Thursday, April 03, 2008

(S)TRAINING


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.]

23 comments:

rlbates said...

Wow! Dr Sid, do the programs not pass out free knot-tying boards to practice? The interns could do that on off-time.

Buckeye Surgeon said...

It's amazing. As a chief resident a couple years ago, it was dismaying to see so many second and third years residents struggle to do things like tie knots quickly and place central lines. Something is happening to our conception of the term "general surgeon". It may very well go the way of the "general practitioner". Chiefs who opt to become simply general surgeons, like myself, are becoming a rarity. The drive for fellowships has fragmented the field of our profession into superspecialists. It reminds me of baseball with its myriad categories of middle men, long relievers, set-up guys, lefty specialists, and closers. A pitcher who can get guys out can pitch in any situation. Same with surgeons. I feel fortunate I was able to complete my training under the old regimen of unlimtied work hours and a broad exposure to a variety of abdominal, vascular, and other standard gen surg procedures. And I think my patients are thankful, as well.

Michael Rack, MD said...

"it was dismaying to see so many second and third years residents struggle to do things like tie knots quickly and place central lines"
It's pretty sad that some surgical residents have trouble doing these basic procedures. It makes me feel less bad, however, that I had trouble doing these when I was a medicine resident (and I'd be even worse now).

Annie said...

I'm going to veer sideways and bring up a separate, but related issue. Nursing graduates have no standardized orientation and guided/supervised practice after passing licensure exams, which are computer-based and non-clinical. That orientation, education and training is left up to the nurses' employers, and it can range from zero - hit the unit running- to a full-fledged internship with formal curriculum and guided practice leading to certification in a clinical specialty, or in a few cases, credit toward a masters degree.

Nursing education is entirely uncoupled from patient care practice settings with just a few notable exceptions.

Now back to your wonderful post. I think there may some avenues to patch and to fix the experience/practice deficits that are facing the residents today. But they require resource allocation that isn't forthcoming in the free market, for-profit, cost containment (mostly on thebacks of physician and nurse salaries and reimbursement rates)atmosphere. At some point, the government is going to have to subsidize medical and nursing education to a greater extent, extend/develop training/education programs, and allow for enough physician and nurse time to develop and sustain genuine therapeutic relationships with patients.

As it stands, there is no reimbursement for talking with patients - even when that is the lynchpin of developing an open and trusting relationship which leads to better disclosure, higher compliance and desired patient outcomes. When we can demonstrate that link between the quality of a therapeutic relationship to morbidity and mortality rates, well, then maybe the money will follow.... /rant

As usual, thanks for bringing this into focus and leaving us with questions and a need to affect change.

2nd year vet student said...

You know, last night we had a practicing veterinarian come in and give us a little speech on how to impress your boss your first year in practice. He's an equine vet, and it ended up being more of a chew the fat kind of session than a formal talk. He told us of one time when he performed a bowel resection during a colic surgery. His associate hadn't seen the procedure before and asked him where he'd learned it. He answered, "I bought a book. A book with lots of pictures." I think it just hightlights the difference that still exists between human and vet med in many instances. We don't have to do an internship, let alone a residency. We take our NAVLE during the spring of our fourth year and then can go out and practice as soon as we graduate (provided we passed!). At my school, we need to show that we can adequately perform common (not basic) surgeries, like spay/neuter, gastric dilation & volvulus correction, tibial plateau leveling osteotomies, etc.

What does this have to do with the subject of your post? I'm not really sure anymore. There are definite advantages to being able to practice sooner (namely being able to make real money sooner), but there are also real disadvantages. Human medicine used to seem to have the edge, but now it seems like you'd need to be in school until your mid-to-late-30s to even get a start on your career.

rlbates: We got our knot-tying boards this semester (spring, 2nd year), and we'll be performing surgeries next semester, our last semester before we enter the clinics.

dr. bean said...

What ARE they teaching them in school these days? As students we used to bum unused no-longer sterile sutures from the scrub nurses and obsessively tie knots on the inside of our lab coat plackets. Anyone who expressed interest got a chance to tie one on in a non-critical area --one of the rewards of retracting for hours! Further chances vs everlasting scorn predicated on whether you muffed the first chance. It boggles the mind to think of second year surgical residents struggling to tie knots--it would be like college journalism majors struggling to construct a SVO sentence.

When (if) I need a general surgeon I will be hoping my contemporaries (buckeye?) are still around.

sciencekid said...

Dr. Schwab,
I want to eventually go into surgery. Any tips on how to keep yourself educated even when fellows don't let you do prochedures? (harsh wording, i know, but can't find substitute)

Sid Schwab said...

sciencekid: no good answer. I never had the problem, and maybe it'll be solved by the time you get there. I'd think it'd be a very important issue to bring up when one is applying for residencies.

dr bean: we certainly did the same, tying sutures to the rungs of chairs or whatever else was available, and practicing all the time.

Anonymous said...

We also have medicine interns who can't read an ABG at the end of the intern year.

