attending level

[nonbilious]

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He/she who holds the right angle is the surgeon. So when does it happen or does it happen, as a resident that you hold the right angle? As of late I have seen fellows wielding the cautery....

Also, I don't doubt that most of the chiefs at my place could do a lap chole or lap appy alone. But, not so sure about an inguinal hernia, or a gastroj.. am I missing something?

I am starting to think that the only way to become a technically strong surgeon is to operate with a senior attending for years or at least have them in the next room.

BTW in private practice, who assists on cases?

 

[JackADeli]

...I am starting to think that the only way to become a technically strong surgeon is to operate with a senior attending for years or at least have them in the next room...

This sometimes blends into the older surgeon mentality. That is, there are those in academia that believe you should spend most of your time reading and observing/assisting. Then, after graduation, you should start "practice". After 10 years of practice (post-graduation from residency), you will have aquired "mastery". It's crap and defeats the purpose of modern education.

The best way to actually learn is to study and then do it ~under guidance of a knowledgeable and competent menotr. That does not mean having the mentor demonstrate to you rather, he/she assume a more coaching role.

...BTW in private practice, who assists on cases?

Depends on you and the practice. It could be a nurse, mid-level, another physician that doesn't independent operate or it could be you assisting a senior partner....

 

[SLUser11]

He/she who holds the right angle is the surgeon. So when does it happen or does it happen, as a resident that you hold the right angle? As of late I have seen fellows wielding the cautery....

Also, I don't doubt that most of the chiefs at my place could do a lap chole or lap appy alone. But, not so sure about an inguinal hernia, or a gastroj.. am I missing something?

I am starting to think that the only way to become a technically strong surgeon is to operate with a senior attending for years or at least have them in the next room.

BTW in private practice, who assists on cases?

These are great questions to ask residents prior to the ranking process. While it is unfortunate, there are a lot of surgical residencies with inadequate autonomy. This leads to inadequate technical training, and graduates that are not prepared for independent surgical practice.

The rumor, while usually false, is that graduates then feel forced to do a fellowship so they can learn how to really operate.

You can only learn so much by observing, and it's borderline unacceptable for a chief resident, or a fellow for that matter, to be bovie-ing between the attending's right angle.

You referred to your program in another thread as "very good." What criteria are you basing this on? Lunch menu?

As for who assists in private practice, often there's nobody to assist. That's the hardest part of independent practice.

 

[nonbilious]

These are great questions to ask residents prior to the ranking process. While it is unfortunate, there are a lot of surgical residencies with inadequate autonomy. This leads to inadequate technical training, and graduates that are not prepared for independent surgical practice.

The rumor, while usually false, is that graduates then feel forced to do a fellowship so they can learn how to really operate.

You can only learn so much by observing, and it's borderline unacceptable for a chief resident, or a fellow for that matter, to be bovie-ing between the attending's right angle.

You referred to your program in another thread as "very good." What criteria are you basing this on? Lunch menu?

As for who assists in private practice, often there's nobody to assist. That's the hardest part of independent practice.

I don't think its necessary or wise to talk specifics about my program in this thread. That said, my objective was to hear what other people's experiences are.

You're a 5, when you go in to do a partial gastrectomy is your attending holding the bovie? Or do they not scrub and you do it with a junior?

I have only 'seen' a few programs but from those experiences its rare to see a chief alone with a 2 or 3 at all, let alone through the critical portion of the proceedure.

what is your experience specifically?

 

[SLUser11]

I don't think its necessary or wise to talk specifics about my program in this thread. That said, my objective was to hear what other people's experiences are.

Fair enough. I agree that it's a small world, and you can get in trouble for calling out your program.....still, I'm gonna say northeast, just to betray my bias.

You're a 5, when you go in to do a partial gastrectomy is your attending holding the bovie? Or do they not scrub and you do it with a junior?

I have only 'seen' a few programs but from those experiences its rare to see a chief alone with a 2 or 3 at all, let alone through the critical portion of the proceedure.

what is your experience specifically?

You're making a big jump from a chief who can't do an inguinal hernia alone to a chief who can't do a gastrectomy.

Still, for gastrectomies it's usually myself and an attending, with me doing the surgery and the attending assisting. But, there's not a lot of bovie work in those types of procedures...more stapling and energy sources, blunt dissection, etc.

As far as my TA cases, these range everywhere from a Hartmann's procedure, right colectomy, trauma ex lap, IVC filter, then down to appys/choles/mastectomies/colonoscopy/EGD, then to things as simple as a central line or I and D. This may not be the norm, but I'm blessed with some excellent junior residents.

