Community vs. Academic vs. Military: Some new perspective.

[SLUser11]

I've attached an article from this month's JACS. Many of you will recognize it because we all filled out surveys on the matter after our 2008 ABSITE.

While it is completely subjective by definition, this article brings to light concerns that residents develop during training, and it shows how different types of programs and different areas of the country affect how residents feel about their training.

It's difficult to develop universally-applicable conclusions from the article, but it may be a springboard to a thought-provoking discussion here on SDN...provided we're done arguing about anastomotic leaks.

The study has an excellent response rate, and does a good job of breaking down the numbers. Things that stood out to me are outlined in Table 4 (Community residents are happier with their operative experience, as are people in the West/Midwest/South). It was also interesting to see that University programs contained a higher percentage of female residents.

Because of the size of the study, there are several areas that show statistical significance, but I wonder if there is clinical significance (e.g. being afraid to ask faculty for help, 12.6% vs. 13.9%, vs. 14.7%). Either way, it's definitely worth reading, and don't forget to read the discussion.

A question for other SDNers: Do the authors sound biased?

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[Dirt]

I've attached an article from this month's JACS. Many of you will recognize it because we all filled out surveys on the matter after our 2008 ABSITE.

While it is completely subjective by definition, this article brings to light concerns that residents develop during training, and it shows how different types of programs and different areas of the country affect how residents feel about their training.

It's difficult to develop universally-applicable conclusions from the article, but it may be a springboard to a thought-provoking discussion here on SDN...provided we're done arguing about anastomotic leaks.

The study has an excellent response rate, and does a good job of breaking down the numbers. Things that stood out to me are outlined in Table 4 (Community residents are happier with their operative experience, as are people in the West/Midwest/South). It was also interesting to see that University programs contained a higher percentage of female residents.

Because of the size of the study, there are several areas that show statistical significance, but I wonder if there is clinical significance (e.g. being afraid to ask faculty for help, 12.6% vs. 13.9%, vs. 14.7%). Either way, it's definitely worth reading, and don't forget to read the discussion.

A question for other SDNers: Do the authors sound biased?

Thanks for posting this, it is highly relevant to my current situation.

My initial reaction was that this paper sounds pro-community programs, and I was surprised to see that it came out of Yale. In the end though I don't think it was particularly biased.

The study has obvious shortcomings, and the results are pretty much as expected with my prior experiences in both university and community programs, but I still appreciate it.

 

[LucidSplash]

I thumbed through that article when I received my paper copy in the mail. One thing that struck me was that I wasn't sure exactly how my program would be classified; we're the "university-affiliated" (or my preferred term "communiversity program") and I didn't think we fit under either the university or community options.

But no, I didn't think the authors were particularly biased. I had the same response as to statistical vs clinical significance. But I tend to chalk most of these survey-type studies up to good food for thought more than anything else. I have trouble getting past response bias, but I felt the authors tried to stick with what the results of their survey showed rather than any personal bias.

 

[Smurfette]

I read this in JACS this month. I remember filling out that survey. I think that if I were to fill out the same survey now regarding my residency training, I'd answer many questions differently (i.e. more positively). I was on a busy rotation, sick, etc. at the time.

 

[SLUser11]

I thumbed through that article when I received my paper copy in the mail. One thing that struck me was that I wasn't sure exactly how my program would be classified; we're the "university-affiliated" (or my preferred term "communiversity program") and I didn't think we fit under either the university or community options.

Agreed. I think some of us would be surprised that we are considered "community" by this survey's definitions.

Another interesting thing: The conventional thought is that community programs have more operative experience, but academic programs have a better curriculum. However, this study shows community residents to be more satisfied with their didactics than those in academic settings. Is this because academic residents are just sharper tacks, and they demand more from their lectures....or does it mean that some academic programs have a heavy emphasis on service over education, and their curriculum is lacking?

Also, look at table 2, specifically the "support from program" and "fit with program" areas. Do military residents seem like they are the least likely to complain about their situation? Does it seem that in academic and military settings there is more hierarchy and intimidation? How does this affect communication between attendings and residents?

