Did the pyramid system make better surgeons?

[Misterioso]

I talked with an old school surgeon who trained under the pyramid system when all GS residents were in the same pool (no separation of prelims and categoricals). They were in direct competition with fellow residents to advance knowing a few of them would not make the cut each year so by the end only a few who had started made it all the way to the chief resident year. He said it was not unusual to start with about 20 residents and out of these only 3-4 made it through. He said this was the true meaning of becoming a chief resident in surgery where you had to earn it unlike today where all PGY5's are called chief residents. Do you think a system like this turned out better surgeons because only the best would make it to the end?

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[geekgirl]

I talked with an old school surgeon who trained under the pyramid system when all GS residents were in the same pool (no separation of prelims and categoricals). They were in direct competition with fellow residents to advance knowing a few of them would not make the cut each year so by the end only a few who had started made it all the way to the chief resident year. He said it was not unusual to start with about 20 residents and out of these only 3-4 made it through. He said this was the true meaning of becoming a chief resident in surgery where you had to earn it unlike today where all PGY5's are called chief residents. Do you think a system like this turned out better surgeons because only the best would make it to the end?

absolutely not!
i think environment like that foster competition of the unhealthy type (i.e. you do better if those around you do worse) rather than healthy competition or, even better, comraderie and a collaborative spirit.

 

[DrDawg]

I don't know. Suppose you started with all those appling through the match that wanted to do surgery. If you use both US and Foreign grads (about 4000 total if I remember) the match itself removes 75% of the competition. The remaining 25% has to do 3x the work without a pyrimidal system. I would guess that the pyrimid would choose better physicians than the match

 

[darrvao777]

I would say definitely not. (I just heard today that this is still the system they use. Is that true??)

This sort of thing encourages backstabbing and massive cutthroat competition.

I'm not sure if that is the system they have in place right now but hearing that alone would want to make me pick another field of medicine!

I understand that in a system like this, the most qualified doctors are the ones that will remain. But if it is at the expense of hospital morale and collaboration, then is it really worth it?

 

[flop]

I'd rather have surgery now than 30 years ago.

 

[DrDawg]

I'd rather have surgery now than 30 years ago.

It would be the ultimate FOX reality series

 

[scrappy]

I'm not sure if that is the system they have in place right now but hearing that alone would want to make me pick another field of medicine!

I understand that in a system like this, the most qualified doctors are the ones that will remain.

totally disagree with the conclusion that the most qualified doctors remain. as exemplified by your first sentence, a system like this would discourage many of the most qualified people to enter the field. those remaining will come from an inferior pool, and they will be the ones most geared to endure that kind of system, not the most qualified doctors.

absolutely not!
i think environment like that foster competition of the unhealthy type (i.e. you do better if those around you do worse) rather than healthy competition or, even better, comraderie and a collaborative spirit.

second this sentiment. perhaps the pyramidal system worked in the past, but the world is moving toward a collaborative philosophy. medicine is too vast and too complex to go it alone. the ones most successful will be the ones most adept at coordinating and fostering collaboration.

 

[BlondeCookie]

Isn't this how it's structured on Gray's Anatomy tv show? I thought that only one of those resident's at the end is going to make it.

 

[Needleandthread]

The federal government discourages this by paying hospitals for only 1 residency per resident. If a resident does a 2nd residency, the hospital still gets most of the money but not 100%. It's called direct and indirect funds and it establishes the number of years a person will be eligible for funds based on the minimum number of years to complete the 1st residency. Therefore, hospitals can get 5 years for funding for each PGY-1 year surgery resident (3 years for family practice). If the surgery program is 7 years, they get full funding for 5 years and nearly full (but not full) funding for 2 years. If the resident leaves after 1 year and goes to a family practice program for 3 years, it's still under 5 so the hospital gets all the money. If the resident leaves after 2 years and does OBGYN for 4 years, the last year of OBGYN is not fully funded.

