Mass Gen On Probation

[Winged Scapula]

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From the Globe today: http://www.boston.com/news/health/blog/2009/11/mass_general_su_1.html

From June 2009: http://www.boston.com/news/health/a...roup_cites_mgh_on_resident_surgeons_workload/

 

[Surgical FMG]

now this is interesting. i understand mass gen is quite famed for being a top notch program. correct me if im mistaken... will this hurt their applicant pool this year?

which other programs are on probation? AMGs are less likely to apply for these, so they might be good options for FMGs?

 

[Winged Scapula]

now this is interesting. i understand mass gen is quite famed for being a top notch program. correct me if im mistaken... will this hurt their applicant pool this year?

I highly doubt it...applications are already in (the deadline was November 1); those who get an interview at Mass Gen probably have other top notch places to choose from, remains to be seen how it will affect them in the match. But I suspect we'll never know...programs don't release how far down on their match list to fill.

Besides, its Mass Gen. People will rank them regardless of any probation.

which other programs are on probation? AMGs are less likely to apply for these, so they might be good options for FMGs?

The ACGME used to publish program probationary measures. You might check their website; a friend sent me the link I posted.

But if I were you I wouldn't necessarily be planning an attack which includes preferentially applying to programs on probation. A program on probation is in danger of closing...programs are not obligated to find you a position elsewhere if they close.

 

[SocialistMD]

Besides, its Mass Gen. People will rank them regardless of any probation.

Exactly. I think the residents that want to go there will probably wear it as a badge of honor- "We work harder than you and we do what's right for the patient no matter what hour," type of attitude. That's the mentality of the surgery resident that trains there, based on my (admittedly limited) experience.

 

[JackADeli]

now this is interesting. i understand mass gen is quite famed for being a top notch program. correct me if im mistaken... will this hurt their applicant pool this year?...

I doubt it will decrease number of applicants. In fact, especially in "big name" programs likely to be subsidized into compliance, it will likely not close down. I think there will actually be an increase in applicants within the next few cycles. Folks that previously thought they would not be competitive will likely believe the upper competitive applicants are avoiding "probation" programs and thus feel an opening may exist.... Furthermore, competitive applicants looking for "big name programs" but afraid of malignancy may now apply feeling a greater sense of protection via the umbrella of probation scrutiny....

The psychology of applicant choices can be vastly interesting.... in the end I don't anticipate MG not filling anymore then other reported "hardcore" programs.....

Just a final point, the "80 hour rule" changes are NOT new. We are talking about in excess of SEVEN years and still big name centers getting "surprise" citations. The fact that programs are still being cited and found to be in violation suggests that numerous programs are likely perpetually in violation. Things continue and/or fail to improve based on residents' action or inaction. It is just when a few residents stand up and behave honestly that programs get cited. If you lie then you are a liar regardless the "extenuating circumstances".

JAD

 

[Winged Scapula]

Exactly. I think the residents that want to go there will probably wear it as a badge of honor- "We work harder than you and we do what's right for the patient no matter what hour," type of attitude. That's the mentality of the surgery resident that trains there, based on my (admittedly limited) experience.

Agreed. Its Mass Gen and we see enough people on SDN impressed by that alone or who want to train at such a program, regardless of probation, work hours, etc.

I remember reading the June 2009 article and noting that the faculty at Mass Gen laid the blame on the residents, "why we just can't get these silly kids to go home. Its not the culture or the expectations of the faculty that they work a bazillion hours a week!" 🙄

 

[SouthernSurgeon]

Agreed. Its Mass Gen and we see enough people on SDN impressed by that alone or who want to train at such a program, regardless of probation, work hours, etc.

I remember reading the June 2009 article and noting that the faculty at Mass Gen laid the blame on the residents, "why we just can't get these silly kids to go home. Its not the culture or the expectations of the faculty that they work a bazillion hours a week!" 🙄

I also liked that in the more recent article, they reveal that their solution to going over hours was to cut their educational conferences down...

 

[7abiby]

Personally, I feel that people who were turned off by MGH's work conditions might be more interested now that they're on probation and likely to try to somewhat limit the work hours and hopefully hire more NPs/PAs.

Does anybody know how many applicants they interviewed last year? They're interviewing 30/day x 4 days which surprised me

 

[JackADeli]

...I remember reading the June 2009 article and noting that the faculty at Mass Gen laid the blame on the residents, "why we just can't get these silly kids to go home. Its not the culture or the expectations of the faculty that they work a bazillion hours a week!" 🙄

It's so amazing to me. The faculty, aka professors, aka ones in charge, blame the residents. God forbid they take responsibility and do their jobs as the individuals paid to run a residency. Instead they want to blame the residents for in effect.....

not running the the residency correctly.....
or
not being qualified program directors....

I would hope at some point the faculty/staff will look in the mirror and be to embarassed to make these claims... It would be like a surgeon saying the patient overdosed cause the nurse told me the dose and so I ordered too much. Or better yet,, "I didn't know the patient had a pneumothorax because the medical student told me the film looked OK".

