Future of Surgery....

[DocnHoc]

---

Members don't see this ad.

Two part question here:
1) Any insight into the outlook for surgical specialties in the future (above the maxim of "there is always a job for a skilled surgeon"!)? Read a post on here earlier about how CT surgery is considered to be a dying breed in terms of its importance and use. What specialities are known to be in trouble due to problems with managed health care, oversaturation of practitioners in the field, or in danger of becoming relics to new technologies (such as perhaps IV radiology)

2) I know this has probably been MUCH debated and discussed already and I apologize in advance for bringing it up; but for those of us who missed it the first time and are still in medical school, can someone please recap the ACTUAL impact of the new 80 hour work week on surgical resident workload, and on length of residencies? While I realize this topic has been all over the media, it's hard to get a real idea of the actual impact because you hear all sorts of conflicting things in med school (i.e. i've heard from some students that some programs will be lengthening due to the new restrictions, while my advisor claims that this is nonsense)

Thanks again

 

[hotbovie]

It's difficult to assess the impact of the 80 hour work week, as the rule doesn't offically start until July 2003. Some programs have been experimenting with different schedules this year to see if what they come up with on paper works in the real world.

I've been told, though haven't taken the time to research myself, that there is data from NY programs saying that it doesn't impact quality of training. (These rules have been in effect in NY state for years, and recently have actually been enforced) Realize that much of what a resident had traditionally done does not contribute to his/her education, but is merely provides cheap labor for the hospital. So there is plenty of room to cut hours without sacrificing quality of training, IF done properly.

I did a surgery elective in NYC, and the numbers of cases that the residents graduate with were far less than the residents at my program. However, they still exceeded all of the minimum requirements. Average census of pts on the general surgery sevice at the county hosptial was 15-20. I also think it was due to the fact that there are so many programs in NYC that the number of patients per resident was far less than in my program, the only program for 200 mile radius. On the other hand, a resident from NYC would likely consider my program "malignant" due to the much higher work load (residents come close to the maxium limit of cases allowed, and that's without logging every single one, and average census at the county hospital general surgery service 50-60). Up intil recently, average work hours at my program were 110-120 a week.

NO WHERE on the interview trail did any faculty/ program
directors think that lengthening programs was a viable option. IN fact, generally surgery faculty and program directors are very concerned because the applications for surgery have been trending downward, and they realize that the lifestyle is a big factor keeping students from choosing surgery. To lengthen the training would be to deal the specialty another blow. Faculty want the career to be attractive to students so that they can fill their slots with strong students. However, as you may know, there is much talk that surgery may start doing a 4+2 type of training, with 4 years of general then 2 of a subspecialty. From what I heard on the trail, I wouldn't be surprised to see some pliot programs in a few years. The vascular folks seemed most amenable to this from my experience.

When you get ready to go through the match, and if you choose surgery, ask lots of questions of those who go through the process the year before you. The focus and slant of the issues are likely to change (for example, this year I was leery of any program that wasn't implementing trials of new schedules...made me wonder how seriously they were taking it. And while I don't necessarily agree with the rules, I don't want to wind up in a program that gets put on probation). If you happen to be in the year when trials of the 4+2 option are going you, that will open a new set of things to ask about.

According to the surgery faculty at my school, surgeons are retiiring at a rate greater than programs are producing graduates. Plus over half of the graduates of general surgery programs go on to a fellowship, rather than do general surgery. SO there will be a shortage of general surgeons. Beyond this, some areas of fellowship training are very hot, with plenty of jobs and opportunities and others may be waning. As far a specifics, I only know that my area of interest, trauma, is one that has lots of unfilled jobs. Also, advanced laparoscopy is a field where demand is ahead of supply (lot of hospitals are hopping on the laparoscopic bariatric bandwagon)

Hope this helps

 

[Pilot Doc]

Question #1) Anybody's guess. Physician workforce prognostication has a long and very undistinguished history.

Question #2) Agree with previous post, especially about adding years residency. (I've been interviewing for GS this year.) For some insight into what the program directors are thinking, take a look at

Residency program models, implications, and evaluation. Surgery . 133(1):13-23, Jan 2003.

Some big names in surgical education put this together. It will give you some idea of how programs may evolve.

 

[DoctorDoom]

However, as you may know, there is much talk that surgery may start doing a 4+2 type of training, with 4 years of general then 2 of a subspecialty. From what I heard on the trail, I wouldn't be surprised to see some pliot programs in a few years. The vascular folks seemed most amenable to this from my experience.

I generally agree with you hotbovie, here's my shading of some of your points.

The fact is most subspecialties are already in that mode, except it's 5+2 with the chief resident basically doing nothing but operate when they feel like it in their chief year. De facto rather than de jure, you might say. Vascular, colorectal, heck even breast is moving towards true fellowship/subspecialty status. Vascular is now occassionally 3 years including a year of research. Sooner or later there must be a move towards the combined plastic surgery program approach.

As for the 80 hour work week, even in New York it's impact is unknown, except that residents sleep more. No way to really tell until people are out there a few years. County hospitals have lower census of patients because most elective surgery is performed in private hospitals in NYC; lower resident work hours probably does not affect patient load. The attendings don't stop operating. The malignancy of NYC residencies has to do with a whole lot of other painful factors, from nonchalant support staff to attendings who throw fits, and then instruments at you because you're there. Removing that malignant attitude and crap like making residents wheel people to radiology for standard exams more than makes up for the time lost to work hour restrictions.

 

[vuillaume]

I agree with hotbovie and DoctorDoom.

What the 80-hour week is exposing is that much of what residents do is non-educational, and that most teaching hospitals that never had an incentive to streamline systems for non-educational activities like discharge paperwork, orders, and recording labs will finally have to come to Jesus. I can't know for sure, but I think the thought that work-hour reductions will result in less well-trained residents is a fallacy. Hopefully all the new rules will mean is that we will trade paperwork for the OR, and the OR's I've seen are still as busy as ever.

The legitimate question is whether continuity-of-care will suffer. Again, if hospitals--and it has to be the hospital, not just the residency training programs--configure their systems so that information is comprehensive and easily-accessible so that hand-offs are smooth, hopefully this question will be obviated. Also, culturally, I think the type of people who become surgery residents just ain't the types who will walk out on an unstable post-op patient. It's the responsibility of the hospital and all of its systems that that resident didn't burn up work hours sitting in front of a terminal transcribing labs and studies to an index card.

Old fogies in my father's generation had (1) fewer patients, (2) patients that stayed longer and that they knew better, (3) WAY fewer labs and studies to occlude their memory banks, (4) and far fewer interventions available to them. Acknowledging that they had to trudge through six feet of snow to get to the hospital and slept on gurneys, medicine is very different and more complex nowadays. I honestly would've chosen surgery work-hour rules or no; but I despise inefficiency and busy-work so I'm glad there's now an incentive to get rid of that crap.