Do community surgery programs provide better training?

[Dunkthetall]

I’ve only ever been exposed to university programs, but I’m starting to look at community programs for general and orthopedic surgery. One thing on my mind is, if I went to a community program, would I have earlier and more frequent exposure to surgery?

As an aside, if residency programs have a minimum level of surgeries residents must complete to be graduate and be competent, why do some surgeons say it took years before they became comfortable as attendings? Is it due to lack of autonomy in training?

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[DOVinciRobot]

Depends on what your goals are, and it can be quite program specific. It’s not as black and white as community equals operate more and better clinical training vs university equals research/fellowship and zebras

No matter where you go for training or how good it is, there is always an attending learning curve. Residency is designed to make you safe and competent at bread and butter, you won’t do enough of any specific case type to cross the learning curve hump into mastery level. A lot of becoming an expert surgeon is simply experience over a long period of time and being put in different scenarios and having to think yourself through them on your own.

For example, the learning curve for lap colons is reported to be 50. No one is getting that in residency, honestly a lot of CRS fellows won’t hit that number by the end of fellowship either with everything else they have to do.

 

[voxveritatisetlucis]

Depends on the program and hospital. For example, at my hospital OBGYN residents get hardly any support in the OR and are glorified first assist in the OR even as chief residents. For gen surg, they are usually leading cases by third year

 

[Dunkthetall]

Depends on what your goals are, and it can be quite program specific. It’s not as black and white as community equals operate more and better clinical training vs university equals research/fellowship and zebras

No matter where you go for training or how good it is, there is always an attending learning curve. Residency is designed to make you safe and competent at bread and butter, you won’t do enough of any specific case type to cross the learning curve hump into mastery level. A lot of becoming an expert surgeon is simply experience over a long period of time and being put in different scenarios and having to think yourself through them on your own.

For example, the learning curve for lap colons is reported to be 50. No one is getting that in residency, honestly a lot of CRS fellows won’t hit that number by the end of fellowship either with everything else they have to do.

Ahh that makes sense, thank you. At this point I think I want to exit academia as soon as I can and work as a community/rural surgeon. Was wondering community would better prepare me, especially if I become pretty certain I don’t want to do a fellowship.

 

[Dunkthetall]

Depends on the program and hospital. For example, at my hospital OBGYN residents get hardly any support in the OR and are glorified first assist in the OR even as chief residents. For gen surg, they are usually leading cases by third year

I guess this begs another question: how do you tease this out for other programs? Interviews? Word of mouth from faculty/mentors?

 

[voxveritatisetlucis]

I guess this begs another question: how do you tease this out for other programs? Interviews? Word of mouth from faculty/mentors?

So I’m interested in general surgery and when I’ve had coffee chats/meetings with people from other programs, usually I just ask what level of operative experience do residents usually get by the end of intern year? i think it definitely helps to speak with residents compared to faculty regarding this question

 

[operaman]

I guess this begs another question: how do you tease this out for other programs? Interviews? Word of mouth from faculty/mentors?

Great question. No easy answer. A few thoughts:

1) don’t believe anything junior residents tell you about their operative experience. They just haven’t done enough yet to grasp how little they’ve done of any given case.

2) don’t waste time comparing junior resident experience between programs. There’s a lot of variation depending on rotation timing. A 2 in one program may tell you they’re doing XYZ that another program may not do until pgy3, but if you did deeper you’ll find it balances because the other program gets something else earlier than others.

3) focus on the chiefs and what they’re actually comfortable doing by the end. If you can find recent grads in practice, even better - ask them what they’re actually doing and what they’re referring and what they wish they had gotten more of.

4) early operative experience and autonomy sound nice but are rather worthless in reality. Doing a big case too early is kind of a waste and you’ll get little out of it and maybe not even remember much from it years later. What you want is level appropriate experience where you’re doing cases that you can feasibly become autonomous in. Good programs will be thoughtful about this; others will use residents as glorified first assists and those juniors will brag about their OR experience because they don’t know any better yet. Autonomy sounds nice but you get plenty of autonomy after you graduate. You need enough of it in training to make you appreciate How much your attendings are helping you, but then you want to pick up as many pointers as you can before you’re done. VA/county hospitals are great for this - you get a little taste of flying solo but then you go back to the mothership.

