Friday, March 4, 2016

Are today’s surgery residents poorly trained? What can be done about it?

A surgical resident writes

I’m sure you have read several recent studies suggesting that current general surgery residents are poorly trained and unprepared for independent practice at the completion of residency.

My questions for you:

1. In general, do you agree that current general surgery residents are poorly trained and unable to operate independently at the completion of residency?

2. What should we do differently? I personally don’t feel that “more simulation activities”, which many have suggested, is an adequate solution.

Thank you for the excellent questions.

I have been out of the surgical education loop for a few years and no longer have first-hand experience, but the literature does indicate that some surgical residency graduates are not ready to practice by themselves.

In 2013, I blogged about an Annals of Surgery paper reporting as many as one third of subspecialty general surgery fellowship directors felt that about one-third of incoming fellows were deficient in several areas and unable to independently perform a laparoscopic cholecystectomy or 30 minutes of a major case unsupervised.

Click on the table to enlarge it. You can see the responses of the program directors.

This paper was criticized by some because the fellowship directors surveyed were not subspecialtists recognized by the ACGME. The implication was that fellows in these programs might not be representative of all surgical graduates. However, many of them were minimally invasive fellowship programs which continue to be highly sought after.

Does it really matter? Some general surgery graduates apparently can’t operate by themselves.

In 2011, I blogged about a paper that reported 27% of all graduating surgical residents surveyed were not confident performing surgery by themselves. That was approximately the same percentage identified by the fellowship program directors.

Regarding what can be done about the issues of confidence and training, I agree with you about simulation. You can simulate all you want, but being alone at 2 AM with a patient who is bleeding out cannot be adequately simulated.

The American College of Surgeons created a Transition to Practice Fellowship in 2013. They later change the name from a fellowship to a program. Of course, I blogged about this too. As far as I know, not many hospitals are involved. How many graduating residents have enrolled in this fellowship program is unknown.

Henry Buchwald, a prominent senior surgeon, recently advocated establishing “open surgery” fellowships and wrote, “I submit that it would behoove our training programs to return open surgery schooling to their curricula.” However, he doesn’t explain how this could be done or where one would go to do a fellowship and open surgery.

Life imitates art. In a post last year, I cited the visionary surgeon Leo Gordon who saw it coming in 2002. He predicted the need for a "macrolaparotomy" course, and said it could be run by the newly created "American Board of Open Surgery."

The lack of confidence stems from the gradual increase in supervision of residents over the last 15 to 20 years. In yet another blog post, I pointed out that many of today’s residents rarely if ever operate independently during residency training. To realize you are on your own as a full-fledged surgeon without ever having performed a case by yourself must be frightening.

With all the ACGME regulations, medicolegal concerns, and extensive scrutiny surgeons and trainees are subjected to, I don’t see this problem going away anytime soon.

All you can do as a surgical resident is to try to scrub on as many cases as possible and take care of as many patients as you can. With luck, you may have faculty who have enough confidence in themselves to allow you some autonomy and decision making in the OR and when managing patients pre-and postoperatively.


artiger said...

I like your answers. As with so many other things that get politicized, resident supervision and work hour limitations needed to occur, but the pendulum swung way too far. There is a happy medium that can satisfy the needs of training experience and autonomy while still giving trainees a reasonable quality of life and avoidance of burnout. Unfortunately, the powers that be reacted too far to the extreme, and we are just now starting to see the effects of it.

I think work hour limits can be extended beyond the 80 hour/week average limit, say 90-95 (I am including on call time in that), and still give residents adequate time off, like a day per week, or getting to go home early after being on call. I don't know that independence is as important as volume of cases seen and participated in.

Anonymous said...

Linking to your last blog-post, if you are not confident of operating on your trainer and your trainer is not confident of letting you do so, then both have failed. In the UK, the hour-limiting EWTD has become a clipboard exercise, with trainees seeking to sneak in more training hours. Have we have let our professionalism deteriorate such that we can not turn out competent surgeons?

Just a thought said...

As a resident about to graduate from a community program and rotates at many ivory towers. It is not the work hours. It is the comfort of the doctors you operate with. That is the real issue. I think that working with the same surgeons over the last 5 years allows for comfort on both sides. Also, if you are just doing busy work and you never see an operating room until your late 2 year then maybe that is the real problem.

I will be able to comment further in 2 years after doing it on my own.

