The requirement that residents must be involved in research should be abolished

In a 2012 blog post called “Things that puzzle me about surgical education,” I wrote the following:

“There was the emphasis that still exists today on making sure every resident did research. At last, some are questioning the value of this for the average clinical surgeon. Contrary to the prevailing wisdom, there is no evidence that a resident who is dragged kicking and screaming through a clinical research project or who spent a year in someone’s lab really learns anything about research or how to read and understand a research paper.”

Nothing has changed.

According to the ACGME Program Requirements for Graduate Medical Education in General Surgery Section II.B.5.e: Clinical and/or basic science research must be ongoing in the residency program; based at the institution where residents spend the majority of their clinical time; and performed by faculty with frequent, direct resident involvement.

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.”

Surgical residents have lots of problems, need more time off

A recent survey of surgical residents regarding their personal and professional well-being revealed that while most of them enjoyed going to work, they had many serious issues.

All 19 surgical residency programs in the New England region were invited to participate, and 10 did so. Of 363 trainees contacted, 166 (44.9%) responded to the survey with 54% of respondents saying they lacked time for basic health maintenance. For example, 56% did not have a primary care physician and were "not up to date with routine age-appropriate health maintenance such as a general physical examination, laboratory work, or a gynecologic examination."

I am not surprised that young men and women averaging 30 years of age or less have no primary care physician? I wonder what percentage of young people who are not surgical residents have one.

Should asymptomatic people in this age group or anyone in any age group have a general physical examination and lab work?

Who really did the case?

According to the Residency Review Committee for Surgery, "A resident may be considered the surgeon only when he or she can document a significant role in the following aspects of management: determination or confirmation of the diagnosis, provision of preoperative care, selection, and accomplishment of the appropriate operative procedure, and direction of the postoperative care."

In nearly all instances, resident "determination or confirmation of the diagnosis, provision of preoperative care, selection of the operative procedure, and direction of the postoperative care" happen only in emergencies. For the majority of elective patients and same day operations, the residents do not play significant roles in most components of perioperative management.

What about "accomplishment of the appropriate operative procedure"? Are the residents really doing the cases they scrub on?

A recent paper from the University of Texas Medical Branch in Galveston, called "Who did the case? Perceptions on resident operative participation," looked at this question in a surprisingly candid way. The authors asked residents and faculty to independently assess what percentage of the operation the resident performed.

For the 87 cases for which responses from both resident and attending surgeon were available, agreement on percent of the case performed by resident (< 25%, 25 to 50%, 50 to 75%, > 75%) occurred in 61%, agreement of the role the resident played (first assistant, surgeon junior year, surgeon chief resident, teaching assistant) occurred 63% of the time, and agreement on both percent and role occurred only 47% of the time.

This reminds me of a story from when I was a resident. In the surgeons' locker room one day, someone asked a senior attending if the resident who scrubbed with him had done the case. The attending replied, "He thinks he did."

That's what the authors from Texas found too. In about two-thirds of the cases with disagreement about the percent of a case the residents did, the residents felt they performed larger portions of the case than did the faculty.

What constitutes "a significant role" is open to interpretation.

A resident once came to me and said, "I'm not really sure I should claim I was the surgeon for a case I scrubbed on today. Should I log myself as 'surgeon' anyway?"

I said, "If you have to ask, you probably shouldn't claim it."

Surgical residents are supposed to enter the cases they do in an online database, and the RRC uses these data in its accreditation process. The American Board of Surgery mandates that residents perform specific numbers of various types of cases in order to be eligible to take their boards.

A 2016 study in the Journal of Surgical Education surveyed 82 residents from various surgical specialties at UC Irvine and found only about half of the responding residents were told how to assess what their role was, and they were often delinquent [for more than one year at times] in logging their procedures leading to inaccuracies in the logs.

The authors concluded that the way cases were being logged raised "concerns about the use of the system for assessing surgical preparedness or crediting training programs."

The two papers cited above are small studies from single institutions, but in my opinion, probably reflect the reality in most residency training programs.

Submitted case log numbers may be misleading. This may be a previously unidentified factor in the crisis in confidence afflicting some graduating chief surgical residents.

Would competency-based training be better? The buzz about competency-based training has died down, and there are skeptics including the authors of this thoughtful editorial from the Journal of Graduate Medical Education.

Starting in the 2017-2018 academic year, the American Board of Surgery will require a minimum of 850 operative procedures for the five-year training period and 200 operations in the chief resident year—increases from 750 and 150, respectively.

Will competency-based training or increasing the number of operations required help?

Not if the residents aren't really doing the cases.

Board passage rates and residency program quality

On my "Ask Skeptical Scalpel" blog, a medical student wonders if a program's board passage rate is a good measure of whether its graduates can practice independently.

You can read that post here.

Author! Author!