Some programs use that as an excuse not to take someone but, in reality, the less than full funding is not much less.
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The pyramidal system is very hard on residents and exploits them. Why not have a system that 10% of residents who score low on a new test will have to serve the government for 10 years without pay on the guise of "re-education" (re-eduation is a term used by communist countries for forced labor and imprisonment).

Residents and MD's are professions who are ethical enough to try to learn as much as possible. If they really can't operate, then there can be counseling and extra training to either get them up to speed or to have them do another field. If there are, say, 5 PGY-1 categorical spots and 5 chief spots, then the incentive for a resident to finish is to do well and the incentive of the program is to work at training them because if they don't and the resident is fired, they will have fewer chiefs to do the work. If there are really too few chiefs, then the faculty will have to do more work. With the pyramidal system, it's too easy for the faculty to be dictators and unreasonable and for the residents to feel like they are living under Saddam.

 

[Needleandthread]

totally disagree with the conclusion that the most qualified doctors remain. as exemplified by your first sentence, a system like this would discourage many of the most qualified people to enter the field. those remaining will come from an inferior pool, and they will be the ones most geared to endure that kind of system, not the most qualified doctors.

This has already happened. Too many medical students have heard the horror stories of surgery residents lives ruined from the pyramidal system and for surgery residents to be abused. As a result, more medical students are doing other specialties and surgery residents are stuck with the lousy medical students.

ENT and ophthalmology are surgical fields that have traditionally been kinder to residents. Medical students still fight to get in to those fields.

We surgeons, especially surgery faculty, have cut our own throats.

 

[Needleandthread]

I talked with an old school surgeon who trained under the pyramid system when all GS residents were in the same pool (no separation of prelims and categoricals). They were in direct competition with fellow residents to advance knowing a few of them would not make the cut each year so by the end only a few who had started made it all the way to the chief resident year. He said it was not unusual to start with about 20 residents and out of these only 3-4 made it through. He said this was the true meaning of becoming a chief resident in surgery where you had to earn it unlike today where all PGY5's are called chief residents. Do you think a system like this turned out better surgeons because only the best would make it to the end?

Why not make it even more important to work hard. At the end of the PGY-5 year, the weakest chief will be killed. Then everyone will work extra hard, right? Of course not, everyone would go into ENT.

 

[darrvao777]

Why not make it even more important to work hard. At the end of the PGY-5 year, the weakest chief will be killed.

Where do I sign up for this program?

 

[scrappy]

Isn't this how it's structured on Gray's Anatomy tv show? I thought that only one of those resident's at the end is going to make it.

nah, if you go back and watch the pilot, you'll see that they're just one group of what looks like 20-30 interns. dunno where they're supposed to be the rest of the time, though... also, a couple of times, other pgy-3s tried to fill in for bailey.

of course, the show isn't exactly centered on the reality of surgical training programs.

 

[apma77]

ya the pyramidal system was great..so were the times that surgeons use to (some still do) throw instruments across the OR and abuse the OR staff

 

[darrvao777]

My instincts would tell me to pick the instruments up and throw it right back

I don't think I would make a good surgical intern 🙂

 

[DoctaJay]

Dr. Johanningman, a surgery attending at University of Cincinnati told me that that system is almost nonexistent. And its not like that at UC. I could have heard wrong, but I think that's what he said.

 

[Lloyd Christmas]

In order to a surgical program to be accredited by the RRC/AGCME they cannot be "pyramidal." That means they must graduate the same number of residents as start the program (with a few exceptions of course). This is not to say that people don't get fired, take lab time (or are forced into lab time), or just leave a program, but the pyramidal system of the past is for all intents and purposes, gone.

 

[Roux-en-Y]

Isn't this how it's structured on Gray's Anatomy tv show? I thought that only one of those resident's at the end is going to make it.

who cares?

 

[PhillyGuy]

Definitely not!

I think neurosurgery still has a pyramidal system. We have a resident here who started at Columbia for residency, but I guess didn't get the position for her third year. Now she's doing night floats everyday and it's unclear where she would go from here. I definitely would not want to be caught in that position.

