huge reduction in med students and residents actually getting to do anything. Then after we graduate from residency we're supposed to come up to speed -- please tell me how insufficiently trained attendings doing unsupervised procedures benefits patients.

The loss of skill acquisition starts in medical school, where students no longer permitted to write chart notes (sure they can write ones for themselves, but few get reviewed by residents/attendings, so benefit is limited). They enter internship with little clinical competence. Then as residents they don't get to do enough procedures to gain real competence.

Anonymous said...

Ive been in surgical resident education for over 15 years now, both as a PD and Chairman. You are 100% spot on with your comments about residents not being able to perform open surgery anymore. Unfortunately, I believe that is a sign of the times, both because of the rise of laparoscopy (which for the most part is a good thing), and because of the work hours restrictions we now have to abide by (which for the most part is a bad thing). I am most worried about the MIS fellow who cant do MIS surgery, and that leads me to ask if a Fundamentals of Open Surgery course (FOS, for those readers paying close attention) would be any better at solving the problem. I think we need to either relax the work hours restrictions, or make the 5 year residencies 6 years long.

Anonymous said...

I honestly don't think that erasing the duty hour restrictions would solve this problem. Residents would still be in the hospital doing resident jobs which have a very significant administrative burden. Many rotations are strictly "service" for the juniors especially. More hours at the hospital would just mean more service.

What is necessary is more time doing things that are actually educational. For the surgery resident, those are cases. And cases where the resident participates meaningfully.

Every resident can tell you which attendings in his or her program let residents actually operate and which don't. Why aren't efforts made to ensure that attendings employed at teaching institutions actually teach the residents in the OR?

The hammer of "excessive work hour restrictions" needs to stop being wielded for every issue with surgical education. Attention instead should be paid to how residents actually spend their time in the hospital and the educational opportunities available to them. Trust me, THAT'S where improvements can readily be made.

Making residency longer and erasing duty hours do nothing to make residency training smarter. More of the same will just yield the same results.

PGYx said...

Wholeheartedly agree with Anon 5:58 PM:

Making residency longer and erasing duty hours do nothing to make residency training smarter. More of the same will just yield the same results.

Anonymous said...

Loved that I trained at a community hospital: lots of cool cases with attendings who wanted to teach and train good surgeons

Skeptical Scalpel said...

I want to thank everyone for the comments. I agree that the duty hours issue, while certainly a factor, is not the main reason for this problem. I think it has more to do with the attitudes of attending surgeons in some programs and the almost smothering amount of supervision that seems to be taking place right now. I also agree that administrative duties, the electronic medical record, and paperwork consume a lot of resident time. This has been documented by a few published papers.

The comment from the anonymous European was interesting.

What is the solution? Lengthening the residency by a year would certainly give each resident exposure to more cases. However, if the resident is not allowed to perform the key parts of the case, how is watching more cases being done going to produce a more technically competent surgeon? There would also be issues with paying back loans and the already lengthy general surgery training time commitment.

frankbill said...

For us non medical people it is interesting to read how providers are trained or not trained. Non of us want to be the first one that a new surgical resident performs surgery on. But someone has to be the first.

We have to trust what ever training the new resident has had is the best it can possible it can be. It has to hard for the attending surgeon
to have that resident do that surgery. They have to be thinking if things go wrong how bad is going to be and can I fix it.

I do think we are just starting to see a technology that is going to change much in how residents are trained to do surgery in a very safe way and it will seem like they are doing the surgery on a real person. This technology is all ready helping surgeons as this link shows

It will be just a matter of time where the 3d printer will with other technology print out a lifelike model of someone. When this happens The needed surgery can be done on the live person and the persons model can be printed out as many times as needed for training new surgeons.

Sharda Hinkel said...

Keep sharing.

Skeptical Scalpel said...

Mark, I will.

Anonymous said...

Nice post

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