Of course, there are things that I feel less confident about. I wouldn't feel comfortable doing a liver resection or pancreas surgery without staff, and newborn surgery scares the crap out of me. Also, I have a hard time not eating 1-2 donuts from the lounge every morning, and this is becoming a serious problem as my activity decreases.

Anyway, let's get back to the main point: Are your chiefs assisting on cases or are they doing the cases? If it's a mix, what things do you think they are prepared to do alone?

 

[jc7721]

As far as my TA cases, these range everywhere from a Hartmann's procedure, right colectomy, trauma ex lap, IVC filter, then down to appys/choles/mastectomies/colonoscopy/EGD, then to things as simple as a central line or I and D. This may not be the norm, but I'm blessed with some excellent junior residents.

Of course, there are things that I feel less confident about. I wouldn't feel comfortable doing a liver resection or pancreas surgery without staff

I'll second all the above, and add inguinal & ventral hernias/AVFs/amputations/trach-peg/anal pathology/thyroids/pulmonary wedges & decorts to the list of TA cases. When you break it down, there are a lot of cases, more than mentioned here, that chiefs should be TA'ing. Then there are cases that chiefs could TA, but it's unlikely an attending is going to sit out, and there's obviously going to be a lot of variability in what each chief feels comfortable doing. Gastrectomies, pancreatectomies, hepatectomies, esophagectomies, lap adrenalectomies: attendings are probably going to scrub, maybe not for the whole thing, but they're going to scrub, and that's a good thing on complex cases. As mentioned above, however, the chief should be doing the dissection.

 

[treehorsio]

I think this is a very provocative and important topic.

I think resident involvement is a huge, often undiscussed, issue, and often difficult to define, esp since one resident usually only has experience at one program, making it difficult to define the "norm".

In my program, at a major academic center in the Midwest, it runs the gamut. Our private guys let us do little of the "right angle holding", but they tend to have only PGY1-3s, so that's likely appropriate. At the other end of the spectrum, we are lucky to have a VA experience, where the attendings rarely scrub. However, in between there is a wide range of experience, and I would venture to say that during most BIG cancer whacks (panc, esoph, etc), I don't think the chief is doing all the dissecting, at least during the critical part. But I have only finished 3 clinical years so I guess I can't say too much yet.

However, I feel that, especially in bigger centers, there is an expectation on behalf of the patients that the attending scrubs the entire case. Of course this is not always true, but I have seen an evolution towards this in the past 5 years of my residency.

 

[Guile]

Of course, there are things that I feel less confident about. I wouldn't feel comfortable doing a liver resection or pancreas surgery without staff.

I've only been to one program where its graduates (or at least one) felt comfortable doing liver resections by themselves. And he's doing them in private practice right out of residency.

I think this is a very provocative and important topic.

I think resident involvement is a huge, often undiscussed, issue, and often difficult to define, esp since one resident usually only has experience at one program, making it difficult to define the "norm".

As I interview, resident involvement has been one of my primary criteria in evaluating programs. The problem is that it is so difficult to gauge. I've met chiefs who felt comfortable taking interns through right colons and others who say that they rarely take juniors through cases and never get to do critical parts of liver/panc operations. It's a gamut of experience, and it's way more important to me than how many hiking trails are within 10 minutes of the hospital. I've only been to a handful of programs where the PDs emphasized resident autonomy and took time to discuss its importance during the program overview.

 

[Pir8DeacDoc]

Autonomy is very important. I think you are wise to value its importance in the training process. Just make sure you don't go the other direction and choose a program where all of your learning is from another resident. Ultimately your staff know a ton and should want to share that with you, they should be your primary teaching source. Not having their "wisdom" around during cases means you may only learn the bad habits of your chief.

 

[Guile]

Autonomy is very important. I think you are wise to value its importance in the training process. Just make sure you don't go the other direction and choose a program where all of your learning is from another resident. Ultimately your staff know a ton and should want to share that with you, they should be your primary teaching source. Not having their "wisdom" around during cases means you may only learn the bad habits of your chief.

Agreed. What I don't think I can judge at my level, much less evaluate in a program, is how much teaching from upper levels and how much from attendings is appropriate. I imagine I can learn tissue handling, how to open, things like that from an upper level, but complex dissections during the critical part of major operations? Probably need an attending in the room. What I don't want to do is pick up bad habits that I have to un-learn later, so as long as I'm learning appropriate techniques and not learning unnecessary movements, whether it's from a chief or an attending, I'll be happy.

