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Is the current surgery life style necessary?

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trauma_junky

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I was talking with a friend of mine who is in their MSIII surgery rotation. It seems to me that there has to be a better way of doing it, is it really necessary to slave 120+ hours a week? Why not just extend the residency? No one benifits from the current system, the patients suffer, the students suffer, their spouses suffer... Sounds kind of contradictory to what all med schools preach in their ethics of medicine.
 

trauma_junky

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Well why not. Why should those that want to have a family life and be a surgeon have to sell their souls to the slavery industry of indigent care. I think its rediculous. These poor people have no life outside the hospital, they are so tired that they could care less about the acutal needs of the patient, they are so depressed they **** on every nurse and medstudent that comes through. Why not just extend the program and learn in an "employee friendly" atmosphere.
 

Idiopathic

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I dont disagree that the current system might need a little tweaking, but adding time to an already long training period would certainly not make those individuals more likely to be caring, compassionate, receptive, and family-oriented. Plenty of doc's make it work and plenty of families make it work, but it is a sacrifice. We have all heard that before, but it is really true.

And if someone really wants to make a point of it, there are 80-hour workweek restrictions in effect. They should challenge having to work 120+, because it is against the law, and quite possibly does interfere with patient care.
 

doc05

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Originally posted by trauma_junky
I was talking with a friend of mine who is in their MSIII surgery rotation. It seems to me that there has to be a better way of doing it, is it really necessary to slave 120+ hours a week? Why not just extend the residency? No one benifits from the current system, the patients suffer, the students suffer, their spouses suffer... Sounds kind of contradictory to what all med schools preach in their ethics of medicine.

wow. what a super-naive question. First off, patient care doesn't really suffer, except perhaps in exceptional circumstances.

Extend the residency? Are you insane? How many more years do you think it should be?

Surgical residents suffer, but that is the nature of the field. Sacrificies are necessary, just accept it.
 

Minimalist M

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The answer is definitely not to extend the residency. Surgical residencies are a certain number of years because of the experience needed in the OR. The 120 hr work week has to do with floor work in addition to the OR experience. To cut the 120 hr work week, the slack has to be taken up on the floors. Many hospitals have taken to hiring PAs to do scut work such as ordering tests or scans, transfers, consults, etc. Believe it or not, some PAs can take overnight calls. All this will allow the residents to go home early post-call (like after signing out) or go home early on normal days because all the floor work is done.

Also, the answer to the 120 hr work week will not be adding another resident to the program because each resident must have a certain amount of allotted OR time, so residents cannot be added just to work on the floor, a program must be able to train that resident in the OR.
 

trauma_junky

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Originally posted by doc05
wow. what a super-naive question. First off, patient care doesn't really suffer, except perhaps in exceptional circumstances.

Extend the residency? Are you insane? How many more years do you think it should be?

Surgical residents suffer, but that is the nature of the field. Sacrificies are necessary, just accept it.

You still have not answered why! Why are the sacrifices necessary? Really, please just make note why you think it requires 120 hours a week. If its or training vs. floor work then why not have designated or times and designated floor times. When your taking call for your practice you will have to do floor work on patients you did not operate on. It needs to be fixed. I think a lot of it has to do with incompetent nurses as well. I know my friend states they can't trust the nurses to page them when important things are changing, so I'm sure this is part of the problem.
 

Been there

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Originally posted by trauma_junky
When your taking call for your practice you will have to do floor work on patients you did not operate on. It needs to be fixed. I think a lot of it has to do with incompetent nurses as well. I know my friend states they can't trust the nurses to page them when important things are changing, so I'm sure this is part of the problem.

Whoa, Stop the nurse basting. There are no places for that in health care. We are a team.

I will now let you in on the Three Basic Laws of General Surgery.

1) Trust no-one including your mother-- always get a name.

2) Don't take "no" for an answer

3) If you are going to go down take someone bigger with you-- call the person above you.

Your friend should be checking on his/her patient at night and not just sleep in the hospital to wait for things to go bad. Surgery residency has gotten alot better than it use to be. The old days were q2 calls (that mean every other night)--they use to say it means "you will missed 50% of the operative experience". All residency have a 80hr/wk rule that is govern by ACGME. Most programs still go over this limit, but at least they are trying to reduce work hours. Some members of the American College of Surgeons have suggested to extend the residency period, but that will just prolong the pain. There are numerous purposal to help reduce work hours, and they are trying them now. Just give them a chance to pilot it.

