Are today’s surgery residents poorly trained What can be done about it

A surgical resident writes

I’m sure you have read several recent studies suggesting that current general surgery residents are poorly trained and unprepared for independent practice at the completion of residency.

My questions for you:

1. In general, do you agree that current general surgery residents are poorly trained and unable to operate independently at the completion of residency?

2. What should we do differently? I personally don’t feel that “more simulation activities”, which many have suggested, is an adequate solution.

Thank you for the excellent questions.

I have been out of the surgical education loop for a few years and no longer have first-hand experience, but the literature does indicate that some surgical residency graduates are not ready to practice by themselves.

In 2013, I blogged about an Annals of Surgery paper reporting as many as one third of subspecialty general surgery fellowship directors felt that about one-third of incoming fellows were deficient in several areas and unable to independently perform a laparoscopic cholecystectomy or 30 minutes of a major case unsupervised.

Click on the table to enlarge it. You can see the responses of the program directors.

This paper was criticized by some because the fellowship directors surveyed were not subspecialtists recognized by the ACGME. The implication was that fellows in these programs might not be representative of all surgical graduates. However, many of them were minimally invasive fellowship programs which continue to be highly sought after.

Does it really matter? Some general surgery graduates apparently can’t operate by themselves.

In 2011, I blogged about a paper that reported 27% of all graduating surgical residents surveyed were not confident performing surgery by themselves. That was approximately the same percentage identified by the fellowship program directors.

Regarding what can be done about the issues of confidence and traing, I agree with you about simulation. You can simulate all you want, but being alone at 2 AM with a patient who is bleeding out cannot be adequately simulated.

The American College of Surgeons created a Transition to Practice Fellowship in 2013. They later change the name from a fellowship to a program. Of course, I blogged about this too. As far as I know, not many hospitals are involved. How many graduating residents have enrolled in this fellowship program is unknown.

Henry Buchwald, a prominent senior surgeon, recently advocated establishing “open surgery” fellowships and wrote, “I submit that it would behoove our training programs to return open surgery schooling to their curricula.” However, he doesn’t explain how this could be done or where one would go to do a fellowship and open surgery.

Life imitates art. In a post last year, I cited the visionary surgeon Leo Gordon who saw it coming in 2002. He predicted the need for a "macrolaparotomy" course, and said it could be run by the newly created "American Board of Open Surgery."

The lack of confidence stems from the gradual increase in supervision of residents over the last 15 to 20 years. In yet another blog post, I pointed out that many of today’s residents rarely if ever operate independently during residency training. To realize you are on your own as a full-fledged surgeon without ever having performed a case by yourself must be frightening.

With all the ACGME regulations, medicolegal concerns, and extensive scrutiny surgeons and trainees are subjected to, I don’t see this problem going away anytime soon.

All you can do as a surgical resident is to try to scrub on as many cases as possible and take care of as many patients as you can. With luck, you may have faculty who have enough confidence in themselves to allow you some autonomy and decision making in the OR and when managing patients pre-and postoperatively.

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My response to a misguided opinion piece about surgery

"There is no place for the surgeon myth in modern medicine" says writer Alexis Sobel Fitts in Aeon Magazine.

Having a sister in medical school apparently qualifies Ms. Fitts to critique the specialty of surgery.

She starts with an old joke "An internist can figure out what’s wrong with you, but he can’t fix it. A surgeon has no idea what’s wrong with you, but he’s happy to fix it." If you read it carefully, you should note that it’s not that funny, and it’s wrong on both counts. No surgeon would ever fix something unless she knew why, and internists have these things called pills which can successfully treat a number of diseases.

She goes on, "After all, fixing problems is corporeal, often removed from the more intellectually nimble task of diagnosis." Apparently she is unaware that surgeons often make diagnoses—occasionally even correct ones, and I’ve written before about the misconception that doing an operation doesn’t require thinking [here and here].

"Surgeons are descended from the barber or the butcher," she says. That was hundreds of years ago. Nowadays, surgeons complete four years of medical school just like her sister and all the other doctors.

"Any missteps might incite devastating consequences, as the surgeon navigates around the vagus nerve, which dictates facial response…" I hope her sister didn’t give her that information. The vagus innervates many structures, but the face isnt one of them.

"Before anaesthesia and antibacterials, a patient undergoing surgery could be assured of two things: immense pain and the likelihood of infection and death." That’s actually three things. Of course without surgery, patients experienced immense pain, infections, and death anyway.

"Since the 1950s, laboratory science has increasingly been the origin of medical innovation. Which is why, over the past four decades, merely a 10th of the articles published in The New England Journal of Medicine have covered surgical innovation." Or maybe its because The New England Journal is a medically, not surgically, oriented journal.

Here’s the winner. "Surgery’s place at the bottom of the medical hierarchy can be attributed to the crude cruelty of early surgical procedures." Other than Ms. Fitts, who has placed surgery at the bottom of the medical hierarchy? It’s certainly not US medical students who make the surgical specialties among the most competitive of all.

In the 2015 resident match, surgical specialties filled their first-year positions with 80% or more US medical school graduates. In fact, orthopedics matched with 94.3% US grads. Compare those numbers to internal medicine and family medicine, which filled their first-year positions with 49% and 44% US graduates, respectively.

Heres what Wikipedia has to say about its Aeon Magazine entry:

This article has multiple issues. Please help improve it or discuss these issues on the talk page.

The neutrality of this article is disputed.

This article contains content that is written like an advertisement.

This article contains weasel words: vague phrasing that often accompanies biased or unverifiable information.

That pretty much describes the Aeon essay about surgeons too.

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