5) I’m 3 years out from fellowship now and can’t even begin to express how much I’ve learned and grown as a surgeon since graduating. The learning doesn’t stop!

6) community programs can offer good training, but the key issue will be just how focused they are on teaching and growing your skills or whether you’re just a cheap first assist. No doubt you’ll get better at bread and butter stuff, but you may miss out on other less common things. One of my mentors used to say that in training you don’t want to do 5 things 20 times each, but rather 20 things 5 times each.


In the end, best sources of info are chiefs and recent grads, faculty mentors who have worked with grads of your chosen program, and faculty at that program itself. Just be sure you’re asking the right questions and focusing on the end product rather than what you’ll do as an intern.

 

[DOVinciRobot]

Ahh that makes sense, thank you. At this point I think I want to exit academia as soon as I can and work as a community/rural surgeon. Was wondering community would better prepare me, especially if I become pretty certain I don’t want to do a fellowship.

Again, it’s very program specific. As mentioned above, you need to talk to current residents, and recent grads are even better.

 

[LucidSplash]

Ahh that makes sense, thank you. At this point I think I want to exit academia as soon as I can and work as a community/rural surgeon. Was wondering community would better prepare me, especially if I become pretty certain I don’t want to do a fellowship.

Then I would start by looking at each program you are interested in and see how many of the graduates go directly into practice vs who does fellowships. Many programs list such information on their website. If there’s 40-50% who do, chances are the graduates as a whole feel confident enough in their skills to do so without doing a fellowship or “finishing school.” Next, see how many do MIS fellowships. While there a number of other reasons, very reasonable reasons, to do an MIS fellowship (desiring “marketability” if want to practice near a larger city, wanting to do bariatrics), sometimes graduates who want to do general surgery or rural surgery but don’t feel confident in their skills will choose to do an MIS fellowship as a bridge. A general surgery program that finishes chiefs confident in their general surgery skills, including laparoscopic and robot skills, is much less likely to pursue an MIS fellowship if they plan on doing general surgery. If you see a lot of people doing MIS and not a lot of people going directly into practice, you might suspect they feel less confident in their skills. I would suggest you ferret this information out on interviews by asking senior and chiefs residents what their plans/goals are for after graduation. Places where the residents don’t feel confident in their general surgery skills are unlikely to tell you straight out. But they will say things about “refining skills” when referring to MIS. But places that instill appropriate confidence will tell you that they feel confident in their general surgery skills without you having to ask about it outright. Additionally while not true across the board, many of the top academic programs are more interested in turning out research powerhouse residents and expect that their training will be finished in fellowship. I would avoid anyplace where very few if any former residents go directly into practice without doing a fellowship. Many academic places also tout their fellowship match rate of almost 100% as a marker of success and will unofficially frown on a resident that doesn’t want to do one.

I suggest looking for what I call “communiversity” programs. These are programs that straddle the line between academic and true community programs. They are often still attached to tertiary care centers and have their own level 1 trauma (they don’t send their residents elsewhere for trauma) and have a couple of surgical fellowships on site, but do not have a complete complement of all residencies or fellowships. The absence of fellows in some areas and some types of residencies opens up more opportunities for general surgery residents to operate and also to gain non-operative surgical assessment and management skills.

Lastly, look for places that still have a chief service. These are few and far between, but to trust a chief to run their own service (with oversite) requires that you have a training program that regularly turns out chiefs capable of acting as an attending, with training wheels, while still a chief. I strongly believe chief services are highly beneficial to instilling that final confidence. While you still learn a lot in your early career, so much the better if your first attending job isn’t the first time you’ve ever been the senior person in the room for a gallbladder or appy.

 

[Dunkthetall]

These posts are pure fire🔥🔥🔥

Thank you all for the fantastic responses!