In the old system, there was no hour limit and trainess (like Sid and I) were expected to be involved from admission to discharge. Like it or not, we were immersed in patient care and learned it almost by diffusion.

In the new system, a trainee has to want to learn in order to gain competance - it is no longer automatic.

This is in part due to hour restrictions but also because faculty are constantly present writing notes and billing but not teaching (worst on the medicine service). We are seeing non-teaching services pop up all over the country. Residents have "caps" - no more than x admissions per day.

A medicine intern can now be promoted having worked up 250 patients - less than one a day!

So yes, we now need someone to do nothing but make sure that trainees have gained the skils we once thought of as "automatic"

In medicine - physical exam, ABGs (drawing and interpreting), EKGs, differntial diagnosis.

In surgery, I guess these are suturing, knot tying, central line placement and abdominal pain workups.

But everyone knows how to document!

Hopefully the pendulum will swing the other way in a few years.

Anonymous said...

This has almost nothing to do with the 80 hour work week. You correctly identify the primary driver, namely the increase in specialization in all areas of medicine that first began long ago when general surgeons were truly "general". The second causative factor is poorer operative experience due to Medicare's increasingly onerous requirements regarding resident participation and an increasingly CYA attitude towards things that might not play well in front of a jury (like having a resident do the case). Yes, I know, you had to spend 150 hours a week in the hospital back in the day and it seems unfair that we don't. But 150 hours a week in current residencies wouldn't solve the problems in surgical training today.

Anonymous said...

Anon 3:29,

You are correct. If we took away the admit caps and hour limits, residencies would still have very similar problems.

This is as true about medicine training as it is as about surgery training.

The world changed - there is no such thing as a "resident only case" any more. Maybe this is a good thing, maybe it's a bad thing, but it's certainly the truth. The rules for documentation have changed and long hospital stays are the exception, not the rule now.

Training needs to change to get the trainees ready for the world of 2008, not the world of 1990. Maybe caps and hour restrictions are part of the needed changes, but they are not the entire solution.

It has nothing to do with fairness - it has to do with deciding what the best way to learn medicine is. Perhaps "immersion" is not the best way, but it works.

Very long periods of observation where residents watch fellows do the actual patient care does not work as well.

There is likely another solution that works as well (or better) than immersion but as a whole, graduate medical education hasn't found it yet.

Those of us who are middled aged will certainly need the services of the current generation of medical and surgical trainees in our lifetimes. Hopefully the next major change in medical training will be about content and increasing exposure to patient care - what we used to call "high yield" work.

More time in the hospital by itself would solve very little (if anything) in 2008. It has to be more quality time and less down time in training.

I just don't know how to make that happen.

Sid Schwab said...

There are many thoughtful comments here, and they're appreciated. I don't know, either, where the solution lies. I do think the reduced hours play more of a part than some have said, but it clearly isn't the only -- nor even the most important, necessarily -- factor. And it's not going to go back. The solution, one would think, needs to be found within training programs. But something that could be very helpful, probably for all docs exiting training, is a formalized mentoring program run by the various colleges or boards, utilizing us "older" people, maybe even the recently retired, connecting each "grad" with someone with whom to discuss care and who can, in the case of surgery, be present to continue the training beyond training.

Meanwhile, the trend seems clear: for a variety of reasons, including time, dilution of experience, fellowships, all of which act to kick experience uphill, and maybe even changes in attitude among trainees, people are coming out of residency less prepared to practice independently.

Anonymous said...

Here are a couple of thoughts . . .

1. I'm a PRS resident (integrated model) in my 5th of 6 years. I'm going to do a fellowship in Hand/Micro. I have lots of background in hand surgery (more than a few of the hand fellows at some places where I interviewed). So why am I doing a fellowship? I want the CAQ. And I want a year to spend doing things in a different way.

2. General surgery residents are being killed by trauma. My friends who are finishing GenSurg have had 6 months of trauma as a junior resident (PGY 1-3), 3 months as a trauma chief (PGY 4) and two months as "night float" chief (PGY 4-5). That's 11 months of mostly non-op surgery. That's almost 20% of their residency babysitting ortho patients. Doesn't seem like a great use of time, does it?

3. Most GenSurg residents that I know are taking a fellowship because they want an extra qualification in the field of their choice to make them more marketable. It's just good business sense to be able to market yourself as the fellowship-trained _______ guy in your practice.

General surgery training needs to evolve. Plastics has done it quite well. Vascular is starting to get into gear. CT is moving (slowly) in that direction. When will General Surgery come up with a better way to train their residents?

adventures in disaster said...