Skeptical Scalpel said...

Artiger, I don't think we will ever get anyone to agree to more than 80 hours per week. We are going to have to figure out how to get it done in the allotted time.

Anon, I don't think all trainees are incompetent, but it looks like a portion are not able to work independently when they graduate.

Just, the American Board of Surgery and the RRC now require the PGY-1s and 2s do a minimum of 250 case in the first two years. That should take care of some of the busy work problem.

I agree that working with the same surgeons over 5 years build trust. It is the ideal way to train residents.

Anonymous said...

Training should not be about "hours" as some type of "currency" for resident competency or the flips-side, abuse. The focus is all wrong. The model for training needs to be revamped, given the addition of new technologies and the top-down pressures of productivity and resource restrictions facing the surgeon trainers which have occurred over the 100 years since the adoption of the current model.

Blacksails said...

Skeptical - the 250 case requirement for PGY 2s includes first assists, which counts stuff like holding a retractor like a MS3 and also counts things like lipoma excision or lymph node biopsy

Skeptical Scalpel said...

Anon, I have blogged for years about the fact that we still train students and residents just like we did 50 years ago. A paper published ahead of print in the Journal of the American College of Surgeons discusses what you are talking about. Here's the link

Blacksails, thanks for the clarification. Here's the direct quote, "A minimum of 250 operations by the end of the PGY-2 year for applicants who began residency in July 2014 or thereafter. The 250 cases can include procedures performed as operating surgeon or first assistant." Even if they are just first assisting, it is better than doing scut on the floors. Source of quote:

Chris said...

I don't think this problem is limited to surgery. Trainees coming out of Internal Medicine programs in many cases are not competent to manage moderately complicated cases without the assistance of multiple subspecialty consultations that would've been considered wasteful a generation ago. Newly minted family physicians can barely keep up with their patient load, much less expertly manage difficult cases across a spectrum of patient groups.

However, I do not say this as a criticism of the individual practitioners. Think how much medicine has changed over the course of the last 50 years. People used to be admitted for a week for "work-up". That all happens in 7-12 minutes outpatient visits now. Treatment for diabetes used to be insulin or metformin. Now think about how many new diabetes drugs with unpronounceable names are advertised in the pages of our journals every week. As a rheumatologist, it's easy for me to contend with the 12 (and growing) medications approved for treatment of RA, but I don't expect an internist, much less a surgeon of any stripe, to have any detailed familiarity with them.

We are getting to a point where the complexity of medicine is outstripping the ability to teach it in a compressed period of time. I think Osler and Halstead were visionaries, who shaped the future (our present) of medicine and through their training models allowed for incredible advances in medical care. But as mentioned above, our approach to medical education is now in great need of overhaul. There is just too much internal medicine for one person to know. There is too much surgery for one person to be able to do. I hope this doesn't just mean acceleration of the fractalization of sub-sub-sub-specialization, but I don't personally have the foresight of an Osler to envision what the future holds...

Anonymous said...

I graduated residency from a community program about 11 years ago. I felt that most of my attendings didn't care about teaching me. Learn by osmosis, sink or swim, if you don't know how to do the case then we'll take it away/make fun of you/etc. I personally don't think that watching is a way to learn surgery, and back when I was doing all my watching, I was generally so dog tired that staying awake was the name of the game. Not much learning was happening in that state of being, in the OR or the conference or wherever.
I would never teach surgery to my own child the way that they "taught" me. Most of my 5 years were wasted -- either I was "watching" or scutting, or maybe I was doing portions of cases that I would never dare to do or be able to do in the real world with better-qualified subspecialists nearby (e.g. Whipple's, pulmonary lobectomies, pyloromyotomies, facial flaps, neck dissections, vascular cases, etc.)
Yes, residency does a bad job of teaching, and hence many general surgeons have to do their learning post-residency, and they have to refer away difficult cases unless they have wonderful senior partners. (I failed in that last department also.)

Chris said...

Specifically regarding duty hours, I think this Atlantic piece makes an important point that is often overlooked: less restrictive duty hour rules inherently disadvantage current or potential trainees who are the primary caregivers for children (primarily women)

Skeptical Scalpel said...

Anon, I am sorry you have had such a bad experience, but I'm also not surprised. I've heard stories like this before. It's one of the reasons that I wrote about the possible downside of creating so many new residency programs.