Really, it's a declaration by the program director and faculty that:
a) they are not in charge of the residency
b) they are not in charge or aware of what residents are doing with patients
c) they are not in charge of their patients' care
Could a more embarassing set of declarations be made by any respectable physician? MassGen and the whole lot of them need to cowboy the *uck up and do their job!!!

The whole thing from attending whining to resident lying to blaming the janitor is really embarassing and nauseating. Of course, why expect anything less.... you have lousy conferences/academics (which are quickly cut) and when grads fail the boards, blame the residents, that you failed to teach. I see a pattern.

JAD

 

[Thanatos]

I highly doubt it...applications are already in (the deadline was November 1); those who get an interview at Mass Gen probably have other top notch places to choose from, remains to be seen how it will affect them in the match. But I suspect we'll never know...programs don't release how far down on their match list to fill.

Besides, its Mass Gen. People will rank them regardless of any probation.



The ACGME used to publish program probationary measures. You might check their website; a friend sent me the link I posted.

But if I were you I wouldn't necessarily be planning an attack which includes preferentially applying to programs on probation. A program on probation is in danger of closing...programs are not obligated to find you a position elsewhere if they close.

Which is why most (if not all) programs violate hours and will continue to do so. They know they won't be reported because even the residents that hate going over hours don't want to be unemployed.

The residents at MG will gladly take the blame for this if it will allow them to finish their training without having to re-match or beg for vacant spots. Can you imagine a bunch of harvard trained residents out there thumb wrestling for prelim spots in rural arkansas.

 

[JackADeli]

Which is why most (if not all) programs violate hours and will continue to do so. They know they won't be reported because even the residents that hate going over hours don't want to be unemployed.

The residents at MG will gladly take the blame for this if it will allow them to finish their training without having to re-match or beg for vacant spots. Can you imagine a bunch of harvard trained residents out there thumb wrestling for prelim spots in rural arkansas.

Yes, that perspective works for community and smaller programs.

However, it doesn't work for the big names. It is a bluff they play on the residents. Programs like Duke, MassGen, Brig, etc... will not close if probationed. They will deploy large sums and hire PAs & NPs. The community programs with a small number of residencies do close. The large programs as noted with multiple other specialties can NOT simply close GSurgery without a massive domino effect impacting the other residencies. Thus, big name program residents are NOT going to find themselves hunting for spots...

 

[Moonglow]

JAD has it exactly right. But, we now see residents bringing lawsuits against residency directors and chiefs. There is no way to know how the results of those suits (whether ajudicated or settled) will affect hospital board room decisions. The shock felt at Hopkins concerning the Serrano suit has brought on a substantial awareness of what the implications could be when "violating the rules" becomes practice.

 

[JackADeli]

JAD has it exactly right. But, we now see residents bringing lawsuits against residency directors and chiefs. ... The shock felt at Hopkins concerning the Serrano suit has brought on a substantial awareness of what the implications could be when "violating the rules" becomes practice.

I wanted to comment a little further and hark back to something I think I posted elsewhere previously....

It has already started to be published in surgery periodicals about attendings being removed from malpractice suits leaving the residents holding the bag. How? Well, the attendings are declaring a lack of awareness of what the resident did.... or more specifically, attendings declared/testified that the resident acted independently outside of supervision.

What are we looking at now? MassGen is declaring (aka washing its hands) that the rules were broken/violations occurred because the residents acted independently. By all accounts, at least within the legal system.... MassGen is right!!!!

Wait a minute now JAD; how can you say that? You got to be smoking something.... Well, I will spell it out for you.

MassGen and ALL other accredited residencies sign an agreement with ACGME stating they will abide by x, y, z, & 80hr/wks. I suspect all the faculty sign such a contract. I also suspect EVERY resident signs an agreement that they too will abide by the rules and regulations to include ACGME x, y, z, & 80hr/wks. Further, I suspect MassGen and most other residencies have trainees sign some document/s at certain periodic intervals attesting to their compliance. In essence, MassGen and other residencies are being excellent physicians with CYA skills.... they are documenting everything. So, at the end of the chain of signed contracts and agreements, were is the violation? It happens at the resident level. It is more often then not accompanied by a resident produced/signed fraudulent document.... i.e. resident lied.

Now, let's go to court when the patient died or had a complication. All that paperwork. The paper trail of contracts and agreements.... It all points to a young, immature dishonest trainee that was at the hospital unknown to the attending and endangering the patients out of pride and ego. (at least that is the easiest case made)

"Your honor, Trainee Dr. Smith signed this agreement with full knowledge that these limits on work are in place for patient safety. We have attendance records to show young Dr. Smith attended the required lectures on patient safety and fatigue as is required by the RRC. Dr. Smith fraudulently signed this document to trick his supervisors in believing he was following safe practices. Your honor, the preponderance of the evidence clearly shows that not only was Dr. Smith knowingly acting in an unsafe manner but systematically deceived his attending physician staff".

I assure you the continued violation citations with the ever increasing cry of the regulations being implemented for patient safety are not lost on trial attorneys. It is nationally known (or perceived by the ignorant) now that MassGen was in violation of these "safety rules". Let's see how many attorneys link this recent citation to the time frame their client suffered a bad outcome. Let's see, with computer records rampant, how long it takes for attorneys to confirm a resident in the hospital when their "punch card" supposedly shows they were not.

