If you were an omnipotent program director and could build a surgery residency from the ground up, how would you structure it?
How many residents would be ideal? What would be the ideal setting (academic, hybrid, community; mega-urban, city, small town)? What kind of rotations would you build in? Would you offer electives? What about research? How could you increase operative volume, decease scut and ensure the pursuit of happiness for all?
And how would you pick your residents?
First off, how you liking UCLA transplant research? One of my chiefs is going there next year as a transplant fellow... if you are going to be around next year and interact with the fellows at all, shoot me a PM and i'll let you know who to look out for
So, I'm gonna start out and say my residency will not be kosher with ACGME/ACS guidelines. I would throw out the current residency model, and do it more like a tracking model.
I am biased by my current situation, but I think a multi-hospital setup is ideal to give exposure to different walks of life. I like the Urban Public Univeristy hospital where all the services are resident run teaching services, and the Suburban Private hospital where they are operating factories and a bit more hands on but teach the bread and butter. I think a VA is also invaluable.
Research would be optional but highly encouraged and flexible. You can go after 2nd or 3rd year, and go in for 1 or 2 years. Class numbers will (and in my program which has this setup, it does) get messed up, but again, in my imaginary world I don't have to answer to the ACGME... I think during the research time we would also foster a relationship to pursue a research oriented terminal degree, such as either an MPH for clinical research, or a PhD for basic science research (which might be difficult to manage in 2 years, but we could structure it that the data collection/experimentation is done during the 2 years of research and the dissertation writing is done over the next 1-2 years of clinical work). I'm doing an MPH during my research time now, and think it is invaluable for both doing my research well, and for putting myself in position for future opportunities.
The program would have minimal fellows. The only area I think fellows would be welcomed would be trauma surgery, and that would be the chief resident would be considered on equal terms as the fellow and they would be interchangable in the schedule. All other services would lack a true fellow. Rotations for the first 3-4 years would be fairly straight forward and similar. I think a strong ICU experience is key, with rotations likely in your first 3 years (again, in my made up world, the 16hr intern day would be eliminated and the 24+4 model would apply to all years). The other core rotations of general surgery, vascular, trauma, CT, peds, plastics, transplant (my program would have kidney, liver, pancreas transplants that are resident driven services, again, no fellow). Where my program really would differ would be the 5th year. Clearly by the time you are a 5 you will have either applied to or already matched into your desired field, and I think the typical senioritis or checking out that happens the last 6 months + of residency is a problem, and I think we waste a lot of time and cases on individuals with no intention of performing them. Shouldn't that person going into surg onc/hpb/transplant be the one doing the whipples, not the person going into vascular surgery? That total proctocolectomy with J-pouch, that ivoy-lewis esophagectomy? This is a big discussion in surgical education, and I am on the side of focused education. So the 5th year in my program (and the 4th year in conjunction) would be very tailored to each residents wants. I would keep a few required chief year services, like a general surgery service where they spend the entire time doing teaching cases, as well as the rotations that no one is going into will be up for grabs in a lottery type of situation since the services would need to be covered, and if we have a class where 6 are going into surg onc, that may make things difficult and dilute the experience for any of them, but ideally the class would have 1-2 going into each field and allow them to spread out nicely and dedicate a good 6-9 months of their chief year essentially doing a mini-fellowship
I think the residency size would end up being in the 8-10 per year, spread out over the 3 hospitals. Physician extenders would be very important, and from my bias, would be predominantly PA's (not to spark a PA vs NP debate). I think they need to work side by side with the junior and mid level residents, and would be able to teach them a lot as far as the "getting stuff done" aspect, but would not compete with residents for OR time. They can be instrumental in teaching bedside procedures (lines, chest tubes, i&d's, etc) to the junior/mid level resident. I think a night float system at all 3 hospitals would be important for the intern/mid levels, but for the most part 4's-chiefs would be considered like junior faculty and be first call (with some cross coverage on weekends to allow the required time off - my program does this junior faculty thing but doesn't do a lot of the cross coverage thing, which is just insane to me, so that the chiefs rarely have a day they aren't at least on phone call for their team. In the real world, we have to be able to sign out to our partners and trust our partners at times, so why can't we start that now is beyond me...)
Case numbers would be no problem, but I envision the yearly breakdown to be
PGY1 ~100-150 cases, more you appy's, your breast cases, inguinal hernias, your ivcf's, trach's, amputations, chole's at the end of the year
PGY2 ~100-150 cases, chole's, a-v fistulas, organ procurements, etc
PGY3 ~100-150 cases, kinda the wedge year... uncovered chief cases or the junior cases where you need more numbers/uncovered otherwise. This is also the major year where the chief will be walking you through cases (but that will also happen with PGY2... less so with PGY1)
PGY4 ~ 200-250 cases, will be chief of service and expected to cover any case... might not be operating every day (trauma service, clinic days, not counting scopes if on colorectal as cases, etc)
PGY5 ~ 250-??? cases, (will hit the 750 if does minimum in each year). As I said above, will be focused predominantly in the area of desired career, so will not be uniform throughout the years.