You are way to young to be this whiney
 

womansurg

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I'll just echo the remarks of the folks whom I trained under, and say that the life of a general surgeon only gets more busy and more stressful once you graduate from residency.

Chief year was a cake walk compared to private practice. My devoted husband, who went through med school and surgery residency by my side without ever muttering a complaint, is now for the first time expressing unhappiness at how unavailable I am. I get home between 7 and 10 pm on nights that I'm not on call. Last weekend I was in the hospital for nearly 72 straight hours, with a total of six hours of sleep for three days.

Part of the purpose of the long hours of surgery training involves testing your ability to withstand the physical rigors. When I'm on call and have been up and on my feet for 36 hours, and a gunshot victim or perforated viscus rolls into the ED, I must be able to pull my act together, think clearly, perform with a steady hand and get the job done. Period.

Once you graduate you can tailor your practice to lifestyle. For instance, one of the GS's in town does almost exclusively small bread and butter type cases - breast, hernia, gallbladder. In fact, that is partly why I'm so busy - I'm getting the reputation of tackling the bigger cases in town, so docs send me referrals even on days when someone else is on call for consults. So, you don't necessarily have to run this hard, but chances are you'll be in some sort of call pool where you'll have to perform when you are tired and overworked at times. It's important that you have established your competency under these types of stressful conditions.
 

Tenesma

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if you want a longer residency with better hours move to europe or australia or new zealand... there the government limits your hours to 56 hours per week, (with plans in france and england to drop it to 48 hours/week)!!!! but in return your residency lasts 4-6 years longer.... i don't know about you, but i want to be my own boss by my early to mid=thirties....
 

trauma_junky

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Originally posted by Been there
Whoa, Stop the nurse basting. There are no places for that in health care. We are a team.

I will now let you in on the Three Basic Laws of General Surgery.

1) Trust no-one including your mother-- always get a name.

2) Don't take "no" for an answer

3) If you are going to go down take someone bigger with you-- call the person above you.

Your friend should be checking on his/her patient at night and not just sleep in the hospital to wait for things to go bad. Surgery residency has gotten alot better than it use to be. The old days were q2 calls (that mean every other night)--they use to say it means "you will missed 50% of the operative experience". All residency have a 80hr/wk rule that is govern by ACGME. Most programs still go over this limit, but at least they are trying to reduce work hours. Some members of the American College of Surgeons have suggested to extend the residency period, but that will just prolong the pain. There are numerous purposal to help reduce work hours, and they are trying them now. Just give them a chance to pilot it.

You are way to young to be this whiney

Not whiney, just curious. I also want my cake and eat it too. I want to be able to spend a, "reasonable time" with my family and possibly become a surgeon in the future. I know the trauma surgeon states that it is the best work in surgery, all shift work.
 

Winged Scapula

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Originally posted by trauma_junky
Not whiney, just curious. I also want my cake and eat it too. I want to be able to spend a, "reasonable time" with my family and possibly become a surgeon in the future. I know the trauma surgeon states that it is the best work in surgery, all shift work.

Huh? What Trauma Surgeon told you that? I don't know any who work shifts. They generally divide nights on Trauma call with the rest of the Trauma attendings/surgeons in their practice but they will have a full day of practice/office hours/surgeries the next day, regardless if they've been in the OR or Trauma Bay all night.

If its shift work you want, check out EM.
 

Been there

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I think you watch way too much ER. You are confusing ER Docs and trauma surgeons. Trauma surgeons tends to have the worse lifestyle in the business. I still remember a chief resident said when I was a third year med student. He said "trauma surgeon! You are either crazy or stupid. Life sucks as a trauma surgeon. You baby sit all night and then you take up the ass the next day."
 

trauma_junky

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This guy is a trauma surgeon in Phenoix AZ. He clocks in and clocks out. That's it. I've found, by talking to NUMEROUS sources, that surgery life depends on where you are and what you make of it. Some programs are out to make you miserable (Baylor) and others are out to train you. He told me that the Navy program in Bethesda is very fair and you are well trained. He did his residency in the Navy.
 

trauma_junky

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Originally posted by Been there
I think you watch way too much ER. You are confusing ER Docs and trauma surgeons. Trauma surgeons tends to have the worse lifestyle in the business. I still remember a chief resident said when I was a third year med student. He said "trauma surgeon! You are either crazy or stupid. Life sucks as a trauma surgeon. You baby sit all night and then you take up the ass the next day."