Anyway, I thought the article seemed ironically biased toward community programs, having come from research at an academic institution. I don't think the numbers are super-compelling, as I'm not sure how relevant a 15% vs. 19% satisfaction rate is on any particular subject. However, I think that this is research that needs to be done more often. If nothing else, it helps to dispel rumors and stereotypes, and opens the minds of young impressionable medical students to life outside Man's Best Hospital.

 

[Dirt]

However, I think that this is research that needs to be done more often. If nothing else, it helps to dispel rumors and stereotypes, and opens the minds of young impressionable medical students to life outside Man's Best Hospital.

I find myself wanting of a public database of caselogs for each program similar to the one for board pass rates.

I have found it almost impossible to compare different programs due to a lack of transparency at most programs. Some list total cases and chief cases, some give the full breakdown, some just say "you'll get enough".

 

[Seward]

I find myself wanting of a public database of caselogs for each program similar to the one for board pass rates.

I have found it almost impossible to compare different programs due to a lack of transparency at most programs. Some list total cases and chief cases, some give the full breakdown, some just say "you'll get enough".

The other slight of hand some programs use is to show their case numbers versus the required minimums instead of national averages.

 

[Guile]

The other slight of hand some programs use is to show their case numbers versus the required minimums instead of national averages.

"Our residents get DOUBLE the required pancreas cases!" (Eight. Not really impressive.) I've seen that done before. Places that are really proud of their numbers use percentiles for total cases, advanced laparoscopy, etc. to showcase their numbers.

I read this paper too. It was interesting, but another point that came to mind is what is the utility of the data? So community program trainees are more satisfied with their operative experience, but does that matter as much as say, satisfaction with training upon graduation, at the end of 1 year of practice, 5 years of practice, etc.? I think for residency, the finished product is what matters the most, not necessarily your satisfaction with the operative experience when you're on a rotation you don't like, you're tired, overworked, underpaid, etc, etc.

The university vs. community decision is an interesting one. I feel like too many students don't even consider community programs. I'm at a university program personally and didn't consider them. My advisers in med school didn't encourage me to apply to any. If it weren't for SDN, I wouldn't even know about Wichita, Iowa Methodist, UT-Chattanooga, et al. I think more students should consider them, especially since most grads go into PP even from (most) university programs. The only downside is it makes getting really competitive fellowships more difficult, peds surg and surg onc especially. That, and if you're deadset on academics, it gets that ball rolling much easier. But if you train at a community program and then go to a university fellowship and do good research, I think you'd be very competitive for academic jobs too.

 

[Svidrillion]

My advisers in med school didn't encourage me to apply to any.

Exactly. Almost all medical students work exclusively with surgeons at university hospitals who pursued academic careers. This is the cohort from among whom students choose mentors. Thus, all advice points students to follow that same path: university residency and academic practice. The real problem is that even if a student is interested in community programs and private practice, none of his or her mentors can really weigh in on those programs or that career path.

 

[45408]

Like others pointed out, I don't think it seems too biased, but I also don't know how useful this data really is. I was mostly fascinated with the fact that university residents are most concerned about the future of general surgery. I'm not surprised, since "true" general surgeons don't typically work in a university setting, but there are lots of jobs available for them outside of a monster metropolitan area.

 

[Buzz Me]

Very interesting read. Authors don't seem particularly biased to me.

I've also wondered about residents' perceptions of their programs' strengths and weaknesses...and how that differs between academic and community programs. Do residents at academic programs expect hardcore didactics (and thus are unhappy with curricula that would otherwise be considered acceptable)? Do they all demand weekly ABSITE review sessions? Do they expect time with simulators, pig labs or ABSITE-style question sessions?

 

[DoctwoB]

The one that worries me the most "I worry that I will not feel confident performing procedures by myself before I finish training."

 

[Buzz Me]

The one that worries me the most "I worry that I will not feel confident performing procedures by myself before I finish training."

That's a reason some graduates go into a "fellowship"...to actually just finish their Gen Surg training.

 

[SocialistMD]

This article wasn't that surprising to me at all. It is exactly what you'd expect and it is based on the types of people who match at the programs as broken down by the authors.