 

[SLUser11]

I imagine I can learn tissue handling, how to open, things like that from an upper level, but dissecting the pancreas off the portal vein?

Actually, I feel like basic and fundamental surgical techniques are best taught by the attending...otherwise, you have the blind leading the blind, and you learn bad (and sometimes lazy) technique.

As for how much autonomy is too much, as alluded to by Pir8DeacDoc, it's a fine line. I have always been an advocate for programs with a VA, because it can offer some much needed autonomy in a program that may otherwise be lacking.

However, when you have polar opposite environments within a single program, i.e. a PGY-3 that is bovieing at one facility during a hernia, and then makes the jump to TA'ing an intern through one at the VA....that's where things get messy. There needs to be graduated autonomy that is level-appropriate, and there needs to be adequate volume for a resident to have experience with troubleshooting, etc., so they don't need to be rescued when a case doesn't go perfectly.

I'm not going to give details, but I inherited a VA patient here in Wichita with a recurrent inguinal hernia that had his first herniorrhaphy performed at a VA in another state by a resident that I coincidentally was familiar with. I read the op report from the first case, and it delicately described in detail all of the steps in the dissection and repair of the hernia. However, during reoperation, I found the incision to be in a very weird spot, with mesh sewn in randomly above the internal oblique, and the actual inguinal floor and internal ring were virgin and untouched. It was immediately obvious that the resident had no idea what she was doing, and had been very far away from the correct location for a herniorrhaphy. I re-read the op note, and found that it was a PGY-2 and a PGY-4, with an attending "immediately available."

Like all decisions related to residency, it's good to find a program that has balance. While you want autonomy, you don't want to be left out hanging in the wind, either, and you don't want to receive your entire education from other residents.

 

[Dirt]

Great thread.

As a lowly MS3, out of curiosity, how does one go about evaluating such things. Is it as simple as just asking?

 

[ESU_MD]

How much a resident does in the OR cannot be really known til you get to a place. For alot of reasons... Not the least being not alot of residents will admit to outsiders that they dont get to do stuff. Strange but true.

Another thing is that if your skills suck, then nobody will let you do stuff. Ironically, these people tend to still graduate but this is a whole other thread.

Last, some residents get to do more than others for more basic reasons.. Like if you went out drinking with your attendings at a strip joint at the last conference, then they are more likely to let you do stuff. Another common theme is that girls get to do more in the OR than guys at the comparable level.

 

[blue2000]

Last, some residents get to do more than others for more basic reasons.. Like if you went out drinking with your attendings at a strip joint at the last conference, then they are more likely to let you do stuff. Another common theme is that girls get to do more in the OR than guys at the comparable level.

Hmm, this paragraph about gender and opportunity is very interesting to me. can you elaborate?

 

[dynx]

BTW in private practice, who assists on cases?

Apparently surgeons coming from programs like yours.

Seriously, for comparison I think my experience is similar to what other people mentioned. I walk interns through hernias, appys, gallbladders and any bedside procedure I can think of (bronch, lines, tubes) with confidence. For more advanced cases the attending watches and comments sometimes with an insturment in thier hand sometimes not whether I perform the operation smoothly or struggle. Whipples might be the only exception. The surgeons that perform them here are very protective and i'm still primary assist in my mind. The experience seems to be different for chiefs.

 

[Guile]

dynx, what year are you?

 

[ESU_MD]

I have seen in my extensive career as a resident that good looking girls tend to get more attention in the OR, especially from middle age male surgeons who probably like the attention. In fact, maybe the OR is the only time an intelligent female in her prime would even talk to the guy. call it mid-life crisis, favortism, sexism, chauvinism, whatever.
Maybe it doesnt happen everywhere, but I dont think this behavior is restricted to just the surgical field.

 

[JackADeli]

...call it mid-life crisis, favortism, sexism, chauvinism, whatever...

I have seen similar in both directions. I have seen attendings nervous or worried of accusations of favoritism/discrimination being made by females. Thus, they over extend operative opportunities to females. I have probably equally seen attendings feeling females are over extended opportunities and thus the attendings hold back more from females. And, it really has had little relationship to attractiveness. My SO & I have always been amazed at what some consider attractive, etc... Especially, at the hospital, with those med-ctr goggles on...