I used to work in a Level I, thank you. Two to be percise, Ben Taub in Houston and University in San Antonio. Both of them did things WAY different. Ben Taub, lots of cool trauma but those poor residents didn't even know who the president was they worked so much. University: They worked long hours but half of it was wasted on scut and other BS. The interns do all the floor work. One resident said that if they were better organized and the attendings would were more organized, things would get done a lot more efficently. He claimed it would be way east to get everything done in 80 hours if everyone just did their job and did it well.

PS: ER sux! It sould just be called ICU hold over!
 

md03

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To answer the poster who asked why surgery residency is the way it is, I believe you can thank Hallstead for that. He was the one that came up with the graduated responsibilty system for residency. Things have changed some since then (eg the pyramid system has been virtually elimiated. And residents used to actually truly live in the hospital...hence the term "resident physician"). So, the answer to why, is, unfortunately, basically "because we've always done it that way"

There was very interesting article in the ACS journal that came out sometime in the last 3-4 months. It addressed changing surgical residency format dramatically. The answer to making it more humane is NOT to extend it (I doubt very many of current surgical residents would be for that). However, the authors proposed making it more of a mentoring system, with each resident being assigned to a faculty mentor for several months at a time. I'm found the proposal very intrigueing.

The proposed system would require a major paradigm shift on the part of surgical faculty. They would no longer be able to use residents to do the day to day work and leave them more time for their research. They would acutally be forced to speak to, interact with and teach interns.

The proposed model went something like this if I recall: Each resident would be assigned to a faculty member for several months at a time. The would work with that surgeon and that surgeon's patients only. They would see pts in the hospital, office and operate with that faculty. This would mean that the faculty member must be prepared to have a junior resident in the OR for ALL his/her cases, even the most complex, and the upper level residents would be prepared to do (with the attending) the floor work required for those patient's care. Sometimes a faculty member might have a senior resident, sometimes a junior resident, and sometimes maybe even no resident at all.

Anyway, I thought it was pretty interesting. Wouldn't happen for a long time, if at all, though.
 

droliver

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md03,

Actually Hallsted was the one who questioned "the way its always been done" methods of training & brought order to the chaos that was previously surgical training

I remember that article you refer to..... It left me thinking that the author was kind of removed from the realities of training @ large teaching hospitals. His "mentoring" style of program does not work well at many programs other then small "boutique" programs like the Mayo Clinic where you have a lot of super-tertiary care being (no trauma, no indigent, no VAMC patients) delivered with considerably more resources available then other training programs to offload work on the residents.

While I think the continuity offered by the author's suggestion would be nice sometime, the flexibility you give up from the resident POV is not worth it to me. I liked being able to work with 10-15 different surgeons in a week. While there are clearly some Doctors whom you could follow indefinately & never finish learning from, there are a great deal who have little to teach you beyond a certain level.....I can think of a few with whom I would go crazy if forced to be their "apprentice" for any length of time. I also enjoyed the near complete autonomy I had for large blocks of my 4th & 5th year, & I think you really grow up quickly (or your patients die) when that responsibility is dumped on you. A whole residency of being handheld like the author described would chafe on me a bit I think
 

mfleur

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Word of advice...be nice to the nurses for gods sake. Besides the fact that it makes you a bad person if you are not, they can make your life much easier. There's no I in TEAM people!!!
 

womansurg

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Originally posted by mfleur
Word of advice...be nice to the nurses for gods sake. Besides the fact that it makes you a bad person if you are not, they can make your life much easier. There's no I in TEAM people!!!
Although everything you've said is true...this post nonetheless makes me want to beat you to a pulp.



:)
 

Winged Scapula

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Originally posted by mfleur
Word of advice...be nice to the nurses for gods sake. Besides the fact that it makes you a bad person if you are not, they can make your life much easier. There's no I in TEAM people!!!

Repeat slowly, preferably in front of a mirror..."I"m good enough, and gosh darn it, people like me."