Those who match at academic programs tend to be "the grass is greener" sort of people who always feel as if they are being slighted. They are at programs that are more top heavy in their operative experience, leading to less junior resident satisfaction. They expect to be able to be extremely busy with exotic cases all of the time and they think they are supposed to be infallible, making them less likely to ask for help because they also have varying degrees of narcicissm and admitting that weakness would crush their perception of self (but project this onto their attendings' perceptions of them to stabilize their fragile egos). They are in programs with a (more or less) rigid heirarchy/structure, to which some adapt and others don't. However, despite all of this, as they mature through the ranks, they begin to realize all isn't as bad as they once thought and find comfort within themselves. All of their faculty have done fellowships, so they feel they have to, as most of them want to be academic surgeons.

Those who match at community programs tend to be pretty content with who they are and what they are doing. They are comfortable with the bread and butter cases on a daily basis and enjoy the few zebras they get to do. They have more realistic expetations of what they will be doing for the rest of their life and are in programs with surgeons who are a mix of faculty and adjunct staff, leading to a more relaxed and collegial interaction with faculty. They have a mixed bag of faculty in terms of those who have finished fellowships, so they see first hand what they can and can't do without a fellowship and choose their career path based on that.

The military programs know they have a more focused scope of operative procedures (in that many of their patients are younger and healthier than those seen at university/community programs) that they do in repetition. They are in the setting with the most rigid structure, but are used to that/more accepting based on their choosing the military, so it bothers them less and they are trained to question the decisions of superiors less.

The single relationship aspects come with the time and maturation, both as a person and with training in general, as those who are in relationships tend to be less selfish and more mature. The gender aspect comes from the gender discrimination that still occurs in the hospital in general and surgery residency in specific. Regional factors are no different than you'd expect from the general attitude of said populations.

The most interesting finding to me was the overlap in residents who feel they are getting a good experience, yet who feel they won't be confident to perform procedures upon graduating. Both academic and community programs added up to > 100%, meaning there were people who are happy with their operative experience but at the same time don't think they will be prepared. To me, those should be mutually exclusive, as I would never be satisfied with my training if I didn't think I was going to be prepared. Again, I guess it gets down to expectations.

In the end, this paper is nothing more than a study of the psychology of surgery residents. It shows that surgeons are selfish people, with the more selfish person opting for academic programs to prove something of one's self (and, potentially, others). Eventually, most will mature with time and realize the sky isn't falling...

 

[Wustenfuchs]

Because of the size of the study, there are several areas that show statistical significance, but I wonder if there is clinical significance (e.g. being afraid to ask faculty for help, 12.6% vs. 13.9%, vs. 14.7%). Either way, it's definitely worth reading, and don't forget to read the discussion.

The only significant finding I see ( and it concurs with SocialistMD's conclusion) is the inversely proportional relationship between the level of competence of a certain group and its sensitivity threshold.
The job description hasn't changed much despite all the advances and continues to be (even more) demanding (in terms of lifestyle and skin thickness). With all the whiners and the quitters, in the context of steady growing shortage of general surgeons, the deep concern we display in their regards leads invariably to lowering the standard so the slower, fatter and the dumber can eventually make it passed the finish line.
All my respect for CT/Peds Surgery who would rather go on with unfilled fellowship spots than affording an idiot the right of passage.

 

[45408]

All my respect for CT/Peds Surgery who would rather go on with unfilled fellowship spots than affording an idiot the right of passage.

There are unfilled peds surgery spots on a regular basis?

 

[Guile]

There are unfilled peds surgery spots on a regular basis?

The better question is has it every gone unfilled? I would be surprised. Peds is probably the most competitive. They are certainly not lacking qualified applicants.

 

[Wustenfuchs]

I may have said too much....

 

[SLUser11]

There's an article in this month's Journal of Surgical Education that I found interesting. Unfortunately, I've lost my access to the wonderful TMC library , so I can't attach the pdf.