Whatever the scenario, there is an atmosphere that can be created. It may or may not be intentional. It may or may not be real. But, one thing is true. If an attending tries to make the female residents feel "like one of the guys" they are damned if they do and damned if they don't.... It can be high stakes!😱

 

[Smurfette]

I think most of the women from my program would say the guys get a slight preference...the attendings always seem more friendly with the guys, in and out of the OR. Maybe it's because my program had more women than men...or maybe because most of us women wouldn't flirt to gain favor. It was a boy's club at one of the hospitals we worked at and it drove the women crazy. Probably a reflection more on the culture at a given program than anything else.

 

[thedrjojo]

yeah, the topic of autonomy was huge in my residency evaluation. And even as a PGY1, at the end of my breast surgery month, the chief of breast basically said to me, here's your final exam, i'll be scrubbed in, but this is your show, and didn't touch the patient until the end to help me get hemostasis.. which was awesome and nerve wracking at the same point. I mean, did everything from prep, drape, picking where to make the incision, removing the fibroadenoma (a malignant case he probably wouldn't have let me do it 😉 ). Then the next day with a different attending i retracted and suctioned, didn't even get to do the subq. its always going to be a crapshoot.

 

[chowhound]

I am starting to think that the only way to become a technically strong surgeon is to operate with a senior attending for years or at least have them in the next room.

BTW in private practice, who assists on cases?

The best way to actually learn is to study and then do it ~under guidance of a knowledgeable and competent mentor. That does not mean having the mentor demonstrate to you rather, he/she assume a more coaching role.

Having been in academics and private practice, I’d say it takes five years to approach the expert level. The first 1-2 years are ideally your chief year of residency. The next two to three years are either in fellowship or practice. No matter how many fellowships you do, nothing compares to having your name on the chart. In private practice I operate with my partners assisting me, some who have been in practice for over 25 years… and it is awesome. My first few years of practice are what I imagine chief residency should have been. My name on the chart, I make the call to take patients to the OR, I do the case, and if I have a questions I’ve got an expert surgeon across the table from me assisting. They make suggestions if I ask.

As a senior trainee, you either have faculty who are not around like I did back in the day. Therefore you operate to keep yourself out of trouble but it may not necessarily be right. Or you have faculty who steal the case from you. Or you have faculty who treat you like my partners did when I first joined them. Ideally everyone can find a training program like example number three, but in this day of surgical training I believe the only place that has something like that is at the VA.

People talk about autonomy, but I can tell you when I trained I would have wanted someone who had been doing this for 20 years showing me the right way to do it.

 

[ESU_MD]

Sadly, even the VA is starting to lose its edge as a place of resident autonomy. Therer is a big push for outcomes, "quality" data and those staff surgeons are being plagued with a mountain of paperwork for each complication.

 

[blue2000]

Sadly, even the VA is starting to lose its edge as a place of resident autonomy. Therer is a big push for outcomes, "quality" data and those staff surgeons are being plagued with a mountain of paperwork for each complication.

Sadly for the resident maybe. Not sadly for the patient. The dirty little secret of resident autonomy is that it may or may not benefit the patient. The difficulty is training residents while still maintaining the best care for the patient. I would suggest that in many cases, an R4 taking an R1 through a case is not in the patient's best interest. Now, an R4 taking an R1 through a case with an attending watching (but not scrubbed, or scrubbed but just observing) may be the best case scenario for everyone. But it's hard to know. As a patient, I wouldn't want my gallbladder removed by an unsupervised R3.

 

[MossPoh]

Having been in academics and private practice, I'd say it takes five years to approach the expert level. The first 1-2 years are ideally your chief year of residency. The next two to three years are either in fellowship or practice. No matter how many fellowships you do, nothing compares to having your name on the chart. In private practice I operate with my partners assisting me, some who have been in practice for over 25 years… and it is awesome. My first few years of practice are what I imagine chief residency should have been. My name on the chart, I make the call to take patients to the OR, I do the case, and if I have a questions I've got an expert surgeon across the table from me assisting. They make suggestions if I ask.
/QUOTE]

Does one's experience and level of confidence coming out of residency dictate the kind of job one takes at first? It does seem preferable to join a practice with multiple partners with much more experience than you from an educational standpoint, but it seems like it might be an awkward launching point for the (rare) occasions when someone aspires to return to a small town where they may be the solo surgeon or run the risk of being with a flat out incompetent surgeon. Is there a certain point where you find a PA you feel comfortable with to train and eventually assist you over having partners scrub in?

Naturally, it depends on the kind of deal you sign with the group and whether you are partnership track, but do people look for jobs in private practice that they view as more of a fellowship/learning experience before jumping off to their next venture?

I'm obviously not at the point where any of this matters for me. It is just a curiosity thing.

