...Well, I imagine one of the concerns might be that these are the same applicants you referenced earlier who focus on how "fun" surgery is without really knowing what surgery is all about. It all exists on a spectrum and what younger generations call "abuse" or "paying your dues" you might just call "work," e.g. scrubbing for a 5th lap chole or a 13th VATS wedge....
Agreed there is a sprectrum. The issue is not the 5th lap chole in a day or 13th VATS wedge. Rather, the finer point in this discussion is, retracting or simply holding the camera while the ATTENDING does the 5th lap chole in the day or 13th VATS wedge. The big question as always is, "Are YOU, the resident, actually doing the case?".
There's just a base amount of footwork that has to be done, and it seems that as time goes on, the willingness to do that work might be declining. There's a subset of students who hate memorizing. For example, they want to be taught how to read EKGs but don't want to memorize EKG criteria for LVH, LBBB, left atrial enlargement, etc. It's tough to learn to do something independently, if all the time is spent re-teaching the fundamentals...
I agree and I suspect all surgeons agree, the trainee needs to do their part... this includes reading for the medstudent and/or resident lectures, memorzing those things that need memorizing, etc...Covering patients, taking call, answering consults, etc... is part of what one needs to do to get trained. That is not the point.
...No doubt that is one of the reasons for the integrated track. As I understand it, the integrated programs have very high quality applicants...
From what I hear, they do have high ranking candidates. I also very much suspect such "high ranking", unseasoned candidates will tolerate the, "pay dues" by "observe me operate and be amazed at how great I am", far less then anyone could have dreamed! But, there are suggestions from the attendings I speak to that integrated is being used to actually AVOID change.
Many (note I did not say "all") senior attendings in "old school" programs have limited aptitude or willingness to provide hands on teaching. The 5 + 2-3 model programs haave been scrambling for some years with very tiny applicant pool. I have heard programs being happy if they can break 10 applicants per interview cycle. The traditional programs that will land quality applicants have had to drastically change their approach and allow autonomy/hands-on. Difficult thing for MANY senior attendings.
However, the integrated, fresh out of med-school, unjaded applicant pool numbers in 100s per application cycle. These nice, young, unjaded/unseasoned applicants are still drinking kool aid, wanting to break the 80hr to prove their power, etc... and see this as a short cut! There will be some very, very disapointed residents in some "old school" programs that have converted to integrated just to keep afloat. I already hear those attendings using an excuse for observation/hands-off training.... "well, you have far less foundation experience then was required in the past. Your young and will enjoy an additional focused fellowship to build on this integrated foundation....".
...Hands-on training is great, but isn't seeing a procedure several times very important when you're inexperienced? I feel like you have to know almost all the steps by heart (pardon the pun) before you try to do it...
That's the koolaid they expect and love from the unseasoned integrated applicant... always waiting and believing you have time and will eventually get a turn. However, if you take pilot lessons, you don't sit and watch the flight instructor fly for 40 hours. You take martial arts, you don't just sit and watch the sensei go through Katas and then sweep the dojo floor. If you aare learning to play the piano, you don't sit and watch your music instructor for hours and days on end play different pieces. They may show you something and then watch you attempt to replicate the action. The same with surgery. At some point... early on, you need to be handed the instrument and start practicing under direct observation.
There is this 10 thousand hours of practice theory. That clock of 10k should start running during your residency in any field. A good portion of your 10 thousand hours of practice should be under the observation and guidance of a master-mentor. That is a fine point most attendings fail to recognize when citing 10 thousand hours. Instead, you graduate and stumble and/or suck at surgery. Your mentors at that point cite you need about ten years and 10k hours..."so don't worry, it takes time"!
...However, to me it seems slightly more complicated. As the fellows have explained to me, there are certain places that have a lot of thoracic training whereas other places are more cardiac focused. It actually wouldn't surprise me if someone came out of a very cardiac-heavy program feeling comfortable with AVRs, CABGs, and transplants but didn't feel great about doing VATS lobes and wedges or vice versa. Not every program is evenly distributed in experience and strength, right?
It would surpise me. That means they chose a name over the training! Anyone that is going to do a 12 month VATS superfellowship is not likely to be planning any kind of cardiac practice. The opposite is true too. Anyone going to do a 12 month aorta/valve fellowship is not likely to be planning any kind of general thoracic program. That/those scenarioes make no sense and again suggest someone seeking diploma name over training/competency....
And, frankly any grad that is not comfortable with VATS wedges is really in trouble. I did those in general surgery!
...Maybe I'm naive in thinking that working your butt off at a big name will get you good training (as is the case with working your butt off anywhere) and then give you a better shot at the fellowship of your dreams...
Yes, it is about hard work. But it needs to be the right kind of work! You can work hard on the track, transporting gear, etc.... That won't make you the faster runner. Being "Johnny on the Spot" on the floor all night long is not going to make you a good technical surgeon... and the exhaustion can work against you maximizing the operative opportunities you think you are earning by sacrificing these long nights!