This is a survey study of surgical residents focusing on their perceptions of how attendings teach in the OR. 70% of respondents were from academic institutions, and 28% were from community programs. It has several limitations, e.g. 20% response rate and sample bias, but brings up interesting points:

1. Only 55% of respondents agree that attendings "think out loud" and verbalize their operative approach.

2. Only 52% agree that attendings review a patient's indications for a procedure before the case.

3. Only 34% agree that attendings reinforce the educational points of the case after completion.

4. Only 41% agree that attendings provide positive feedback after a case, and 37% agree that attendings discuss areas for improvement or future learning objectives after a case.

Two main thoughts came out of this:

1. As attendings, we're doing a pretty crappy job of teaching in the OR. With ward teaching potentially being limited by work hour rules, the OR is probably the best classroom.

2. Since residents tend to absorb their attendings' bad behavior, this may have a major trickle-down effect on the way that the residents teach the junior residents and the students. Think of how important those 4 numbered activities are to the learning process, and how seemingly absent they are in training.


There is also a significant difference in the responses based on community vs. academic residents. I want to place a disclaimer here since I've been perceived as biased toward community programs in the past: I am currently working at an academic institution and I have no affiliations with community hospitals.

For those of you who can pull up the PDF, I think it would be helpful to attach it in this thread. Table 3 is quite important:

#1 above: 49% of academic residents agree vs. 67% of community residents (p<0.001).

#2 above: 48% vs. 61% (p=0.002)

#3 above: 31% vs. 44% (p=0.002)

#4 above: 35%/33% vs. 54%/49% (p<0.001)



Thoughts?

 

[45408]

It is incredibly helpful when attendings do it. I had one of my attendings do it several times this week, and it's definitely a plus. I've never thought to suggest it though, so maybe I will...

 

[Rollo]

Interesting..

 

[opr8n]

Interesting..

This threAd made me remember my day today when I was frustrated at the intern scrubbing my gallbladder. When I was dissecting the triangle of calot. I was asking what the structure were. I got blank stares. Then out of the blue "the common bile duct?". Umm no. Fail. How are we as attendings supposed to teach anything if people don't come prepared to the or? I mean the questions I was asking were. Not rocket science. They are clearly laid out in the doctor.books and cartoon versions as well. I also don't think it is the attendings responsibility to go over the indications for the operation. The resident should be telling the attending that upfront to justify their privelidge to do that case. ..

Sorry for the rant

 

[Winged Scapula]

This threAd made me remember my day today when I was frustrated at the intern scrubbing my gallbladder. When I was dissecting the triangle of calot. I was asking what the structure were. I got blank stares. Then out of the blue "the common bile duct?". Umm no. Fail. How are we as attendings supposed to teach anything if people don't come prepared to the or? I mean the questions I was asking were. Not rocket science. They are clearly laid out in the doctor.books and cartoon versions as well. I also don't think it is the attendings responsibility to go over the indications for the operation. The resident should be telling the attending that upfront to justify their privelidge to do that case. ..

Sorry for the rant

True and I understand your pain.

However, in the intern's defense IF they were assigned the case at the last minute (which my Chief was wont to do), they may not have had much time to prepare

That being said, what with work hours these days...I'm just sayin'...

 

[cpants]

This threAd made me remember my day today when I was frustrated at the intern scrubbing my gallbladder. When I was dissecting the triangle of calot. I was asking what the structure were. I got blank stares. Then out of the blue "the common bile duct?". Umm no. Fail. How are we as attendings supposed to teach anything if people don't come prepared to the or? I mean the questions I was asking were. Not rocket science. They are clearly laid out in the doctor.books and cartoon versions as well. I also don't think it is the attendings responsibility to go over the indications for the operation. The resident should be telling the attending that upfront to justify their privelidge to do that case. ..

Sorry for the rant

I get what you are saying, and not being prepared for cases is not acceptable. On the other hand, your responsibility to teach does not disappear just because a resident is underprepared. It's fine to chastise him, and lay out expectations for next time. Also fine to talk to his chief resident and/or program director about his lack of motivation/preparation. Not fine to expect him to silently hold retractors. The concept of 'justifying the privilege' to do a case is pretty old fashioned. If the kid is not well read and needs an anatomy lesson, give him one. Teaching is your part of the bargain when you accept resident coverage of the floors/consults and assistance in the OR.