 

[dilated]

Sadly for the resident maybe. Not sadly for the patient. The dirty little secret of resident autonomy is that it may or may not benefit the patient.

It's going to be a lot sadder for patients when new attendings who are uncomfortable operating alone start operating on them... alone.

 

[Guile]

It's going to be a lot sadder for patients when new attendings who are uncomfortable operating alone start operating on them... alone.

You beat me to it. That's exactly my thought. There's not something magical about the last day of your chief year after which you are completely competent and able to care for patients independently. Ideally, you should be given increasingly more autonomy, with attendings close by for consulting purposes, so that as you grow as a chief, you are able to operate independently well in advance of your chiefs' banquet. As an attending, you may be very hesitant to give your residents a longer leash, and even more so to allow them to get into some trouble, but if your primary objective is education and ultimately better patient care, then you must give your chiefs that chance to get into trouble and not take the case away immediately. What happens when you get into practice, and the first time you have to operate yourself out of a hole is when you're by yourself? That is much worse for patient care. I know no one wants to be "practiced on," but it's a fine line, and it's negligent if you're an attending and contribute to this problem of inadequately-trained chiefs by never letting them get into trouble and attempt to get out of it. No one wants to discuss teaching points and what you could have done better over a dead body, but there is a way to safely let residents grow into independently-practicing surgeons. Halsted thought this should start in the chief year, and I believe he's still correct. Attendings should have the cautery and be assisting as a chief, ideally much earlier, but solely when you're a chief.

 

[SLUser11]

I know no one wants to be "practiced on," but it's a fine line, and it's negligent if you're an attending and contribute to this problem of inadequately-trained chiefs by never letting them get into trouble and attempt to get out of it.

Ah, the greater good. If you want to make a surgeon omelette, you have to break a few eggs.

John Stuart Mill would be proud.

All joking aside, it is difficult to walk the tight rope between appropriate autonomy and attending negligence. I think a mid level (PGY2 or 3) walking an intern through a major case with the staff down the hallway is probably a bad idea. I think letting the chief flop around and struggle a little bit is a good idea.

I think letting chiefs hone their teaching skills through TA'ing cases is a very good idea, as you need to learn to do the case and teach the case without the attending's pristine exposure/retraction.

 

[BlondeDocteur]

I have seen in my extensive career as a resident that good looking girls tend to get more attention in the OR, especially from middle age male surgeons who probably like the attention. In fact, maybe the OR is the only time an intelligent female in her prime would even talk to the guy. call it mid-life crisis, favortism, sexism, chauvinism, whatever.
Maybe it doesnt happen everywhere, but I dont think this behavior is restricted to just the surgical field.

I think this is a double-edged sword. The kind of attention you're talking about doesn't usually arise from the male attending's perception that the female resident is a terrific surgeon. It might seem like "attention," in terms of conversation, amount of time spent chatting with her, and so forth... but not usually anything to be jealous of.

I think it can be quite difficult for males of a certain generation to graft the concept of "surgeon" onto a younger female... especially if they find her attractive.

 

[dpmd]

I make the call to take patients to the OR, I do the case, and if I have a questions I’ve got an expert surgeon across the table from me assisting. They make suggestions if I ask.

You have just described how a senior resident should be trained (a chief for more complex cases, earlier for basic stuff). I think the fear of the young trainee causing a catastrophic complication is probably greater than what is actually seen. Having the attending scrubbed in is nice, but if everyone misidentifies the CBD as the cystic it is getting cut regardless of who is holding the scissors. There is no industry where people start with the inherent ability to do their job. Training needs to happen. There are people who are going to fly in a plane on the pilot's first commercial flight. They will have had some training prior to this, and hopefully will be flying with someone who has experience, but all the simulators and training flights in empty planes will be different than the first time out in a plane filled with customers where you are in charge. We can choose to start that process in residency (or in med school at those places where students are still allowed to suture-I was even allowed to do the entire approach during an ortho case once becuase I could describe the steps), or we can start it after. The problem is that at some point the training wheels need to come off. I think that if you have them on too long it becomes harder to feel comfortable-and therefore become competent.

 

[cpants]

The best resources for finding out about the operative experience is to talk to the residents at your home program and medical students who have done aways or go to the school in question. You can't always expect people to be objective about their own program, but they often can provide good insight into other programs in the area. Doing aways yourself is an invaluable experience for seeing the operative experience first hand. It doesn't matter how good the program's name is. You want to be a good surgeon, and you want to end up somewhere that will teach you to be one.