Chris, thanks for the link. It's an interesting article with some marked differences of opinion in the comments section.

Anonymous said...

To Anon who posted on 3/7/16 @ 8:57 pm: Thank you for your honesty. Reading your note, it reflects my own experiences in residency. I remember one case (in particular--though there were many) where the Chief Resident claimed the case as "teaching assist", (even though the attending was scrubbed in as well), the 3rd-year resident claimed the case as "surgeon", and the intern claimed first-assist although they just stood at the patient's feet. Now, let's throw in a little bit of "lawyer-speak." Let's say your residency program, via your contract, requires you to get a medical license as soon as legally possible (some states that is after your intern year). Now the patient sues.

Here's my question: NOW, who is the surgeon? The attending who bills for the case? The Chief Resident who (has a license) and is just "teaching", or the third-year resident (who has a license), but has no real-life experience in this complicated case? The 3rd-year resident has "claimed" to be the surgeon--but in reality wasn't. HOWEVER, (and I speak from experience), IN THE EYES OF THE LAW, the attending, the Chief, and the 3rd-year are all "licensed to practice medicine and surgery" and will be viewed, in the eyes of the law, as "equivalent" to any and all doctors so licensed. The 3rd-year resident is held equally as liable as his Chief and attending--and all 3 go to the National Practitioner Data Bank.

I agree with Skep there's a problem opening new residencies. Lack of cases, "fudging" data in a low-volume program, and holding residents ("legally") equally "liable" for mishaps, while paying them $50K/year while an attending may earn $400k/year.

Our residency experiences have changed. Now ask that 3rd year resident how his confidence and self-esteem were shattered before he ever left residency. And what effect this had on his/her patients after residency.

In 5-years of residency, NOT once. . .NOT once...did our Chairman give a lecture to the residents, operate with the residents, or teach ethics/business with the residents. I would have been better off had they closed our program. . .but the data we submitted to the ACGME probably was "just fine."

Skeptical Scalpel said...

Anon, thanks for commenting and sharing your equally bad experience. It sounds like you had a really bad experience.

However, I don't think you are correct about the degree of responsibility that a resident has for a bad outcome.

Residents do not carry individual malpractice insurance. If a resident is on the losing end of a malpractice case, the hospital is the one who pays because residents are all covered under the hospital's malpractice insurance, or in some cases, hospitals are self-insured. Because of that, I don't believe that residents are routinely reported to the National Practitioner Data Bank.

My experience with malpractice cases is that the attending surgeon usually takes the biggest hit if a judgment is found for the plaintiff. Even if a resident is judged to have been at fault by a jury, the hospital is the entity that pays and the resident' name is not reported to the databank.

I agree with you that fudging of case log data probably occurs more frequently than most surgical educators are willing to admit.

Anonymous said...

Anonymous Europe: This question concerns me too, as I am a trainee. Guys, the problem lies not in the amount of working hours, but what you do with them. (But if you ask me, you can also train people with 48-64 hour working weeks, IF they do the RIGHT kind of work). I have gone once through what you need in the US to pass your board exam. It was not the exam that was truly scary, but the paperwork involved (hospital bills from the last patients, etc, why???)...As long as trainees have to do meaningless paperwork instead of operations and patient management, the situation is only going to worsen...
But the situation is hardly better in some Western European countries, where doctors are employed as bureaucrats not as actual medical personnel..
Thank God where I am, we do not have this kind of problem (yet), I get to operate mostly, or do the outpatient unit work, than do meaningless, harrowing paperwork. I would go crazy, sitting all day in front of a stupid desk with a computer on it.

Skeptical Scalpel said...

Europe, thanks for commenting. On another post of mine people from a few European countries have weighed in. It seems like everyone violates the work hours rules there anyway.

Anonymous said...

Anonymous Europe: Unfortunately they do, otherwise the system would collapse, if they didn't. The question is, in my opinion, how this "extra time" is utilized. If someone tells me at 15.30-16.00 pm (that is when work (should)end(s) in Europe usually)that there is a case I may get to operate and the attending would assist me, I would do it without hesitation for the "fun" and "experience" and of course I would signal my extra hours to bookkeeping for the money... But if the "extra time" would involve paperwork, I would just sign off. Life is too short to fill it with useless paperwork..:)

Skeptical Scalpel said...

