Some general surgery residency graduates may not be competent to operate

A new study says 84% of general surgery residents in their last six months of training were rated as competent to perform the five most common general surgery core procedures—appendectomy, cholecystectomy, ventral hernia repair, groin hernia repair, and partial colectomy. However the percentage of those judged competent varied from a high of 96% for appendectomy to a low of 71% for partial colectomy.

When analyzing the other 127 core operations of general surgery, the investigators found that 26% of residents in their last six months of training were felt to not be competent to perform at least some of those procedures.

The study was presented at the annual meeting of the American Surgical Association in April 2017 and reported in ACS Surgery News.

Data were compiled from ratings of 522 residents by 437 faculty yielding 8526 different observations.

For all of the procedures rated, maximum resident autonomy was observed for 33% of cases, and the more complex the case, the less ready the residents were to perform it on their own.

The lead author of the study, Dr. Brian George of the University of Michigan, was asked whether the duration of surgery training should be increased. He answered, “The 20,000 hours of surgical residency should be enough to train a general surgeon to competence—it's up to us to figure out how.”

As currently constructed, the 20,000 hours isn't enough. This 2011 post I wrote explains why. Much of the residents' time is taken up by tasks other than operating such as electronic charting, conferences, scut work, activities of daily living, sleep, and more.

I was surprised the residents had maximum autonomy one-third of the time because I have blogged about autonomy and pointed out that some graduating residents have never done a single case by themselves.

If the one-third number is reproducible, it is encouraging but clearly inadequate because except for some simple cases, over 25% of residents are not proficient enough to perform complex cases alone.

Past surveys corroborate these findings. A 2011 survey of residents found one quarter did not feel confident to operate by themselves, and another reported fellowship program directors felt about the same number of residency graduates were unprepared to operate independently.

Fixing this will not be easy. I agree with Dr. George that increasing the length of general surgery training is not the answer. More resident autonomy and less scut work might help, but both may be difficult to accomplish.

The current study’s findings should worry the leaders of general surgery training—the Residency Review Committee for Surgery and the American Board of Surgery—and the general public who has no way of knowing which 1 of 4 recent graduates of general surgery training might not be competent to operate on them.