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Trauma Surgeon

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… Obviously such questions are hard to answer, but there are more and more studies coming from US warning for the competency in surgical skills of the trainees.

Is there any truth to this or is it as it has always been, "our generation worked harder and were more competent than this generation of physicians/surgeons"...

http://www.mdedge.com/acssurgerynew...y-identifies-gaps-surgical-trainees-readiness

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I think it's good that we're learning how to measure this, but any comparison to prior generations is essentially impossible since it begs the question "Have graduating senior residents ever been truly competent?"

The assumption of these discussions always seems to be that the previous generations were more competent, and we've somehow lost that. I'd agree that the autonomy has likely changed substantially, but how do we know that 20 years ago they weren't independently doing things with the same technical ability as chiefs are now.

Worrying about this in the context of historical norms may be interesting, but it's also not necessarily useful. The most effort should be focused on restructuring surgical training to improve on where we are now.
 
… Obviously such questions are hard to answer, but there are more and more studies coming from US warning for the competency in surgical skills of the trainees.

Is there any truth to this or is it as it has always been, "our generation worked harder and were more competent than this generation of physicians/surgeons"...

http://www.mdedge.com/acssurgerynew...y-identifies-gaps-surgical-trainees-readiness

The problem is that this is a brand new metric. Getting beyond the fact that it has no proven internal or external validity, we have no idea how graduating residents would have fared on this same scale 10 or 20 years ago. They need to show that this rating system corresponds to something tangible in the real world beyond the opinion of the attending.

The study that needs to be done is where complication rates are compared for surgeons entering practice now compared to before, though that data may not have existed in the past. In the other direction, comparing rates of adherence to best practices over time may favor more recent graduates. Until we have new or better data, I believe that there's a lot of older surgeons who walked uphill in the snow both ways to work.
 
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I think the two above posters make a good point. And it gets to the "solution" to the problem, which is hard to assess when we dont actually know what the problem is. Perhaps instead of adding an additional year of training, we could just reduce the number of procedures trainees must learn to get it back to pre-work hour restriction levels. I'd say I spent roughly half of my residency training learning how to do operations that were either non-existent or very rare through most of the pre-work hour time period. At the same time, I was still expected to know all of those same procedures as well. Was it the lack of work-hour restrictions that led to a feeling of confidence for those older trainees, or was it the fact that they weren't expected to know how to do a lap colon, a lap graham patch, a lap RNYGB, breast-conserving surgery, minimally-invasive parathyroids, lap spleen, lap distal panc, robotic anything, TARs, lap inguinals, or endoscopy?
 
I also wonder if these suggestions consider the fact that medical technology and discovery is increasing at an exponential rate and has been since about the late 80s? The residents and medical students of today are expected to master an increasingly large body of medical knowledge/procedural techniques compared to their predecessors. Anytime you increase the breadth of someone's education or training in a finite timeframe, you have to sacrifice depth. So it seems possible to me that, as just an example, residents are graduating having done 200 different surgeries once, rather than having done 4 really common surgeries 50 times each.
 
Thank you for your responses which are "exactly" how I interpret the data and question the "previous" generations superiority…
I do believe the best way to go is earlier sub-specialization and to concentrate more on fewer diagnosis/procedures (as one post above suggest), why the hell do I need to know the procedures for lap/robot colon resections when as an acute care surgeon I only do open ones…
 
I also wonder if these suggestions consider the fact that medical technology and discovery is increasing at an exponential rate and has been since about the late 80s? The residents and medical students of today are expected to master an increasingly large body of medical knowledge/procedural techniques compared to their predecessors. Anytime you increase the breadth of someone's education or training in a finite timeframe, you have to sacrifice depth. So it seems possible to me that, as just an example, residents are graduating having done 200 different surgeries once, rather than having done 4 really common surgeries 50 times each.
This was what I told myself during medical school when thinking about the titans that came before me and how accomplished they were, how they mastered so many fields of medicine and so many aspects of being a physician. My freshman first semester courseload was like pharm, genetics, embryology, and anatomy...of those they did....anatomy. I'd have "mastered" pharm too if there were 4 drugs.

So nowadays when I want to feel inadequate I have to compare myself to my peers who are way better than me
 
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Thank you for your responses which are "exactly" how I interpret the data and question the "previous" generations superiority…
I do believe the best way to go is earlier sub-specialization and to concentrate more on fewer diagnosis/procedures (as one post above suggest), why the hell do I need to know the procedures for lap/robot colon resections when as an acute care surgeon I only do open ones…
My actual thought for improving training is to reject the "procedure based" paradigm and shift to a "skill based" paradigm. So instead of learning how to do 175 different operations, break all those operations down to their component parts and work on mastering the 10, 20, 45 core skills. Make it more analogous to learning to play an instrument. You don't learn to play guitar by just playing a random assortment of 175 different songs, 1200 times over 5 years. You learn chords and scales and bends and progressions. Once you've mastered those learning any given song is much simpler, and you can choose your "setlist " of songs you perform more frequently
 