(Please excuse womansurg and I...our sarcasm has been stewed in years of the bitter broth of surgical training). ;)
 

droliver

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There's still a nurse at one of the hospitals here with a mad-on for me 6 years after we got into it during my intern year over something
 

womansurg

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Originally posted by droliver
...with a mad-on for me...
Haha! Is this a Louisville thang?

Gotta remember to start using that...
 

mfleur

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Originally posted by Kimberli Cox
Repeat slowly, preferably in front of a mirror..."I"m good enough, and gosh darn it, people like me."

(Please excuse womansurg and I...our sarcasm has been stewed in years of the bitter broth of surgical training). ;)

Bring it on...BTW are you ladies surgeons. People keep telling me that I should be a surgeon and I am wondering if I should be offended by that.
 

mfleur

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Wow...I didn't mean for that last statement to be so confrontational. But you guys know the rep that surgeons have. My only point is that being a bitch to the nurses does not accomplish anything. Yes, it may be fun but that's no excuse.
 

tofoo

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Whoa, Stop the nurse basting. There are no places for that in health care. We are a team.

I will now let you in on the Three Basic Laws of General Surgery.

1) Trust no-one including your mother-- always get a name.

2) Don't take "no" for an answer

3) If you are going to go down take someone bigger with you-- call the person above you.

Your friend should be checking on his/her patient at night and not just sleep in the hospital to wait for things to go bad. Surgery residency has gotten alot better than it use to be. The old days were q2 calls (that mean every other night)--they use to say it means "you will missed 50% of the operative experience". All residency have a 80hr/wk rule that is govern by ACGME. Most programs still go over this limit, but at least they are trying to reduce work hours. Some members of the American College of Surgeons have suggested to extend the residency period, but that will just prolong the pain. There are numerous purposal to help reduce work hours, and they are trying them now. Just give them a chance to pilot it.

You are way to young to be this whiney


I thought the three laws of surgery was:

1. Eat when you can.
2. Sleep when you can.
3. Don't mess with the pancreas.
 
B

Blade28

(1) Yes, those are the rules of surgery!
(2) Wow, a 3-year thread bump?
 

Knight_MD

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Why not take in one more resident into the program? Distribute more time, have a life. (financial reasons?)
 

iliacus

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Wow...I didn't mean for that last statement to be so confrontational. But you guys know the rep that surgeons have. My only point is that being a bitch to the nurses does not accomplish anything. Yes, it may be fun but that's no excuse.

Don't think that all nurses are sweet little angels that are battered around by overworked residents...Some bash the hell out of doctors...and ESPECIALLY residents whenever they can. I remember a venomous nurse who would call a certain IM attending "Fat, worthless, and incompetent," when in fact the guy was an excellent doctor and teacher. I finally got so fed up hearing the verbal attacks behind the attendings back that on my last day of the rotation I told her she wasn't very attractive herself and I'd seen better legs on a pool table.
 

boston

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Why not take in one more resident into the program? Distribute more time, have a life. (financial reasons?)

Minimalist hit the nail on the head. The answer is that learning surgery requires a certain amount of clinical and operative experience. Adding more residents dilutes this experience and leads to suboptimal training. The only solution is to reduce the inefficiencies and non-learning scut, e.g. by hiring PAs and NPs to help with floor work, paperwork, dictations, etc.

Otherwise, no matter how you divide up the work or the hours among residents, whether it's an 80 or 120 hour work week, the numerator and denominator don't change. In other words, it's the same amount of work, done by the same group of people. Hence, one of the few things that would improve education and improve lifestyle is to hire physician-extenders to help reduce scut

The answer is definitely not to extend the residency. Surgical residencies are a certain number of years because of the experience needed in the OR. The 120 hr work week has to do with floor work in addition to the OR experience. To cut the 120 hr work week, the slack has to be taken up on the floors. Many hospitals have taken to hiring PAs to do scut work such as ordering tests or scans, transfers, consults, etc. Believe it or not, some PAs can take overnight calls. All this will allow the residents to go home early post-call (like after signing out) or go home early on normal days because all the floor work is done.

