Should residency program directors look at applicants’ social media activity?

Please take a look at my new post on Physician's Weekly: My thoughts on whether residency program directors should review applicants' social media activity.

A Venezuelan surgical resident appeals for help

I received the following email. It has been edited for length and readability.

I assume you know is happening in my country, Venezuela. Basically a communist-socialist party has taken control of the government for 20 years now and has the citizens under the worst economic crisis of South America along with one of the most important refugee situations of the continent.

I can write 300 pages about it, but I believe I’ve said enough. As you may know, EVERYTHING has gone to bad situations in this country: public services, roads, HOSPITALS, UNIVERSITIES, food shortage, lack of water and electricity, freedom of speech, and the list goes on and on.

“Number of medical students pursuing surgery specialty drops by half”

That was the headline in a September 10 Becker’s ACS Review article. The first sentence of the piece was more specific, “Only 4 percent of medical students surveyed in 2018 said their chosen medical specialty is general surgery, compared with 8 percent in 2016, according to Medscape's Medical Student Life & Education Report 2018.”

This caused some consternation among general surgeons on Twitter. I tweeted, “Interesting. Lifestyle is finally catching up to us. I think it will get worse.”

The dark side of academic research

A new study found several senior academic surgeons had published papers in what used to be termed “predatory journals.” The newer, gentler term is “solicited publishing,” but it defines the same pay-to-play, low quality publications.

Surgeons from the University of California, San Diego examined 110 emails sent to the senior author from 29 publishers during a six-week period and early 2017. Nearly all were requesting manuscript submissions. The 29 publishers represented 113 different surgery journals most of which had existed for two years or less. Only 12 were indexed in PubMed, and of the 9 that mentioned a self-reported impact factor, the median was 0.24 which means they had less than one citation per article in the last two years. The median publication fee for the 88 journals posting the information was $755.

Emails from the publishers contained a mean of 9.6 grammatical errors, possibly because more than half had addresses in foreign countries, and of those with US addresses, 30% were residential.

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.

Chronic shortage of training sites worries medical schools

The Association of American Medical Colleges (AAMC) says many of its members are worried about a shortage of training sites for students and residents.

The AAMC’s 2016 Medical School Enrollment Survey found that 80% of schools were concerned about the number of available clinical training sites. There were also issues with the numbers of primary care and specialty preceptors.

The graphic below shows that these problems are not new, but in general seem to be worsening. [Click on the figure to enlarge it.]

The situation is exacerbated by increasing competition for clinical sites from osteopathic schools, offshore medical schools, and nurse practitioner and physician assistant schools.

Residents, duty hours, and respect

The following is an email I received.

I, a surgical resident, would like to ask for help navigating conversations about resident duty hours. You had a very strongly worded post on the subject. My intent is not to contradict your perspective, but perhaps get and give some insight on this question. First, I wish to show you the conversation with a surgeon "fossil" as I experience it:

Fossil: "In my day we worked __ many hours and operated all night and never slept or ate and were glad of it. It made me the surgeon I am today. You will never have this privilege."

Me: "Wow, I agree. You had it much harder." Meanwhile, I am thinking:

A surgical resident’s legal battle with her program

My new post on Physician's Weekly is about a dispute between a resident and her surgical residency program that has escalated to court and the news media. Click here to read it.

Causes of death among residents

What is the leading cause of death among residents in all specialties?

A. Accidents
B. Neoplasms
C. Suicide
D. Miscellaneous diseases

If you answered C, you were wrong. The correct answer is B, neoplasms. Suicide was the second most common cause, followed by accidents and miscellaneous diseases.

A study in Academic Medicine looked at resident deaths over a 15 year period and found that of the 381,614 individual physicians in ACGME training programs, 66 died of suicide. For the over 1.6 million person-years studied, the suicide rate for residents was 4.07 per 100,000 person-years—well below the figure of 13.07 per 100,000 years in the general population of people aged 25-34.

Residents in age groups 35-44 and 45-54 had suicide rates higher than the 25-34 group and higher than the rates of those in comparable general population age groups.