Folks, it is time for complete honesty. If one lies, you do so at your own choosing. Further, you greatly enhance the case to absolve your program and attendings of any responsibility. That's not "old-school"; it's STUPID school.

JAD

 

[JackADeli]

...The shock felt at Hopkins concerning the Serrano suit has brought on a substantial awareness of what the implications could be when "violating the rules" becomes practice.

it is an interesting read:

http://browngold.com/news/physician...r_lawsuit_against_johns_hopkins_complaint.pdf

Makes me ever more pleased to not have applied or even considered Hopkins. I wish the best for those that are there.

JAD

 

[7abiby]

Holy &*%$ that's totally messed up!
If half of what's in there is true, which I suspect it might be, this guy is going to win easy.

I don't think this sits well at all for Hopkins' program

 

[filter07]

it is an interesting read:

http://browngold.com/news/physician...r_lawsuit_against_johns_hopkins_complaint.pdf

fascinating. i like the part about cameron writing letters to other PDs. and the part about poor absites being common and chief res getting 5th percentile.
whistleblower blowback huh?
for shame.
i hope serrano gets every penny.

 

[JackADeli]

Holy &*%$ that's totally messed up!
If half of what's in there is true, which I suspect it might be, this guy is going to win easy.

I don't think this sits well at all for Hopkins' program

fascinating. i like the part about cameron writing letters to other PDs. ....
whistleblower blowback huh?
for shame.
i hope serrano gets every penny.

I would just hope he does NOT settle. I encourage him to take this to the mat. Unfortunately, attornies, even well intentioned will get eyes full of dollars and encourage a settlement. If this case has wings, Hopkins will slink around and offer up to even full asking just to settle without a judgement and under a confidentiality clause. I also found some websites discussing his current status. If I read it correctly, I think one of his attornies is already making comments to the extent of , "he really needs to get out of surgery and do another specialty...". I can see now a recommendation to accept some multimillion settlement and just do family practice and be happy....

I think with his credentials and the work he put forward, settling would be a mistake he would live to regret.... to the mat I say.

As for the claimed "Cameron letter".... pretty disgusting. It is kind of a reverse black-ball. It definately interferes with one's ability to pursue options when an institution is floating claims to an individual....

Also, how far do you think it will get before Hopkins starts to plan an exit strategy to cut bait and blame the attendings.... How far before ACGME starts feeling some pressure???? This can be huge. It could also really open things wide around the country for residents. Hospitals are places in which conduct is illegal in other industries is allowed, enabled, and sometimes encouraged.

JAD

 

[Winged Scapula]

fascinating. i like the part about cameron writing letters to other PDs. and the part about poor absites being common and chief res getting 5th percentile.
whistleblower blowback huh?
for shame.
i hope serrano gets every penny.

It was actually FIRST percentile - not that it makes much difference, as I would have expected more.

That's a devastating document JAD - thanks for providing the link.

 

[JackADeli]

it is an interesting read:

http://browngold.com/news/physician_files_multimillion_dollar_lawsuit_against_johns_hopkins_complaint.pdf

Makes me ever more pleased to not have applied or even considered Hopkins. I wish the best for those that are there...

...That's a devastating document...

I hadn't heard anything about this matter until the post earlier in this thread. The truth is that I encourage every resident from every specialty throughout to review and follow this case closely. It could have potentially wide sweeping impact.

The stories I hear from residents accross the country, often afraid they will be fired, often afraid to be honest, often accused of psychiatric disorders and being marginalized by their programs with amature psychiatric diagnosis from PDs & assistant PDs.... I wonder if they all get together at PD meetings to talk about "tricks" and "manipulation" techniques to keep residents in-line. Got to tell you the .... "required to be seen by psychiatrist/psychologist" and then telling others he was seeing mental health specialist.... well NOT an unusual theme. I have heard it on numerous occassions. I have seen females pushed out of residencies and vocal residents quieted with these techniques. If accurate, we are talking superstar, supernova track with three years stellar performance, NIH grants, etc.... abruptly tanked!!! It is frightening.

JAD

 

[Winged Scapula]

Ahh...guess you don't venture into the Gen Res forum much. It was talked about for several weeks there but I hadn't seen the document you found. You might find the thread of interest.

I have some vague recollection of someone telling me that at some national meeting (how's that for vague) for PDs that they *were* taught about disciplinary psychiatry and how to get rid of problem residents.

It really makes you feel like "but for the grace of God"...doesn't it? 😡

 

[njbmd]

I hadn't heard anything about this matter until the post earlier in this thread. The truth is that I encourage every resident from every specialty throughout to review and follow this case closely. It could have potentially wide sweeping impact.

The stories I hear from residents accross the country, often afraid they will be fired, often afraid to be honest, often accused of psychiatric disorders and being marginalized by their programs with amature psychiatric diagnosis from PDs & assistant PDs.... I wonder if they all get together at PD meetings to talk about "tricks" and "manipulation" techniques to keep residents in-line. Got to tell you the .... "required to be seen by psychiatrist/psychologist" and then telling others he was seeing mental health specialist.... well NOT an unusual theme. I have heard it on numerous occassions. I have seen females pushed out of residencies and vocal residents quieted with these techniques. If accurate, we are talking superstar, supernova track with three years stellar performance, NIH grants, etc.... abruptly tanked!!! It is frightening.

