My thoughts, many of which are borrowed from Frank Lewis:
1. Resident work hours are more strictly limited than in the past, which adds up to about a year of residency when it's all done (assuming 80x48x5=19,200 vs 100x48x5=24,000, i.e. 4,800 less work hours), thus limiting the clinical experience of graduating residents.
2. The hours that have been lost were mostly nights and weekends, which is when residents tended to have the most autonomy.
3. PPIs have drastically reduced the number of foregut operations, with many residents doing 0 to 1 surgeries such as vagotomy/antrectomy.
4. Trauma has become increasingly non-operative, drastically reducing the number of laparotomies/thoracotomies
5. Laparoscopy has made it so that residents have to learn 2 operations rather than 1 for most diseases, e.g. open chole and lap chole.
6. There has been a national push toward quality, and outcomes are much more closely monitored, which reduces autonomy.
7. Attending surgeons in academics are now asked/forced to be more clinically productive and RVUs are more important than they were in the past, so there is more impetus to work faster and do more cases, reducing autonomy.
8. Surgery has become increasingly specialized, which changes patient and physician expectations, thus reducing autonomy in the OR and in patient care.
9. Treatment is generally more regulated and evidence-based, so there is much more to know now, and you can't "wing it" through clinical scenarios, thus more expertise is required and the ability to be a jack-of-all-trades is not truly possible.
10. Finally and perhaps most importantly, residents have become increasingly self-aware. They learned whipples from a world-expert high-volume HPB surgeon, and when they compare their own skillset to that surgeon instead of the random general surgeon who did the occasional whipple in the 1980's, they feel more deficient on graduation day.
One of my partners, who trained in the 1970's, jokes that his first 2 esophagectomies as an attending had horrible outcomes, and the third one did great. Back then, surgeons graduated with extreme confidence, and more wiggle room to screw up once they were in practice.
I don't want to be too specific as it will reveal identities, but a relatively well-known surgeon who speaks on the "problem with residents these days" has a power point where he shows a graph of "here are where residents are today" and "here is where I was when I graduated" trying to illustrate how much more prepared he was for practice than modern graduates. What I found extremely amusing about his slide is the associated N, as he graduated with less than 800 cases.
Basically, what I'm trying to say is that modern residents are not less competent, they are simply less confident. They are more Socratic (
http://en.wikipedia.org/wiki/I_know_that_I_know_nothing) and generally more self-aware of their limitations. Overall, I believe it's a good thing.