As journals proliferate, so do authors.

New journals are appearing almost every day. Does anyone read them? Journals keep popping up because of the need for faculty to publish. Another reason could be that publishers, particularly those who charge authors fees for publishing, are in the business of making money.

Authoring journal articles is not only enhancing to one's CV (the old "publish or perish" cliché), it is required by Residency Review Committees as evidence of "scholarly activity" in training programs. Maybe it's good for attracting referrals too.

Without too much difficulty, I have collected some interesting information about the number of authors per paper in several specialties.

First noted in 1993 by a paper in Acta Radiologica and a letter in the BMJ, the number of authors per paper has risen dramatically over the years.

A study of 12 radiology journals found the number of authors per paper doubled from 2.2 in 1966 to 4.4 in 1991. 

A review of Neurosurgery and the Journal of Neurosurgery spanned 50 years. the average went from 1.8 authors per article in 1945 to 4.6 authors in 1995.

Of note, the above two articles were each written by a single author.

Three psychiatrists from Dartmouth analyzed original scientific articles in four of the most prestigious journals in the United States—Archives of Internal Medicine, Annals of Internal Medicine, Journal of the American Medical Association, and the New England Journal of Medicine—from 1980 to 2000. They found that the mean number of authors per paper increased from 4.5 to 6.9.

The same is true for two plastic surgery journals, which saw the average number of authors go from 1.4 to 4.0 and 1.7 to 4.2 in the 50 years from 1955 to 2005. The number of single-author papers went from 78% to 3% in one journal and 51% to 8% another.

In orthopedics, a review of the American and British versions of the Journal of Bone and Joint Surgery for 60 years from 1949 to 2009 showed an increase of authors per paper from 1.6 to 5.1.

An impressive  rise in the number of authors took place in two leading thoracic surgery journals. For the Journal of Thoracic and Cardiovascular Surgery the increase was 1.4  in 1936 to 7.5 2006 and for Annals of Thoracic Surgery it was 3.1 in 1966 to 6.8 in 2006.

Where will it end?

As far as I know, the current leader in the race for the paper with the most authors is "Observation of a new particle in the search for the Standard Model Higgs boson with the ATLAS detector at the LHC" in a journal called "Physics Letters B" with 3171. The list of authors takes up 9 full pages.

Finally, an internist discovers some pitfalls of the ACGME work hours restrictions

In a blog post, noted patient safety expert and hospitalist movement founder Bob Wachter discussed some new realities in resident education as a result of the recent [July, 2011] ratcheting down of resident work hours by the Accreditation Council for Graduate Medical Education [ACGME]. While applauding the more humane conditions under which residents now labor, he noticed disturbing changes in the way residents are being trained. The issues he raised have been well-known to surgical educators since the institution of the 80-hour work week in 2003.

He unknowingly agreed with something I wrote recently about today’s residents lacking opportunities to function independently, which leads them to worry about their competence after graduation. Wachter wrote: “Learning from one’s mistakes is fundamentally unethical when you have a human life in your hands. But an environment in which the housestaff are trained to read the attending’s body language before making a tough call can’t be right either, particularly when our third-year residents morph from resident to attending on June 30th each year.”

Continuity of care is another issue. Wachter: “A second worry is the relative dearth of patients being followed by a single resident from admission to denouement. Our teams inherited nearly half their patients as handoffs from night admitters.”

He stated the problem very well. “So many emergency admissions traverse a trajectory in which an early assessment is followed by a period of data gathering (tests, consults), followed by an initial patient response, which is evaluated in context. In a system in which half the patients are cared for by two sets of doctors during these crucial stages, neither group fully sees this arc play out, and their education suffers.”

And regarding hand-offs. “While some trainees forced themselves to rethink their patients’ problems and actively ward off anchoring bias, others didn’t, accepting what they were told as gospel and never coming to know the handed-off patients as well as those they admitted themselves.” This happens a lot more often than most people think.

He wondered how this fragmentation of care could be ameliorated but did not offer any solutions. Fragmentation of care during resident training will at least prepare internal medicine residents to become hospitalists, since lack of continuity permeates most hospitalist services that I am aware of.

Wachter has also just noticed that formal educational conferences are another casualty of the time limitations. He said: “The other thing that worries me about the new schedules is the palpably limited time available for education. In the 16 days I spent as attending in January, I recall only two in which the entire team was available for our traditional hour-long teaching rounds.” Bob, this has been a significant problem since 2003. It didn’t start last July. There is no such thing as an afternoon educational conference any more.

It’s nice to know that someone else is at least concerned about this. Neither Wachter nor I have any answers. I will just echo what many doctors of my generation are saying. We hope we still can figure out who the good MDs are by the time we need care for ourselves.

Thanks to Susan Carr for tweeting a link to Dr. Wachter’s blog.