JAD

There is absolutely no accountability when it comes to a PD wanting to dismiss a resident for any reason-doesn't like the way the guy wears his hair. The PD does not have to provide proof of anything but present the resident with a letter charging that the resident didn't meet a specific criterion that was never discussed or clearly stated that their contract won't be renewed.

Only a few residency programs spell out specifically what residents should be accomplishing as they progress through the training years. The good programs will do everything possible to make sure that any deficiencies that a resident might have would be addressed and worked out.

A good PD is not "out to get the residents" but will attempt to provide the best training and learning experience that they can. Unfortunatly, most of the evaluations of residents are "subjective" and as I suspect in the case stated at Hopkins, have nothing to do with the ability of the resident but more to do with subjective (read political) problems.

Residency is certainly stressful enough without having to constantly "look over your shoulder" to see who is politically after you. Unfortunatly, the high profile residency programs have tons of politics and lethal personalities. The low profile community programs have tons of resident abuse which many FMGs willingly put up with in order to have a shot at practice in this country.

 

[filter07]

Assuming that the facts of the document are true, Hopkins really screwed themselves. They picked the wrong guy and AND picked the wrong time to fire him. To have this guy plastered everywhere on PR events, like photo-ops, Hopkins 24/7, and tours with visiting professors is one thing. But to fire the guy for poor ABSITE scores and not getting along with nurses... during the research years, after voting him intern of the year and awarding him an NIH T32... that's just poor decision making.

It just goes to show how much power residency programs have over us. This guy, at least on paper, comes as close to untouchable as far as residents go. Other than poor ABSITE scores, and what seems like one wrong-site surgery (which is really an attending problem, either due to not participating in the time-out or not being there at all), he is a surgical stud. For someone to think they can just fire a guy like him, during his research years of all times... seems pretty arrogant. I wish I had 1/10th the credentials of this guy, and even then I'd think twice about being more vocal about the abuse and BS we endure.

 

[JackADeli]

The following responses on my part are ALL opinions and/or hypothetical....

There is absolutely no accountability when it comes to a PD wanting to dismiss a resident for any reason-doesn't like the way the guy wears his hair. The PD does not have to provide proof of anything but present the resident with a letter charging that the resident didn't meet a specific criterion that was never discussed or clearly stated that their contract won't be renewed...

Actually, there are real employment laws, etc.... Further, given the intricacy and entwinement with federal funding... they technically do have to provide proof. The reason they don't in most cases is because the resident is left to feel defenseless and left to believe the PD is god and has no accountability. It is an atmosphere and aura of smoke and mirrors. Residents represent one of two things or even both.... They are either students or employees. Both have protections. But, as a student, one has wide protections that are akin to protections for children and elderly.... Students are regarded as "vulnerable" populations. The veneer and facade generated by PDs is the same one that leads residents to lie about hours, etc...

...It just goes to show how much power residency programs have over us. ...For someone to think they can just fire a guy like him, during his research years of all times... seems pretty arrogant...

They really don't have that much inate power.... rather it is bestowed upon them by resident fear. The arrogance is garnered over years of being on one side and then following historical models and expectations of the otherside. There are few other employments in the USA in which an employer van act as is suposedly to have occurred in this case.... I will also add, there are potential legal ramifications in requiring a trainee/student to seek mental health care and then disclosing to colleagues that said individual is receiving such care.....

If one chooses to lay down in front of a door and someone then walks upon you.... is because they have some power to walk on you or is it because you chose to lie down???

 

[VPDcurt]

Is it acceptable, at an interview, to ask what is being done to prevent a work hours violation in the future?

 

[SouthernSurgeon]

Is it acceptable, at an interview, to ask what is being done to prevent a work hours violation in the future?

All the advice I've received is that if you bring up things like work hours, vacation time, etc. it will give a bad impression - namely that you will be "high maintenance" and not someone who is ready/eager to put in the hard work

 

[JackADeli]

Is it acceptable, at an interview, to ask what is being done to prevent a work hours violation in the future?

while it should be OK... i.e. should be full disclosure and transparency.; unfortunately it is "not OK" to ask.

But, in reality, almost every program proclaims compliance and has a song and dance about how they are compliant and what the call schedule is like and how many PAs they have, etc.... So, there really is no utility to asking and asking may unfairly impact your application...

Ultimately, if you are going to ask questions at the interview, I encourage you to think about what will get you real information thus making the question even worth asking.... Most programs with the help of the residents are going to tell you a) how cush the program is, b) how compliant the program is, c) how great the ancillary staff is, and d) how all the residents truely and honestly really operate, really operate early in training, and really do most of the cases with oh so much autonomy..... So, it really is an exercise of little utility to ask any of the such questions as the programs' answers are already prepared and rehearsed and forthcoming even if you do not ask....

 

[Buzz Me]

Is it acceptable, at an interview, to ask what is being done to prevent a work hours violation in the future?