 

[45408]

This threAd made me remember my day today when I was frustrated at the intern scrubbing my gallbladder. When I was dissecting the triangle of calot. I was asking what the structure were. I got blank stares. Then out of the blue "the common bile duct?". Umm no. Fail. How are we as attendings supposed to teach anything if people don't come prepared to the or? I mean the questions I was asking were. Not rocket science. They are clearly laid out in the doctor.books and cartoon versions as well. I also don't think it is the attendings responsibility to go over the indications for the operation. The resident should be telling the attending that upfront to justify their privelidge to do that case. ..

Sorry for the rant

One of my attendings always expects us to know what we are scrubbing into, and I prepare as much or more for his cases than others, but he still explains the particular rationale for the case. If it's obvious (he has a hernia, he wants it fixed), then that's fine, but if the case involved a discussion with the patient about the pros/cons of proceeding, then it can be very helpful to explain how he came to the conclusion.

 

[SLUser11]

This threAd made me remember my day today when I was frustrated at the intern scrubbing my gallbladder. When I was dissecting the triangle of calot. I was asking what the structure were. I got blank stares. Then out of the blue "the common bile duct?". Umm no. Fail. How are we as attendings supposed to teach anything if people don't come prepared to the or? I mean the questions I was asking were. Not rocket science. They are clearly laid out in the doctor.books and cartoon versions as well. I also don't think it is the attendings responsibility to go over the indications for the operation. The resident should be telling the attending that upfront to justify their privelidge to do that case. ..

Sorry for the rant

Yes, that resident was being a poor student, but it seems like we are also to blame if the system is broken because we are being poor teachers.

 

[opr8n]

Sadly I think education is changing. Students and residents today just expect to be spoon fed knowledge without contributing some work on the front end. Teaching professionalism is also important and one if the core values if the acgme. I am not far out of residency training but have sonewhat of an old school thought on preparedness. I the resident can't dedicated 15m of their time to reading about the patient and the operation they are scrubbing into. I personally don't think they should be surprised when they are not doing the operation. I would never dream to show up to a case unprepared when I was a resident

 

[SLUser11]

Bump. Interesting thread for those about to embark on many interviews...

 

[dienekes88]

This threAd made me remember my day today when I was frustrated at the intern scrubbing my gallbladder. When I was dissecting the triangle of calot. I was asking what the structure were. I got blank stares. Then out of the blue "the common bile duct?". Umm no. Fail. How are we as attendings supposed to teach anything if people don't come prepared to the or? I mean the questions I was asking were. Not rocket science. They are clearly laid out in the doctor.books and cartoon versions as well. I also don't think it is the attendings responsibility to go over the indications for the operation. The resident should be telling the attending that upfront to justify their privelidge to do that case. ..

Sorry for the rant

It sounds like the resident was pretty clueless. However, I will point out that the cartoons look markedly different from real life if you're not used to seeing the real thing. It's easy for someone who has done hundreds of gallbladders to immediately see the similarities, but I remember preparing for my first gallbladder and then getting in and being very confused. The only time I had seen a lap chole done prior to my first as a resident was on a YouTube video the night before as I was trying to prepare. Same thing for an inguinal hernia. It looked nothing like the color-coded cartoons.

The new training paradigm means that there is a lot less time these days spent assisting, because the work hours require the same amount of work to be done by fewer people or the same number of people in fewer hours. Residents end up dealing with ward duties, consults, etc instead of "holding hook"/second assisting. In retrospect, I wish I had spent a lot more time second assisting in my early years or even just getting in there to watch 10 minutes here and there from the head of the bed. These days, there seems to be a lot of negative attitude towards being second assistant or even first assistant; there were several people on SDN who argued vehemently against me when I advocated for the need to watch and slowly accumulate all of the moves of an operation before attempting it from the right side of the table.