More suicides occurred during the first and second years of training and during the months of July through September and January through March. In my opinion, the months that deaths occurred in can be explained as follows. In the first three months of the academic year, residents in the first and second years may feel overwhelmed and subject to self-doubt—the so-called "impostor syndrome." By the time January and February roll around, it is mid-winter, and it seems like the year will never end.

Residents had a much lower rate of death from accidents, including those related to automobile crashes, than the general population.

The overall death rate from all causes was also lower for residents than the rate of the general population at 16.91 per 100,000 person-years and 105.4 per 100,000 person-years, respectively.

The authors were surprised that resident rates of suicide were lower than age- and gender-matched populations especially because suicide rates for medical students and practicing physicians are higher.

They concluded that suicide was probably the only area in which prevention strategies, such as a supportive environment and medical and mental health services, could reduce the death toll.

Program directors, faculty, and residents themselves should probably show heightened vigilance in the first and third quarters of the academic year particularly for first and second year trainees.

What were attrition rates in surgical residency programs 25 years ago?

Last month I blogged about the 20% attrition rate of general surgery resident over the last 25 years, and a recent paper presented at a national meeting that found after following the general surgery resident class of 2007, 20% had dropped out for one reason or another.

A reader who calls himself Artiger commented on that piece asking, “Is there any data on resident attrition prior to 1992? Just curious if this has been a problem for more than the past 25 years.”

I responded that I wasn’t aware of any such studies but I would try to find out.

Most of the few papers written about attrition back in the day focused on one residency program or one medical school’s graduates.

Until the middle of the 1990s, many surgical residency programs were pyramidal—that is, they took more categorical first-year residents than they had chief residency positions. For example, when I began my training in 1971, my program had 12 first-year residents, decreasing to 8 in the second-year and only 4 chiefs.

How to fix the problem of general surgery resident attrition

Over the last 25 years, about 20% of general surgery residents have failed to complete their five years of training. This compares unfavorably to other specialties such as orthopedics, obstetrics-gynecology, and medicine with attrition rates of < 1%, 4.5%, and 5%, respectively.

A paper presented at the American Surgical Association in April looked at the factors associated with attrition in one year’s resident class. In 2007, 1047 residents began their training and after 8 years of follow-up, 80% had become surgeons. How many non-finishers left programs by their own choice is not clear.

Some highlights of the research are as follows:

24% of women and 17% of men left general surgery training.

Size mattered because 23% of men and 25% of women left large programs compared to both sexes leaving smaller programs at a rate of just 11%.

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?

Can a med student who flunked Step 1 still become a surgeon?

I received these emails (italics) recently. The writer gave me permission to publish them. They have been edited for length and some details have been changed to protect his anonymity.

I'm a third year medical student at an allopathic state medical school. I've always wanted to do surgery. My problem is I failed USMLE Step 1 the first time and got a 207 on my second attempt. I hadn't failed anything else throughout first and second year, with the majority of my grades being my school's equivalent of Bs.

My surgery shelf exam was a week after I received my Step 1 score and, despite studying hard, my low score on that exam got me the equivalent of a C in surgery even with very good clinical evaluations. The rest of my third year has been good with most evaluations saying I'm well-liked and a team player.

Should I give up and go into a different specialty with better odds of matching? Apply to prelim surgery programs and categoricals? Or even apply to all of those things at once? I'm in a large pickle, paralyzed with indecisiveness, and would immensely appreciate your advice.

Disclaimer: This is my opinion. I do not presume to speak for all program directors. I'm going to be honest.

Can surgical residents please have some autonomy?

A comparison of appendectomy outcomes for senior general surgeons and general surgery residents revealed no significant differences in early and late complication rates, use of diagnostic imaging, time from emergency department to operating room, incidence of complicated appendicitis, postop length of stay, and duration of postop antibiotic treatment.

The only parameter in which a significant difference was seen was that attending surgeons completed the procedure significantly faster by 9 minutes—39.9 vs. 48.6 minutes, but this may have been influenced by the fact that attending surgeons used laparoscopic staplers 13.5% of the time as opposed to use by the residents in only 2% of cases, also a significant difference.