Probably not. If the interviewer even gets the slightest whiff of an applicant asking any variation of "do you guys strictly enforce the 80-hour workweek, or should I expect to bust my butt in this residency program", then...well, I'll let you draw your own conclusion.

 

[forbin]

it is an interesting read:

http://browngold.com/news/physician...r_lawsuit_against_johns_hopkins_complaint.pdf

Makes me ever more pleased to not have applied or even considered Hopkins. I wish the best for those that are there.

JAD

If this is really true, I hope he takes Hopkins to the cleaners in court. As much as we doctors like to complain about excessive lawsuits, this case sounds quite warranted.

 

[Thanatos]

Assuming that the facts of the document are true, Hopkins really screwed themselves. They picked the wrong guy and AND picked the wrong time to fire him. To have this guy plastered everywhere on PR events, like photo-ops, Hopkins 24/7, and tours with visiting professors is one thing. But to fire the guy for poor ABSITE scores and not getting along with nurses... during the research years, after voting him intern of the year and awarding him an NIH T32... that's just poor decision making.

This is the part that got me as well...you can't sing the guys praises for ~3 years and then turn around and fire him because...he sucks. Clinically. During his research year no less. Hypothetically, hopkins is supposed to have some of the best/brightest most creative thinkers on the planet, and thats the best they could come up with. Totally disappointing.

Even worse, Hopkins is in Baltimore. Have any of you ever been there? Holy ****! If there was ever a city conducive to planting a dead hooker and a suitcase full of drugs on somebody, baltimore would be it. And yet the best they could do was nursing complaints and absite?

Maybe an ivy league education isn't all its cracked up to be....

 

[lipomas]

That attorney brief was a fascinating read - would be very interested to know how they will justify their claims that he is "mentally ill" as well as their claims that he didn't perform up to standards when everything suggests to the contrary.

 

[JackADeli]

attornies can be quite creative.... but, when all is said and done a reckoning is in order. If this matter has any truth:

You have a guy that has a very long track record that begins long before his three years at Hopkins. By all accounts the track record was sound and even got high end grant/s. The track record apparently continued at stellar proportions for three years at Hopkins. Prominent surgery attendings at a prestigious university (Hopkins), apparently put him forward as the emissary for visiting dignitaries and even on a documentary/reality TV show. Prominent folks signed/attested to his clinical competence to enable him to moonlight... aka function independently in patient care at other institutions!!! He apparently has documentation/evidence from actual Board Certified Psychiatrist attesting to an absence of psychiatric pathology.

When all is said and done, in order to defend against these points, you may need to have these oh so prominent, oh so respected attendings admit they had been lying when attesting to his clinical qualifications to work independently and moonlight!!! That would be a shattering earthquake to say a residency program of such caliber is not being honest when releasing its grads upon society.

They may have to provide the ABSITE scores of all the preceding residents and current residents as well.

 

[SocialistMD]

I would just hope he does NOT settle. I encourage him to take this to the mat. Unfortunately, attornies, even well intentioned will get eyes full of dollars and encourage a settlement. If this case has wings, Hopkins will slink around and offer up to even full asking just to settle without a judgement and under a confidentiality clause. I also found some websites discussing his current status. If I read it correctly, I think one of his attornies is already making comments to the extent of , "he really needs to get out of surgery and do another specialty...". I can see now a recommendation to accept some multimillion settlement and just do family practice and be happy....

The only concerning thing is that it states he was fired 1 week after the anonymous ACGME letter was sent, but he had already been sent to counseling/therapy. It makes it seem like Hopkins had been working on this plan to get rid of him for a while, be he mentally disturbed or not. There is an information gap not seen in this document that would be nice if one wanted to put together the whole picture. He may not win several of the counts because they can show there was at least concern over his mental stability for a while and the firing was not temporally related to the letter (which is the basis for a lot of his claims). That said, it still sounds like there is a lot of suspicious stuff going on up there that should be brought into the light.

Edit: I just went back and redid the time line for myself and it makes more sense now.
May 08- ACGME meeting at which he speaks out.
July 08- Enters lab.
Jan 09- Upcoming site visit.
Early April 09- Site visit.
April 10- Fired.

The document isn't written completely in chronological order, which is what threw me. They could have started him in "therapy" after he initially spoke out or after the spot site visit was announced (in January), fearing that he might become or already is a problem. The fact that they made him take the mock orals in December 08 also kind of suggests they were building a case against him at that time. I wish they had listed the time point at which he was instructed to see the psychiatrist. Very interesting.

 

[dienekes88]

Bringing it back to the original topic, I was wondering what opinions were on the following articles in light of the hoopla about Man's Greatest Hospital violating workhours.

http://www.bmj.com/cgi/content/full/339/nov05_1/b4260
Opinion piece about workhours limiting the acquisition of skills by surgical trainees; mentions an observed decrease in the number of complex cases picked up by senior residents.

http://www.ejbjs.org/cgi/content/full/91/9/2079
Significant increase in hip replacement morbidity in teaching hospitals vs. non-teaching hospitals, pre vs. post workhours.

 

[SocialistMD]

http://www.bmj.com/cgi/content/full/339/nov05_1/b4260
Opinion piece about workhours limiting the acquisition of skills by surgical trainees; mentions an observed decrease in the number of complex cases picked up by senior residents.