Also, the answer to the 120 hr work week will not be adding another resident to the program because each resident must have a certain amount of allotted OR time, so residents cannot be added just to work on the floor, a program must be able to train that resident in the OR.
 

johnny_blaze

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I thought the three laws of surgery was:

1. Eat when you can.
2. Sleep when you can.
3. Don't mess with the pancreas.

you forgot 4 and 5

4. have sex when you can
5. Never lie to your boss
 

johnny_blaze

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if you want a longer residency with better hours move to europe or australia or new zealand... there the government limits your hours to 56 hours per week, (with plans in france and england to drop it to 48 hours/week)!!!! but in return your residency lasts 4-6 years longer.... i don't know about you, but i want to be my own boss by my early to mid=thirties....

The royal college of surgeons are trying to get the working times extended in surgery to ensure that surgical trainees attain enough experience. And with the new modernizing medical careers scheme in the U.K, consultant posts should be attainable within 8-10 years of graduating. Seeing as how the average med graduate here in England is 23 (about the same time you guys are applying to med school) you will be a consultant by your early 30s... and you'll get there comfortably. I was put off by general surgery in canada when one of the residents told me he hadn’t seen his children in over a week because he's been working so much. I think changes may need to be made if sacrifices like that are needed... but that's just my opinion.
 

mcindoe

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Why not take in one more resident into the program? Distribute more time, have a life. (financial reasons?)

sorry, boston, but Knight_MD was right (at least his guess was)....it's pretty much boils down to money.

every resident is very expensive, which seems perplexing at first to many given how meager their salary is and how many hours they work. but as long as there is no negotiation involved in the hiring process, the NRMP match, which has its pros and cons, will keep the wages where they are now.

but to get back to what i was saying, the cost of having a resident is far more than the 40-50K they get for salary....the program pays for many or most of your benefits, malpractice insurance, and other costs that i'm probably not even aware of, but to hire you costs them far more than what they pay you for salary, and most programs just don't have the money to afford it.

there may be some other reasons too, such as regulations that permit only a certain number of residents, and if they wanted another they'd have to formally request permission to do so...i don't know. but if they were able to pay for enough ancillary staff to take care of work that an M.D. shouldn't have to waste time doing, like filling out paperwork, then you'd be able to get all of the requisite training and satisfy all the requirements in probably less time than the current 5 year program length.

i challenge anyone to find any proof that a minimum of five years is absolutely necessary for adequate surgical training. five is an arbitrary number that has become the standard over time because no one bothers to question it and really evaluate if it's the most efficient or ideal way to train surgical residents.
 

boston

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sorry, boston, but Knight_MD was right (at least his guess was)....it's pretty much boils down to money.

every resident is very expensive, which seems perplexing at first to many given how meager their salary is and how many hours they work. but as long as there is no negotiation involved in the hiring process, the NRMP match, which has its pros and cons, will keep the wages where they are now.

but to get back to what i was saying, the cost of having a resident is far more than the 40-50K they get for salary....the program pays for many or most of your benefits, malpractice insurance, and other costs that i'm probably not even aware of, but to hire you costs them far more than what they pay you for salary, and most programs just don't have the money to afford it.

actually, most resident positions are not funded by the hospital or university, but funded by the federal government (Medicare) which uses a formula to pay both the direct costs of graduate medical education (salary, fringe benefits, attending physician compensation) as well as indirect costs (ordering more tests, longer patient stays, sicker patient populations, etc.)

Like you said, it's expensive to train residents -- if hospitals had to pay the entire cost themselves, there would be no incentive to train residents at all. (from a business standpoint, less efficiency versus a private hosptial) Basically, the government subsidizes resident training to provide an incentive to teach hospitals to train residents because there is a societal benefit that can't be quantified by the business bottom line. This is analogous to government funding of basic science research that is far removed from practical (profitable) applications that would be funded by industry.

there may be some other reasons too, such as regulations that permit only a certain number of residents, and if they wanted another they'd have to formally request permission to do so...i don't know. but if they were able to pay for enough ancillary staff to take care of work that an M.D. shouldn't have to waste time doing, like filling out paperwork, then you'd be able to get all of the requisite training and satisfy all the requirements in probably less time than the current 5 year program length.

Actually, we seem to agree. That is precisely what I am arguing. If you read my post carefully, I contend that the only way to reduce work hours, without extending residency length in years is to hire physician extenders to reduce the inefficient scut that eats up our time. Otherwise, hiring additional residents will just dilute your clinical and operative experience, unless you increase the hospital's operative volume proportionally. At our program, the trend the last few years is to hire PAs and NPs on each service to help out with the day-to-day floor work, so that you can be in the OR more.