 

[Ladd's Band]

I talked with an old school surgeon who trained under the pyramid system when all GS residents were in the same pool (no separation of prelims and categoricals). They were in direct competition with fellow residents to advance knowing a few of them would not make the cut each year so by the end only a few who had started made it all the way to the chief resident year. He said it was not unusual to start with about 20 residents and out of these only 3-4 made it through. He said this was the true meaning of becoming a chief resident in surgery where you had to earn it unlike today where all PGY5's are called chief residents. Do you think a system like this turned out better surgeons because only the best would make it to the end?

It’s not a surprise that the harder the training – only the best of the best will be produced. But the question is to what end? After this grueling process – The so-called best of the best will have to face high malpractice and lower and lower reimbursement. Talent needs to be rewarded. This is the best argument against pyramidal program.

 

[Samoa]

Definitely not!

I think neurosurgery still has a pyramidal system. We have a resident here who started at Columbia for residency, but I guess didn't get the position for her third year. Now she's doing night floats everyday and it's unclear where she would go from here. I definitely would not want to be caught in that position.

Most neurosurgery residencies do not use the pyramid system. You start, you finish. Unless you have the misfortune to be at one of those programs that frequently fire people. But usually when that happens, they'll start looking for a replacement to transfer in, because the residents are usually spread so thin already that firing one resident makes life much more painful for everyone else.

 

[Ladd's Band]

It’s not a surprise that the harder the training – only the best of the best will be produced. But the question is to what end? After this grueling process – The so-called best of the best will have to face high malpractice and lower and lower reimbursement. Talent needs to be rewarded. This is the best argument against pyramidal program.

Where is Misterioso?

...Talent needs to be rewarded. This is the best argument against pyramidal program.

 

[toxic-megacolon]

.

 

[Winged Scapula]

Definitely not!

I think neurosurgery still has a pyramidal system. We have a resident here who started at Columbia for residency, but I guess didn't get the position for her third year. Now she's doing night floats everyday and it's unclear where she would go from here. I definitely would not want to be caught in that position.

No accredited program in the ACGME is allowed to have a pyramidal system for residency anymore - and that includes Neurosurgery. It is likely that the resident you mentioned above was not rehired and was forced to find a position elsewhere. This can and does occur but is not the same as a pyramidal system in which some are *guaranteed* to be fired.

I do believe some military residencies and osteopathic programs (which are not under the auspices of the ACGME) have pyramidal positions.

Bear in mind that many programs have Designated and Undesignated Preliminary positions - don't count the number of interns and compare to the number of graduating Chiefs and assume the program is pyramidal (which it appears some are doing in regards to Grey's Anatomy).

 

[Molly Maquire]

Some of the osteopathic surgery programs are still pyramidal.

 

[TheThroat]

Pyramidal systems are largely extinct, but people can get fired from residency. Most residency contracts are one year deals. If you screw up enough, they just don't renew your contract. Seen it happen.

 

[Ladd's Band]

Pyramidal systems are largely extinct, but people can get fired from residency. Most residency contracts are one year deals. If you screw up enough, they just don't renew your contract. Seen it happen.

I do not think the reason for "getting fired" or "not renew your contract" is always for "screwing up enough".
(I am sure you already know that)

But my question is if "the contracts are one year deals" then every PGY level is a preliminary spot?!

Which means pyramidal systems are not extinct. There are "just" operating under the one year contracts.

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Not only does God play dice, but... he sometimes throws them where they cannot be seen.
- Stephen W. Hawking

 

[Winged Scapula]

But my question is if "the contracts are one year deals" then every PGY level is a preliminary spot?!

Which means pyramidal systems are not extinct. There are "just" operating under the one year contracts.

Not necessarily...remember the hallmark of the pyramidal program is that there are more residents than there are positions in the senior levels. There is a world of difference between being fired because there isn't enough positions in the year ahead and being fired (or not having your contract renews) for other reasons, but the position still exists and would have to be filled by someone else otherwise the program is short a resident.