Thursday, April 03, 2008
Just got the latest issue of ABS News, the newsletter of the American Board of Surgery, which is the agency by which surgeons are certified as qualified to practice their craft. Reading it was disquieting.
The ramifications of the recently mandated decrease in the training hours of residents is a subject covered by many medbloggers, including me. And me. The clear inference from the newsletter is that one's fears are being realized: surgical residents, it seems, are getting diminished experience. It's these words that tell the tale:
"The ABS convened a meeting...to examine in depth the rapid growth of gastrointestinal surgery fellowships....to consider the potential reasons residents feel the need to pursue these fellowships and their effect on residency training. The principal outcome of the meeting was that the ABS should work to establish specific standards for the training of residents in GI surgery, including a core set of operations that residents should be competent to perform by completion of residency, to assure that residents obtain sufficient GI surgery experience.... (T)he ABS has examined residents' operative data from recent years which reveal insufficient case numbers for many core GI procedures.... many (laparoscopic procedures) appear to still be considered the domain of fellows when they could be done by senior residents. This...leads residents to enter fellowships..., thus continuing the cycle.... (D)ata also show a decrease in resident's participation as second and first assistant, perhaps signifying that residents are also receiving fewer opportunities to observe procedures before performing one themselves... ...ABS will explore establishing minimum case numbers...as well as a certain level of competency in the care of underlying diseases..."
Elsewhere in the same issue is an article on "Redefining General Surgery," in the context of what a training program curriculum ought to entail. Here's an excerpt:
"Phase 1 of the curriculum has been completed and focuses on 20 basic surgical skills, such as inserting a central line, suturing and knot-tying."
"Well," some might ask. "Isn't this a good thing? Ought not there be standards?" Yes, of course. But until recently, some things went without saying. What is general surgery training if it doesn't produce people ready to do gastroenterological surgery? In the era of my training (he said, proving he's an old fart and sounding like your grandfather claiming to have walked to school uphill both ways), whatever else was true there was never any doubt we'd be getting plenty of experience in such an elemental essence of general surgery. I won't argue that every surgeon coming out of training from every program in every year since time began was adequately taught; nor would I deny that there never has been a perfect way to measure skill and knowledge. (Passing the "Boards" requires both written and oral exams, and the provision of a list of operations done in training; but it doesn't have a means for observation in vivo. Fellowship in the American College of Surgeons requires lists and interview and testimonials, but I can't pretend it's supercalifragilistically rigorous.) That training requirements need to be readdressed, when a few years ago they didn't, means either that we were kidding ourselves back then, or there are big problems now. Maybe it's both; if so, I'd say it breaks out at about 20 - 80. Or 10 - 90.
Suturing? Knot tying??? THAT needs confirming???!!! Holy shit, is what I say. Holy actual steaming shit.
[After writing the above, I was speaking with a good friend in the upper echelons of academic surgery. He said he considers the 80 hour week only a part of a larger trend over the past few years, namely the fragmenting of general surgery into its component parts. Trainees are heading off into many subspecialties which have fellowships (not all of which are certified or regulated from the outside -- a significant but separate issue), whether laparoscopic surgery, or colo-rectal, or oncologic -- not to mention the specialties that once were all part of general surgery: thoracic, vascular, urologic, etc. There are even breast surgery "fellowships!" To me, it seems comparable to auto mechanics needing extra course work in opening hoods. In more and more institutions, the formerly core work of any residency is done by fellows, leaving the surgical residents with less and less experience (and fewer hours in which to find it). This is the point of the article to which I referred above, but it's about more than just gastroenterologic surgery, in my friend's view. And there are other interesting consequences: in many hospitals surgeons practice only in their narrow subspecialty, refusing to take call in the broader general surgical areas, even though they generally request broader privileges. More strain on surgeons like me, and patients like you. The endpoint seems obvious.
And yeah, my friend said: they have interns who, at the end of a year, can't tie knots.]