Did you read the study from which that quote was taken?
Am J Surg 2005;190:947-9 (for those playing at home)
Here is the data table they gave:

Residents' operative experience in emergency laparotomy (mean +/- SD)
Group 1 (n = 6) Group 2 (n = 7)
Total experience as PS 101 +/- 13 vs 110 +/- 33
Advanced 51 +/-5 vs 31 +/- 13†
Basic 47 +/-8 vs 84 +/-19†
* Adjusted mean.
&#8224; P <.05.

Comparison of residents' operative experience as first assistant (Group 1 is pre-80 hours, Group 2 is post-80 hours).
Group 1 (n = 6) Group 2 (n = 7)
Total experience as first assistant 88 +/- 22 vs 58 +/- 14&#8224;
Learning role 36 +/-3 vs 18 +/- 4&#8224;
Teaching role 53 +/-5 vs 31 +/- 6&#8224;
* Adjusted mean.
&#8224; P < .05.

Okay, so it looks like they are doing fewer advanced cases. However, this was a study done at Ben Taub hospital, meaning every case (particularly trauma or emergent non-trauma) is covered by a resident. The number of cases being done isn't any different, they are just doing more basic cases than advanced cases. Is that because the attendings are doing the advanced cases by themselves? No, it is because there was a decrease in the number of advanced cases being done. They even admit that trauma volume was down for the second group:

In addition, when comparing the trauma experience, a correction was made for periodic differences in the total trauma operative caseload between the 2 study periods (523 versus 323 cases, adjustment coefficient = 0.38).

If trauma numbers were down to start with, one could argue that the number of advanced cases also went down, as suggested by the (insignificant) increase in the number of overall cases done and the increase in the number of basic cases done.

Another possibility, not addressed by this paper, is that more junior residents were doing the cases as primary surgeons than before. This paper only looked at the 4th and 5th year case logs from the two classes. Again, this is Ben Taub, a place where attendings rarely (if ever) operate without a resident, particularly on a big trauma lap. What they need to do is look at the overall body of work (PGY-1 to -5) from residents graduating pre- and post-80 hours and see if there is a difference. One of my classmates here did that with our data and found that there wasn't a difference except in the number of advanced laparoscopic cases (we are still in the 90th % nationally, for those med students reading this and wondering if they should apply 😉), and that is because we added an MIS fellow in that time frame (Baylor did not add a trauma fellow, so this, while a possible 3rd explanation for the number change, isn't applicable here)

The main thing to be gleamed from this paper is that the number of first assist cases decreases (meaning people aren't second scrubbing anymore), that residents aren't teaching residents in the OR as much anymore and that residents aren't doing their own takebacks. Does that decrease operative experience and is it an unfortunate casualty of the 80-hour work week? Yes and yes (and the third point is especially painful to me because I really do believe that is one of the best ways to learn from one's mistakes), but the conclusion that there is a decreased number of complex cases done can't be drawn from this data.

 

[JackADeli]

I just wanted to point out some facts.

1. EVERY accredited residency in the country has declared/guaranteed/reported they are/have been compliant with the ACGME rules/regulations/restrictions for at least up to five years now.
2. Almost all residencies have graduated at least ONE full class/contingent of residents trained under these rules regulations during their entire residency
3. In graduating individuals trained under these ACGME rules, all programs are expressly declaring COMPLETE training to competence
4. There are 100s of grads that have gone through said training with said restrictions that are now BOARD CERTIFIED.

I think the argument on numbers and quality of training, etc... is dead and killed by the residency programs themselves (despite their whining to the contrary) because they have succeeded in implementing by the very fact they are graduating candidates. I think continued whining while training and graduating residents is either a testament to dishonesty or just plain sour grapes on the part of programs......

JAD

 

[dienekes88]

Did you read the study from which that quote was taken?
Am J Surg 2005;190:947-9 (for those playing at home)
Here is the data table they gave:

Looked at it. A lot of it was beyond me.

Okay, so it looks like they are doing fewer advanced cases. However, this was a study done at Ben Taub hospital, meaning every case (particularly trauma or emergent non-trauma) is covered by a resident. The number of cases being done isn't any different, they are just doing more basic cases than advanced cases. Is that because the attendings are doing the advanced cases by themselves? No, it is because there was a decrease in the number of advanced cases being done. They even admit that trauma volume was down for the second group:

If trauma numbers were down to start with, one could argue that the number of advanced cases also went down, as suggested by the (insignificant) increase in the number of overall cases done and the increase in the number of basic cases done.

Agree. However, it does mention the decrease in Resident + Resident with attending "supervision," and an increase in Attending + Resident. So that effectively halves the total resident-operation experience on a certain kind of procedure, which would be whatever kind of procedure residents were allowed to do without that much supervision.

If you talk about 50 cases that were done by two residents in a year... that's a rate 100 resident-cases/year. Now an attending is scrubbed. That's 50 resident-cases/year.