Because I work in an academic hospital as a Nurse I have a different perspective. I have noticed over twelve years that it's not the hours or lack of them that is the problem. It's the lack of interest or commitment to teaching.
It's always the same every rotation. The staff and fellows complain constantly about having to teach. They complain that the new interns,residents are too slow, too dumb, too whatever. They literally will not allow a new intern to do anything because they are tired and they want to go to bed by 11pm and they don't want to get held up waiting for an intern to put in an art line or a central line or a chest tube. It's embarrassing.
Because I work er and trauma ICU more than once a fellow or staff have asked me to "just put a few sutures in that head lac' with the intern standing right there. Yes, they do let some nurses suture lacs that are well hidden in the hairline. Because I love to teach I am more than happy to start and then let the intern finish. They need the experience but some of my own colleagues are no better than the fellows and want to get it done quickly so they can get the rest of their work finished.

I don't do central lines but I have sat patiently and supportively with a new resident or intern when it's their first or second time and their resident or fellow abandons them to go get something to eat.I have talked them through the whole process and I have never done it myself. I get to see that explosion of relief , excitement and accomplishment when it all goes well but I am not there to add my comments on their success or failure of a rotation. Some fellow or staff doc who has never spent more than five minutes a day with them gets that honour.

If your colleagues are supportive and enjoy teaching new interns will always get experience even with the new hour restrictions. But when the staff just don't want the hassle which is most of the time new experiences are harder and harder to come by. There is absolutely no reason for a fellow or a third year resident to be starting central lines when junior staff is present but try getting them to stop .

it's got nothing to do with lack of hours. It has everything to do with surgeons who don't have time to teach because their list is full and they need to move through it quickly because if they don't someone else will have their OR time. The surgeon only wants an experienced fellow or resident to second..they ignore the intern completely, hell they don't even offer the retractor any more. And forget getting any where near the lap scope. The fellows fight that out with the third years and the fellows almost always win except when the surgeon intervenes and takes pity on the resident.
Teaching requires time and a supportive environment...we just don't have the time and no one has the energy left to be supportive.
Explain why any fellow needs to do any suturing at all but still they persist. All kinds of general skills could easily and safely be left for the junior staff but no one wants to and there lays the problem.
The only changes needed to curriculum is to tell the fellows and senior residents to cut out the crap and stop being such impatient asses.
If I can find the time to throw in a few sutures and then help an intern do the same with the patient load I carry then the fellow and senior residents can delay their bedtime for an extra hour to do it too.

Sid Schwab said...

adventures: thanks for a very good comment. I think patience is very much an issue, too, and it's a good point. I also think that it's in part due to compressed time: when there's less time to get things done, to get experience, then "wasting" it while attending to an intern or junior resident is less attractive. So it's a feedback loop wherein opportunities move ever higher up the ladder, leaving the lower rungs with less and less; which makes fellowships more necessary, which makes residents get less....

Alice said...

I see I'm late again, but I'll chime in:

Your talk of interns struggling with lines and knots makes me feel a little better: those are things I can do.

Out of all the possible causes of the lack of experience mentioned here, the presence of fellows sounds most familiar to me. I know my attendings would rather have a fellow operating with them than the chief, and rather the chief than a junior resident or intern. We let the students second assist, because they have to see something if they're going to have any idea about surgery - and so there's nothing left for the interns.

Also the part about trauma is true. If you live in a violent town, trauma could get you in the OR a lot. For most of us, it's critical care only; which is medicine, and good, but not so much surgery.

SeaSpray said...

Interesting post and comments.

Also...as a lay person disturbing if I am understanding this correctly.

So...you're saying that new surgeons will be starting their practices with less experience under their belts unless they go into specialties? And the lower standard doesn't bother anyone because they are all too busy or preoccupied to care?

Disturbing and sad.

Sid Schwab said...

yes to the lesser experience; no to the idea that it doesn't bother anybody. It does. The question is how to fix it.

SeaSpray said...

I meant that it doesn't seem to be bothering the educators that aren't taking the time to educate because of their own concerns due to time constraints/overload etc.-my interpretation.

Anonymous said...

The real reason for subspecialization and the death of general surgery is that operating pays so poorly. It's amazing how little this fact gets discussed. I'm a urologist who can make a decent salary by doing procedures in the office. Operating in the hospital is a money loser. The general surgeon has no options and typically call is very difficult with add on cases and long days.

Sid Schwab said...

anonymous: I agree that's a significant factor. I've discussed it on this blog several times. Here, (at the end), here, (also at the end) and here, among several others. And, as you know, there are more cuts in the medicare pipeline. I'm thinking I could make a bundle writing a book on do-it-yourself surgery.

Howard said...

We have been training ortho residents with an 80 hr work week restriction for 10 or so years now. The answers why some are prepared and most aren't are not so simple and straightforward. A few of our residents have risen to be stars and will be tremendous physicians and surgeons. They would have done so with a 40 hr work week. Many residents (like anon who thinks he knows hand surgery) wouldn't make the grade if they worked 100 hours a week in a 8 year program. We have witnessed a significant generational shift in the residents themselves over the last decade. I firmly believe not being able to tie, scope, cut, think or manage disease has more to do with the resident being trained than the training program or the hours spent in the hospital.

Sid Schwab said...

Howard: I think you're right. I've said in several posts here that the changes in medicine in the last decade or so have led, and will lead, to a different sort of people choosing to become doctors.