This before-and-after study of more than 1600 appendectomy patients was published in JAMA Surgery. Between 2008 and 2012, residents were permitted to perform appendectomies without direct supervision by an attending surgeon. The pre-2012 group included 548 operations performed by general surgery residents alone. Because of a policy change, all of the appendectomies from 2012 to 2015 were performed by attending surgeons alone or directly supervising a resident.

Surgical fellowship match results for 2017

Two weeks ago, I reviewed the preliminary results of the 2017 main NRMP match. Data for the specialty match, also known as the fellowship match, recently became available. Here are the outcomes for the subspecialties of general surgery.

For abdominal transplant surgery, 36 of 58 programs filled, comprising 51 of 74 positions. There were 75 applicants with 24 going unmatched. The number of transplant programs has dropped from 69 in 2013 with a concomitant decrease in the number of available positions from 84 to 74. Applicants numbered 116 in 2013, and except for a slight upturn in 2016, interest has steadily declined. Consistent with the previous four years, US grads filled 31% of the positions in 2017.

Colon and rectal surgery filled all 56 programs and all 95 positions; 35 of the 130 applicants failed to match. Colorectal has filled 100% of positions available in three of the last five years. US grads filled 75% of the slots which is fairly consistent with previous years.

Pediatric surgery’s 44 programs filled all but one of the 45 available positions. This is the first time in the last five years that pediatric surgery did not fill 100% of its slots through the match. There were 96 applicants this year, and 52 of them did not secure a position. US grads filled 80% of the slots which is a slightly lower percentage than previous years.

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]

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.

Surgeons are burned out in, of all places, France

More than half of French gastrointestinal surgeons in training are burned out says a paper published ahead of print in the American Journal of Surgery.

Five hundred gastrointestinal surgery trainees were surveyed, and 65.6% responded. Of those responding, 52% had indications of burnout syndrome—emotional exhaustion, depersonalization of relationships, and lack of self-fulfillment at work—on the well-validated Maslach Burnout Inventory.

Other notable findings were 67% had insomnia, and 12% had thoughts of suicide.

On multivariate analysis, the significant factors associated with burnout syndrome included being confronted with aggression from patients, lack of gratitude from senior colleagues, trainees feeling they had too much responsibility, and not participating in extracurricular activities.

The prospects for switching to a different specialty

Could you comment on how an applicant switching into general surgery compares to one that applied directly from medical school would be viewed? I had a very difficult time choosing between specialties and have been regretting my decision not to apply into surgery. I am currently in a prelim year in medicine and am currently matched into radiology. I want to reenter the match process this year but am nervous to give up my guaranteed radiology position at a top program for an unknown where I can go unmatched or matched into an undesirable program. I graduated from a US med school. My USMLE Step 1 score was 235, Step 2 252, and I have published 2 articles in a surgical sub-specialty field.

You are what is known to the National Resident Matching Program (NRMP) as an "independent applicant" (graduate of a US med school going back into the match).

Go to the NRMP website, download the PDF "Main match results and data 2016" and look at Figure 6, you will find that 52.2% of independent applicants in general surgery failed to match compared to only 9.9% of US seniors.

 

This holds true for most specialties. Note that 43% of independent grads did not match in neurology.

Your USMLE scores are quite good, and the fact that you have published to articles will probably help a little. However, the reality is that you probably have about a 50-50 chance of matching in general surgery.

I wish I could explain why this is. All I know is it has been this way for years.

I can't tell you what to do. I suggest you give this some serious thought. It is probably not ethical for you to reenter the match and not tell your anesthesia program that you are doing so, but I suppose that is an option. If you don't match in general surgery, you would still have your anesthesia spot, but if you do match, you will leave your anesthesia program high and dry.

If you decide to apply to general surgery, you should go with mostly community hospital programs and send out lots of applications. By lots, I mean more than 50 or as many as you can afford.

You will be able to better assess your chances as you see how many interviews you are offered.

Good luck with your decision and please let me know how it turns out.