Monday, January 9, 2017

How can we instill more confidence in our graduating chief residents?

For over six years, I have been writing about problems in surgical education. My seventh blog post ever was about the negative impact of changes in surgical residency training.

In that post, I cited a residency program director who felt that rules imposed by the Accreditation Council for Graduate Medical Education (ACGME) resulted in excessive supervision of residents who never had a chance to operate independently. Many feel that this is a major factor resulting in 80% of graduating chiefs opting to do one or more years of post residency fellowship.

Excessive supervision continues in 2016. In his presidential address to the Southwestern Surgical Congress, John R. Potts, III, M.D., a former surgical program director and now Senior Vice President of Surgical Accreditation for the ACGME, had a similar observation. He said, “I have personally encountered individuals finishing general surgery residency programs who have never completed any operation—regardless how simple and basic—without an attending surgeon being with them throughout that operation.” [Emphasis by Dr. Potts]

Potts listed several factors negatively impacting surgical residency training including that graduates of medical schools are often ill-prepared for residency, duty hour limits, changes in diseases and conditions and the way surgeons treat them, the ever-increasing percentage of operations done in an outpatient setting, curriculum deficiencies, decreasing numbers of general surgery faculty role models, faculty obligations other than teaching, and “quality metrics.”

He added, “I believe that the ‘never event initiative’ on the part of CMS has had the unintended consequence of impairing surgical education because it has resulted in demands by hospital administrators for attending surgeons to either more closely supervise all surgical interventions or to perform them themselves.”

His number one concern was that residents are not receiving proper supervision. Neophytes of course should be carefully monitored and directly supervised. However, Potts said, “It is also absolutely appropriate the chief residents nearing completion of their training have conferred upon them a much larger degree of autonomy—with either indirect supervision or simple oversight—in almost everything that they do.”

Fixing this will not be easy.

Potts suggests that the number of teaching faculty be limited so that they can spend more time with each resident, and teaching should be rewarded monetarily. In my opinion, teaching should also be given consideration for academic advancement.

Senior residents should be encouraged to act as teaching assistants. Administrators at teaching hospitals must be educated about the need to allow residents to practice with appropriate supervision.

According to Potts, too many fellows may be poaching cases that would be better done by residents. Persuading programs to eliminate even a few fellows could be challenging.

But the really tough sell will be convincing the American public that residents need to have some autonomy during their training in order to have confidence in their skills after graduation.


Anonymous said...


I work some weekend nights at a rural hospital which is trying to replace the seasoned private practice surgeons with a new hospital-hired group of gen surgeons. The hospital thinks it's going to find fresh graduates ready to practice without senior-partner oversight and even hopes to increase service in trauma and peds surgery.

To me this expectation stands as the best example of how badly aligned our training system is with the needs of the community. While our system is increasingly producing grads in need of supervision, the private practice model of senior/junior surgeons is disappearing.

Even in my urban hospital job, we continue to hire fellowship trained surgeons instead of general surgeons. The result is the 'general surgeon on call' sometimes transfers out abdominal emergencies or temporizes peri-anal emergencies until an old general surgeon is available.

One solution to better meet community needs would be to reduce the number of specialty training fellowships and increase 'transition to practice' fellowships.


Unknown said...

It is a double edged sword. When I trained in the 80's, senior and chief residents has a great deal of autonomy and graduated feeling quite confident in their technical and decision making abilities. I finished my general surgery training with over 1300 cases, despite a non surgical internship year. After my cardiothoracic surgical residency, an additional year of general thoracic fellowship afforded me the opportunity to do over 600 cases as operating surgeon. Today's graduates often lack that experience. We have to find the right balance of oversight and training opportunities to provide for the next generation of surgeons.

Skeptical Scalpel said...

Chris, thanks for your input. Your hospital is hiring fellowship trained surgeons because 1) 80% of graduates take fellowships, 2) specializing beyond general surgery leads to more income for surgeon and hospital, and 3) specialists can beg off taking call or doing case they don't like.

Potts suggests reducing the number of fellowships. I doubt it will happen.

Mark, thats' an impressive number of cases. But I'm not sure what you mean by "double edged sword." I think the more cases you do, the more confident you become especially if you do some of them without an attending standing over you.

Anonymous said...

Sounds like the issue is dirt cheap admin who don't want to pay surgeons for what they are worth. Then its also skimp on the specialists and treat them like dog meat rather than help them mentor.

All in the name of $$$. I have a list of groups that should be paid more and criminal penalties to administration when they pull stuff like this.

Anonymous said...

Is it time for competency-based advancement instead of advancement based on years or case numbers? This would dramatically change the incentives for residents to seek autonomy. The current de facto alternative is extending years in training.

Another huge system flaw, in my opinion, is dilution of senior resident cases among residents 80% of whom will never scrub general surgery cases again. Subspecialty training should begin earlier, reducing the class sizes of the chief year. Also reducing wasted years for specialty-bound residents.

Tough to adapt a system dependent on cheap labor to fit the training needs of the cheap laborers.

Skeptical Scalpel said...

I'm not convinced about competency-based advancement. I foresee some problems such how does program fund those kept back? How do you decide that a resident can graduate in 4 years? What if she is deemed competent in 4.5 years?

I agree that it is time for earlier tracking of subspecialists and not wasting a Whipple on a future vascular, plastic, or cardiac surgeon.

Anonymous said...

Anonymous Europe: As a trainee in Europe, I can totally agree with the post. Of course, when you start out as a surgical trainee, you need someone (a mentor), to teach you. But after 5-6 years of intensive training with your mentor(s), you should be able to remove that appendix, do that circumcision, etc on your own (by which I mean being the most experienced in the room).
What I found is, you need to get used to the feeling that you are "alone in there".
Un-doctorly tasks (burocracy) should be removed from our shoulders, and trainees should spend their whole day in the OR not at a desk or doing things an intelligent secretary could organize......
I am always more than willing to stay longer if something to operate on comes up and I get to do it/assist in it.

Skeptical Scalpel said...

Anon Europe, good points as always.

Anonymous said...

Anonymous Europe:Thank you!:)

Anon321 said...

Forgive my ignorance, but I'm guessing surgical residents can't moonlight in their field?

Skeptical Scalpel said...

Anon123, surgical residents can moonlight if they have permission from their program directors. Most do not have the time to do it. Theoretically it should count against their 80-hour work week, but if no one knows about it...

Anonymous said...

Hello again!
I have followed your blog closely for 3 years since I gave my USMLE and got a score of 220. You said being a surgeon was not impossible and I persisted in those three years. As of today, I have been offered a preliminary surgery residency spot and before I rank the program high and take a leap of faith. I need your valuable insight on it as I am a foreign medical graduate and I want to be fully prepared before I dive deep into this phase of my life

Thank you for inspiring people everyday.

Skeptical Scalpel said...

Taking a prelim spot is always a gamble. Many have gone on to categorical positions, but more have found a prelim spot to be a dead end.

If you can't picture yourself doing anything but surgery, it is probably your only option. Work hard. Study hard. Do as well as you can on the ABSITE. Be the first one in and the last one out.

I wish you the best. Good luck.

Anonymous said...

Thank you so much for your prompt response and I will keep your pointers in mind while stepping into this new phase of my career.

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