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Thank you for your responses which are "exactly" how I interpret the data and question the "previous" generations superiority
I do believe the best way to go is earlier sub-specialization and to concentrate more on fewer diagnosis/procedures (as one post above suggest), why the hell do I need to know the procedures for lap/robot colon resections when as an acute care surgeon I only do open ones…

Well, of all the specialties I think the argument would be that ACS/Trauma probably needs the broadest exposure. And related to vhawks comment, there are many component skills that would transfer to ACS/Trauma. Do you need to know how to do a robot LAR? No, but I would argue an ACS surgeon in this generation should understand how to do a straightforward lap sigmoid. And even if you don't do that case in practice, a lap colon gives you an appreciation for the anatomy that you don't often get in open surgery. Personally, I think that becoming better at lap colons has improved my ability to do the open colon.

Expanding on what vhawks says, I think that the first part of residency should be focused on discrete skills: suturing, tying, tissue handling. Then progress to mastering components of operations, and then being assessed as a chief on ability to complete an entire operation. This would allow junior residents to count specific components of procedures they did, which is now more realistic than being "surgeon junior" for the entire case.
 
Right I just think the focus in training is too blunt. "Today we are doing a lap chole an open hernia and a lap spleen." Instead id structure it as "Today we are doing two blind entries into the abdomen, we are doing 3 blunt dissections around critical structures, we are doing 2 save divisions of vascular structures and we are doing one handling of prosthetic tissue." Those are just examples and probably poor ones but I think we get too big picture too fast. I had an attending in training who would ask me at the scrub sink before every case "what part of this case do you want to focus on Today" and at the time I thought it was a hard and stupid question. "Uh I want to do the whole case duh." But this was because I didn't appreciate that each case is an opportunity to focus on one specific generalizable skill. It's to my great disadvantage that I've only realized this after being through with training. We recognize it for the TRULY basic skills like holding instruments and knot tying, but the skill of getting around the pedicle in a lap spleen and getting the critical view and getting around the splenic v. In a lap distal panc are all very similar skills. I envision something like instead of thinking I'm doing a lap chole today, thinking I'm doing an AEGGF. Instead of a lap inguinal AECL. It probably isn't actually possible to break them into "chords" exactly this way but that way you can recognize which parts you struggle and then practice that skill specifically. The 10k hours thing is a gross simplification but the key part of it it's 10k hours of focused, dedicated practice. It isn't just butchering stairway to heaven 400 times and deciding that's good enough.
 
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The 10k hours thing is a gross simplification but the key part of it it's 10k hours of focused, dedicated practice. It isn't just butchering stairway to heaven 400 times and deciding that's good enough.

100% with you. A good analogy for what I was trying to say above, and also why I think there's a reasonable hypothesis out there that graduating chiefs now are more skilled at specific things than prior generations. The increase in supervision seems always to be framed in a negative way, but with the right supervisor it means you are getting mentored "practice" which is more formative than--as you say--butchering a great song on your own. As a chief, I try to point this out to the juniors. Are most of them going to do angios or fem-pop bypasses in the future? No. But many of them will have to stick in a femoral a-line or be comfortable approaching the groin for a node dissection or traumatic injury.
 
I think the internet age has caused a major shift in how we teach and learn surgery. I can't say if it's been for better or worse.

It's true that we have quick access to more information than ever, which is a mixed blessing. For example, as an intern, I was repeatedly told to "go watch YouTube/ you should already know that from watching YouTube." I found this totally appalling. If YouTube was anywhere near sufficient, 14-year old lunkheads everywhere could be getting online certified to do lap choles. And with limitless information out there, there's "no excuse" for not knowing all of it. It's the age-old surgical game of "read my mind" on steroids- now it's "read my google/pubmed search history."


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Ironically, the same generation of surgeons that likes to criticize the competency of our generation is the same group of people who are quick to take away a case, who want to finish their work load and leave and who are often lousy teachers.

To the posters suggesting a methodical approach to training the surgeon: sounds like a great idea. Good luck finding enough buy in from current surgeons who are often unwilling to do anything differently.

I'm not entirely sure how any residency program decides that it's graduating competent or safe surgeons. It seems very haphazard at times and people just blindly trust the process.

At our program we are lucky enough to have a significant amount of time at community hospitals, the VA and our emergency general surgery services where we actually learn to be surgeons.
 
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I gotta say, never once have I heard the attendings at my (now former) residency program complain that graduating chiefs aren't prepared to operate. But then again around 50-60% of our graduates go into straight gen surg or trauma/ACS and we still have a chief service.
 
I gotta say, never once have I heard the attendings at my (now former) residency program complain that graduating chiefs aren't prepared to operate. But then again around 50-60% of our graduates go into straight gen surg or trauma/ACS and we still have a chief service.

Same with my program. We do a lot of bread and butter cases. Pretty much as long as you have a junior to assist, most attendings will let you do anything short of complex surg onc/hepatobiliary/transplants on your own.

I feel like I could even do robotic cases on my own.
 
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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.
 
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