One of my attendings always expects us to know what we are scrubbing into, and I prepare as much or more for his cases than others, but he still explains the particular rationale for the case. If it's obvious (he has a hernia, he wants it fixed), then that's fine, but if the case involved a discussion with the patient about the pros/cons of proceeding, then it can be very helpful to explain how he came to the conclusion.

I hope all of them expect you to know about the case.

Yes, that resident was being a poor student, but it seems like we are also to blame if the system is broken because we are being poor teachers.

Not exactly poor teachers. I think part of it is a failure to adapt to the rapidly changing work environment. With increasing reliance on shift work and nightfloat, oftentimes the resident admitting the patient will have no part in the operation. As the nighttime 2nd year resident on General Surgery, I worked up and admitted hundreds of patients that I never ended up operating on, and the resident who actually scrubbed for the case only gets a few minutes in pre-op and the consulting resident's note.

Sadly I think education is changing. Students and residents today just expect to be spoon fed knowledge without contributing some work on the front end. Teaching professionalism is also important and one if the core values if the acgme. I am not far out of residency training but have sonewhat of an old school thought on preparedness. I the resident can't dedicated 15m of their time to reading about the patient and the operation they are scrubbing into. I personally don't think they should be surprised when they are not doing the operation. I would never dream to show up to a case unprepared when I was a resident

As others have mentioned, sometimes the chief assigns the cases late. Sometimes it's right before the patient arrives in the room. You prepare as much as you can, but there are things outside of your control.

 

[dr zaius]

It sounds like the resident was pretty clueless. However, I will point out that the cartoons look markedly different from real life if you're not used to seeing the real thing. It's easy for someone who has done hundreds of gallbladders to immediately see the similarities, but I remember preparing for my first gallbladder and then getting in and being very confused. The only time I had seen a lap chole done prior to my first as a resident was on a YouTube video the night before as I was trying to prepare. Same thing for an inguinal hernia. It looked nothing like the color-coded cartoons.

The new training paradigm means that there is a lot less time these days spent assisting, because the work hours require the same amount of work to be done by fewer people or the same number of people in fewer hours. Residents end up dealing with ward duties, consults, etc instead of "holding hook"/second assisting. In retrospect, I wish I had spent a lot more time second assisting in my early years or even just getting in there to watch 10 minutes here and there from the head of the bed. These days, there seems to be a lot of negative attitude towards being second assistant or even first assistant; there were several people on SDN who argued vehemently against me when I advocated for the need to watch and slowly accumulate all of the moves of an operation before attempting it from the right side of the table.

As an intern (urology on general surgery at that) I agree with these statements. I saw my first lap chole ever about 3 weeks ago. The visible anatomy was not what I expected based on readings. If the attending asks what the critical view of safety is and then points to the structure and asks what's this? that's a bit different. But a straight up "what's this structure" question, especially on a lap case, can be pretty confusing for the newbie. One big thing I have learned so far this year is that anatomy books are basically like the sample EKGs you get for board questions. They're the perfect representation. What you see in real life varies incredibly.

In terms of hanging hook as a second assist, I think it is incredibly valuable. I have tried to double scrub as much as possible and pop my head into the OR as often as I can when taking care of ward stuff just to see what's going on. When coach finally called me off the bench for that hernia I felt like I knew the steps. Not just because I read the doctor books, but because I saw it a few times. I may not have been dexterous, but I knew what came next. Most of that came from watching.

Just a wee intern's two cents. Flame away.

 

[Slack3r]

As an intern (urology on general surgery at that) I agree with these statements. I saw my first lap chole ever about 3 weeks ago. The visible anatomy was not what I expected based on readings. If the attending asks what the critical view of safety is and then points to the structure and asks what's this? that's a bit different. But a straight up "what's this structure" question, especially on a lap case, can be pretty confusing for the newbie. One big thing I have learned so far this year is that anatomy books are basically like the sample EKGs you get for board questions. They're the perfect representation. What you see in real life varies incredibly.