Are you saying that you get extra pay if you stay late? That's not the way it works here in the US.

Anonymous said...

Anonymous Europe: Yes. It is common in German speaking countries and some others that I know of that if you have to do extra hours, you get extra money. The same applies for my actual workplace. Either you get extra money if you have to stay in late or you get extra "free hours" you can utilize if you need to get off earlier (e.g. going to the mechanic for the car, etc.). I love staying late, because it is a win-win situation for me. I get to operate and rake in extra money or free time.
How does it work in the US? What happens if you get stuck in the OR, even though your shift is over and has to stay?

Anonymous said...

Two comments: That fellowship director paper is garbage; terribly biased and a low number of respondents. That said, it's clear to me (as a recent graduate of residency now in a fellowship in which I also take acute care general surgery call) that we are not as well-prepared to enter independent practice as were our forebears of 10-20 years ago. I feel strongly this is related to the lack of any meaningful autonomy as a chief resident. I have a sort of "hands-off safety net" for my attending call here at [major university hospital]: I book cases, don't have to check in with anyone before doing anything, but can call a senior guy/gal if I need help. Far more than the learning I'm getting in fellowship (where the faculty are still quite hands on), I'm learning a tremendous amount dealing with these complex cases that present to or are transferred to this tertiary center. I will add that my residency training (at another pretty hands-on University) has prepared me pretty well to take care of these patients, and I haven't needed the safety net much, but I'm sure I'm not as confident as some older graduates were when they were in my shoes (and I'm studying/reviewing prior to doing anything other than appy or chole). The transition to practice fellowships seem likely to provide a similar experience, and I think they're a good idea. Skeptical Scalpel, this is such a great topic. We are in such a time of sea change in surgical education. I don't get to spend much time on here b/c fellowship keeps me so busy, but thanks for keeping this conversation going.

Skeptical Scalpel said...

Anon Europe, if a resident stays late, she doesn't get extra pay. Depending on circumstances, she could get into trouble or get the program in trouble or both. When you stay overtime, how do you reconcile that with your work hours limits? Or do you ignore the limits like residents in other European countries do?

Anon, I agree the fellowship director paper is weak, but it coincides with the other paper I mentioned in the post that said 27% of graduating residents don't feel confident in their skills. It sounds like you have a good setup where you are, and you are aware of your limitations. That's a good quality to have. Don't ever lose it.

Unknown said...

1) Competency-based advancement
2) Early sub specialization

Skeptical Scalpel said...

I'm not so sure about competency-based advancement. It will be very subjective. I'd like to know just how it will be implemented.

Early subspecialization is inevitable.

Anonymous said...

I spoke to a surgeon and we had this same conversation! new grads aren't trained like they use to be. Residents are graduating school and are expected to know how to perform certain procedures
they have never seen before. I agree with what was said before, the lack of autonomy kicks you in the butt when you're finally alone.

im not a doctor and i don't go to med school(someday tho?), but if i was a resident, i would want my program to allow me to work my 40 hours for the week, and then allow me to volunteer my time- as much as i want- to the hospital so i could see as many surgeries as i want with no added school work. in fact, the extra hours should reduce if not eliminate all papers required (depending on the amount of time spent). pay me 0.1cent/hour. have me sign consent/liability forms... i wouldn't care! it's my education on the line and i want to participate in 80+ hours! i want to be a human vacuum when it comes to that stuff without the added stress from school (Im sure they require you residents write all sorts of papers and do all sorts of things, which the stress in my opinion undermines the desire to learn). I am an RN (i know.. it's not the same). but the stress from the school-clinical-hospital complex made it to where i wanted to do my hours and not come back. BUT give me free reign to follow an RN (in your case attending surgeon) to see, learn, ask questions, to be grilled on everything i know, to put me on the spot and make me think and grow- Free from the restraints of "big brother" ---> i'll do that 200 hours a week if my body was able.

doubt this what i said had any answers... i just wish the education system was different.

Skeptical Scalpel said...

Anon, thank you for your comments. Under the current rules, today's residents can work up to 80 hours per week, not 40. However, those rules also prohibit working more than 80 hours per week even if the residents volunteer to do so.

Yes, programs require residents to do research and write papers. That's because the organizations making the rules demand that residents participate in scholarly activities.

There are lots of rules, and more are added every year.

If you decide to go to medical school, I wish you the best.

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