The way residency is currently structured, I can't see finishing training in less than five years. The sheer volume of knowledge and experience to be acquired is enormous. If, however, we were able to get enough PAs and NPs to minimize time spent on scut and our time at the hospital focused solely on intensive educational activities (both within and outside of the OR), then I could see general residency being shorter than 5 years. (Imagine if all the hours spent retracting as an intern or junior resident were handled by a trained monkey, leaving you with the opportunity to spend these hours more productively...)
 

redsurgeon

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There was very interesting article in the ACS journal that came out sometime in the last 3-4 months. It addressed changing surgical residency format dramatically. The answer to making it more humane is NOT to extend it (I doubt very many of current surgical residents would be for that). However, the authors proposed making it more of a mentoring system, with each resident being assigned to a faculty mentor for several months at a time. I'm found the proposal very intriguing.

Isn't this the model used at MSU?
 

trauma_junky

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i can't believe this was resusitated after 3 years.
 

SocialistMD

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The way residency is currently structured, I can't see finishing training in less than five years. The sheer volume of knowledge and experience to be acquired is enormous. If, however, we were able to get enough PAs and NPs to minimize time spent on scut and our time at the hospital focused solely on intensive educational activities (both within and outside of the OR), then I could see general residency being shorter than 5 years. (Imagine if all the hours spent retracting as an intern or junior resident were handled by a trained monkey, leaving you with the opportunity to spend these hours more productively...)

We recently had a grand rounds presentation given by Dr. Dunnington, the chairman at SIU. He is one of the nation's leaders in surgical education and is basically on the forefront of how surgery will change in the future. His program's curriculum is very unique and I think the model for how surgical education will occur in the future; basically you must demonstrate proper technical skills in the lab prior to performing any such procedure in the OR. It improves the learning curve for the junior residents, speeds up OR time and is safer for patients. There was a great discussion about the future of surgical training and he seems to believe the 5-year mandatory training may not be the best way to train residents, but rather advancement through demonstrated knowledge and ability will be the way things are done. It would require a change from the ACS, but it is something that is possible.

The other idea floating around (at least at my institution) is that eventually everyone will fast-track into programs. All surgeons will have the same years 1-3, but each will then decide s/he wants to do CT or vascular or colorectal or transplant, etc..., and all general surgery residencies will look much more like the combined plastics programs than the 5 year programs they are now. There will be a "rural" surgeon tract for those who want to perform (what are now considered) general surgeon cases. Maybe I've been in the ivory tower too long, but it sounds like something that may come to fruition
 

Faebinder

Slow Wave Smurf
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We recently had a grand rounds presentation given by Dr. Dunnington, the chairman at SIU. He is one of the nation's leaders in surgical education and is basically on the forefront of how surgery will change in the future. His program's curriculum is very unique and I think the model for how surgical education will occur in the future; basically you must demonstrate proper technical skills in the lab prior to performing any such procedure in the OR. It improves the learning curve for the junior residents, speeds up OR time and is safer for patients. There was a great discussion about the future of surgical training and he seems to believe the 5-year mandatory training may not be the best way to train residents, but rather advancement through demonstrated knowledge and ability will be the way things are done. It would require a change from the ACS, but it is something that is possible.

The other idea floating around (at least at my institution) is that eventually everyone will fast-track into programs. All surgeons will have the same years 1-3, but each will then decide s/he wants to do CT or vascular or colorectal or transplant, etc..., and all general surgery residencies will look much more like the combined plastics programs than the 5 year programs they are now. There will be a "rural" surgeon tract for those who want to perform (what are now considered) general surgeon cases. Maybe I've been in the ivory tower too long, but it sounds like something that may come to fruition

Ya I was wondering how long will it take for this to happen. I was predicting that surgery in the future will become like Internal Medicine and its subspecialties.... Everyone goes into General surgery for 3 years (just like they do in IM) then you get to apply to surgery subspecialties if you want to specialize (just like in IM subspecialties)... otherwise it's the appendix/hernia/gall bladder for you.... (and whatever else you consider general surgery that remains in general surgery).
 
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