Another possibility, not addressed by this paper, is that more junior residents were doing the cases as primary surgeons than before. This paper only looked at the 4th and 5th year case logs from the two classes. Again, this is Ben Taub, a place where attendings rarely (if ever) operate without a resident, particularly on a big trauma lap. What they need to do is look at the overall body of work (PGY-1 to -5) from residents graduating pre- and post-80 hours and see if there is a difference. One of my classmates here did that with our data and found that there wasn't a difference except in the number of advanced laparoscopic cases (we are still in the 90th % nationally, for those med students reading this and wondering if they should apply 😉), and that is because we added an MIS fellow in that time frame (Baylor did not add a trauma fellow, so this, while a possible 3rd explanation for the number change, isn't applicable here)

Interesting. The conclusion the paper came to was that the seniors were pinching from the juniors. I just assumed that the juniors were left:

1) holding themselves in the wind.
2) doing even more basic cases.

Would it make sense that the seniors weren't doing the cases as primary surgeon but the juniors were?

The main thing to be gleamed from this paper is that the number of first assist cases decreases (meaning people aren't second scrubbing anymore), that residents aren't teaching residents in the OR as much anymore and that residents aren't doing their own takebacks. Does that decrease operative experience and is it an unfortunate casualty of the 80-hour work week? Yes and yes (and the third point is especially painful to me because I really do believe that is one of the best ways to learn from one's mistakes), but the conclusion that there is a decreased number of complex cases done can't be drawn from this data.

I think the assumption on my part was that only senior residents were primary surgeon in advanced laparotomies (especially given the liability issues). Perhaps this is incorrect. I'm not sure how, though, if the seniors are directly pinching cases from the juniors.

 

[dienekes88]

I just wanted to point out some facts.

1. EVERY accredited residency in the country has declared/guaranteed/reported they are/have been compliant with the ACGME rules/regulations/restrictions for at least up to five years now.
2. Almost all residencies have graduated at least ONE full class/contingent of residents trained under these rules regulations during their entire residency
3. In graduating individuals trained under these ACGME rules, all programs are expressly declaring COMPLETE training to competence
4. There are 100s of grads that have gone through said training with said restrictions that are now BOARD CERTIFIED.

I think the argument on numbers and quality of training, etc... is dead and killed by the residency programs themselves (despite their whining to the contrary) because they have succeeded in implementing by the very fact they are graduating candidates. I think continued whining while training and graduating residents is either a testament to dishonesty or just plain sour grapes on the part of programs......

JAD

Isn't there a difference between "adequate" and "good"?

There's the phenomenon that you mention in your other post of people not having the confidence to do elective vascular (AAA, etc.) and doing fellowships for the experience.

Also, the decrease in autonomy, experience, etc. is part of the driving force pushing cardiothoracic surgery to move towards a integrated program. Of course, the other being reason is that nobody wants to do it... I guess they took a hint from the cigarette companies: hook 'em while they're young.

Eh. I'm a medical student in the generation of pass/hug classes (don't even have honors). Of course I hate working hard and welcome the decrease in hours. 😉

 

[JackADeli]

Isn't there a difference between "adequate" and "good"?

There's the phenomenon that you mention in your other post of people not having the confidence to do elective vascular (AAA, etc.) and doing fellowships for the experience....

Maybe....
But, when UofMichigan, Mayo, Cleveland, Stanford, Brig, MassGen, Duke, Hopkins, UVA, etc..... is declaring they are in compliance, and they are graduating residents..... do you think they say/declare they are graduating excellent surgeons? I suspect that is what they claim to applicants at interviews..... I very much doubt they tell applicants, "we are in compliance and while training just isn't what it used to be, you will be adequate when your done here at University x, y, z..."
I vaguely recall the common statement at all interview sessions...., "We have such a variety of cases.... you will get excellent training here...".

As for elective triple AAA, My points I believe is that you are training to be a GSurgeon; not a vascular surgeon. Currently, folks do around 5 of general followed by dedicated 2 of vascular.... It is a high end specialty. If you want it you should get the extra training. The fellowship isn't just for experience... it is for qualification.

JAD

 

[JackADeli]

...Another possibility, not addressed by this paper, is that more junior residents were doing the cases as primary surgeons than before...

Interesting thing to consider.... back when I started my GSurgery internship, the program coordinator logged our cases. We provided her with little slips of paper/mini-forms we completed with the name of patient, med-number, and what the case was and what our level of participation was. We were specifically instructed that as PGY1/intern you can NOT take credit as more then first assist (FA). We were told as a PGY1 is was not conceivable you could cognitively or techniquely meet the requirements as spelled out by ABS to take credit as primary/surgeon (I think it is "surgeon junior" or something).

Now, by the time I was a chief resident, ALL residents including PGY1/interns were taking full credit on all cases.... I even ran into conflicts on numerous occasions were PGY1s that scrubbed with me logged the case before I did and took full credit!!! It became common practice for some to even alter med-number on cases they double scrubbed so they could snatch credit for cases they joined/double scrubbed with a senior resident.

So, I am not sure we will ever have any good numbers to compare before and after. If one wants to graduate, you need numbers.... if the numbers are "not there" in the manner required by the ABS, I have watched them be "discovered" by PDs and the junior residents coming behind me.... It is all very sad.... folks lie about hours, lie about cases, lie and lie and lie...