In terms of hanging hook as a second assist, I think it is incredibly valuable. I have tried to double scrub as much as possible and pop my head into the OR as often as I can when taking care of ward stuff just to see what's going on. When coach finally called me off the bench for that hernia I felt like I knew the steps. Not just because I read the doctor books, but because I saw it a few times. I may not have been dexterous, but I knew what came next. Most of that came from watching.

Just a wee intern's two cents. Flame away.

You made it through medical school without seeing a lap chole?

 

[vhawk]

You made it through medical school without seeing a lap chole?

I never saw an appy, and I probably only saw 2-3 lap choles when I did a week or two at one of the community hospitals. Saw significantly more Whipples.

 

[dr zaius]

Urology, vascular, and colorectal as an MS3. Not a single appy, either. Or hernia (of any kind). I saw three mesenteric bypasses though.

 

[dienekes88]

You made it through medical school without seeing a lap chole?

I saw one lap chole, no appys, no hernias. The lap chole was an unusual referral to this surgeon who mainly did pancreatic surgery and a tiny bit of liver.

 

[SLUser11]

I never saw an appy, and I probably only saw 2-3 lap choles when I did a week or two at one of the community hospitals. Saw significantly more Whipples.

Agree. This is a common scenario at my institution. Students can go 8 weeks without a lap chole or lap appy, but will see plenty of whipples, HIPECs, lap and robotic colons, etc. Most of the straightforward bread and butter cases are done in the community hospitals, which is exactly why our residents spend 6+ months at those community hospitals.

 

[thedrjojo]

Agree. This is a common scenario at my institution. Students can go 8 weeks without a lap chole or lap appy, but will see plenty of whipples, HIPECs, lap and robotic colons, etc. Most of the straightforward bread and butter cases are done in the community hospitals, which is exactly why our residents spend 6+ months at those community hospitals.

which is why our gen surgery rotation as a student is divided 4 weeks in a private, community hospital, and 4 weeks in a public hospital. We also have required cases to see, which includes 2 biliary cases. As a ms3, my 2 required biliary cases were a whipple and a liver transplant, but I also did see a chole or two. We also take call, so would see the occasional appy on call.

 

[dr zaius]

I can see how that would be important for someone going into primary care or a non surgical specialty. In my case I'm glad that I was able to experience more of the exotic things because I have been exposed to the choles/appys/hernias quite a bit during my intern year so far. A lot of the things I saw in medical school I probably will not see in residency, but at least if a patient has a presentation similar to what I saw before I can have enough awareness to have those diagnoses on my differential.

 

[Kahreek]

This threAd made me remember my day today when I was frustrated at the intern scrubbing my gallbladder. When I was dissecting the triangle of calot. I was asking what the structure were. I got blank stares. Then out of the blue "the common bile duct?". Umm no. Fail. How are we as attendings supposed to teach anything if people don't come prepared to the or? I mean the questions I was asking were. Not rocket science. They are clearly laid out in the doctor.books and cartoon versions as well. I also don't think it is the attendings responsibility to go over the indications for the operation. The resident should be telling the attending that upfront to justify their privelidge to do that case. ..

Sorry for the rant

 

[Kahreek]

As an intern (urology on general surgery at that) I agree with these statements. I saw my first lap chole ever about 3 weeks ago. The visible anatomy was not what I expected based on readings. If the attending asks what the critical view of safety is and then points to the structure and asks what's this? that's a bit different. But a straight up "what's this structure" question, especially on a lap case, can be pretty confusing for the newbie. One big thing I have learned so far this year is that anatomy books are basically like the sample EKGs you get for board questions. They're the perfect representation. What you see in real life varies incredibly.

In terms of hanging hook as a second assist, I think it is incredibly valuable. I have tried to double scrub as much as possible and pop my head into the OR as often as I can when taking care of ward stuff just to see what's going on. When coach finally called me off the bench for that hernia I felt like I knew the steps. Not just because I read the doctor books, but because I saw it a few times. I may not have been dexterous, but I knew what came next. Most of that came from watching.

Just a wee intern's two cents. Flame away.

i think it is more like they were doing a cholescystectomy so first thing they go for when in the peritoneal cavity is to dissect for the callot's triangle.
If you dont have a clue where you are you must at least know where to go.