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.