JAD

 

[JackADeli]

...The document ...The fact that they made him take the mock orals in December 08 also kind of suggests they were building a case against him at that time...

One of the things that really bugs the hell out of me on this case... on the part of Serano is the ABSITE. By all accounts he has this superstar track record of hard charger, nose in the textbook, studying bookworm. His primary goal at being in any residency is to become trained in that residency. The only pseudo objective yardstick is always the inservice examination. He went off and engaged in research and moonlighting.... but he didn't take the in-service seriously enough to score well. The ABSITE if nothing else is quite repetitive and quite "study-able". After the first exam, he should have been practicing questions and reading. With his long CV, if there is anyone that should have been scoring well on this exam, it is him. Instead, he is moonlighting and apparently not taking the basic sciences/text book component of his training seriously. You are at a residency PRIMARILY for the residency training, not the social hours, not the research opportunities, not the other distractions. It is sad to see the consistent distraction from the focus on the primary objective. God knows, I have seen some less then stellar residents.... but with just a little bit of effort they achieved reasonable ABSITE results. With the 80hrs thing, days off, and etc.... why are we not seeing the effort (rhetorical)???

It doesn't loose him the lawsuit. But, this glaring component does tarnish him somewhat. He was in the lab, he is doing all this moonlighting, he is missing the objective. I encourage all residents to recognize, you need to set that 1hr a day or 1hr every two days aside to read/practice some questions, do the SESAPS, etc.... You just have to make the text learning a priority.

JAD

 

[SLUser11]

One of the things that really bugs the hell out of me on this case... on the part of Serano is the ABSITE. By all accounts he has this superstar track record of hard charger, nose in the textbook, studying bookworm. His primary goal at being in any residency is to become trained in that residency. The only pseudo objective yardstick is always the inservice examination. He went off and engaged in research and moonlighting.... but he didn't take the in-service seriously enough to score well. The ABSITE if nothing else is quite repetitive and quite "study-able". After the first exam, he should have been practicing questions and reading. With his long CV, if there is anyone that should have been scoring well on this exam, it is him. Instead, he is moonlighting and apparently not taking the basic sciences/text book component of his training seriously. You are at a residency PRIMARILY for the residency training, not the social hours, not the research opportunities, not the other distractions. It is sad to see the consistent distraction from the focus on the primary objective. God knows, I have seen some less then stellar residents.... but with just a little bit of effort they achieved reasonable ABSITE results. With the 80hrs thing, days off, and etc.... why are we not seeing the effort (rhetorical)???

It doesn't loose him the lawsuit. But, this glaring component does tarnish him somewhat. He was in the lab, he is doing all this moonlighting, he is missing the objective. I encourage all residents to recognize, you need to set that 1hr a day or 1hr every two days aside to read/practice some questions, do the SESAPS, etc.... You just have to make the text learning a priority.

JAD

Ironically, I think Serrano wrote several of the practice ABSITE questions in the Johns Hopkins ABSITE Question book, which I read before last year's ABSITE, and which I thought was a really horrible question book.

The funny thing about these super-intellectuals is their inability to answer straight-forward questions. Sometimes they become lost in the minute details and miss the big picture. I specifically remember thinking that book sucked because it consisted of too many trick questions, purposefully meant to mislead the test-taker...much like the PhD's did during our first 2 years of med school.

On a final note, as awesome as some people think Hopkins is, :::cough cough Danbo cough::::, I remember hearing from a co-resident that they saw several Hopkins residents at a Vegas ABSITE review course last January, where they admitted that as a whole the residency scores average to below average on the ABSITE, likely due to lack of emphasis, which is why they were in Vegas in the first place....


I think it's obvious that "Halsted Residents" are very smart, but maybe they don't find the ABSITE to be that important among their multiple other academic endeavors....

 

[Danbo1957]

My comments concerning the quality of Johns Hopkins Hospital residents are restricted to those who went through the Osler Internal Medicine Program. All I know about Hopkins Surgery is what I read or hear.

 

[dienekes88]

Maybe....
But, when UofMichigan, Mayo, Cleveland, Stanford, Brig, MassGen, Duke, Hopkins, UVA, etc..... is declaring they are in compliance, and they are graduating residents..... do you think they say/declare they are graduating excellent surgeons? I suspect that is what they claim to applicants at interviews..... I very much doubt they tell applicants, "we are in compliance and while training just isn't what it used to be, you will be adequate when your done here at University x, y, z..."
I vaguely recall the common statement at all interview sessions...., "We have such a variety of cases.... you will get excellent training here...".

Well, part of that has to be the dog-and-pony show they trot out. Just like every medical school says, "there is no gunner behavior; the students love it; they e-mail out study guides to one another; everyone is relaxed; 90% of our students score in the 90th percentile on Step 1; our average Step 1 is 278.."

As for elective triple AAA, My points I believe is that you are training to be a GSurgeon; not a vascular surgeon. Currently, folks do around 5 of general followed by dedicated 2 of vascular.... It is a high end specialty. If you want it you should get the extra training. The fellowship isn't just for experience... it is for qualification.

JAD

I thought you were referencing the fact that there wasn't enough exposure to these procedures or autonomy in residency to achieve a high degree of confidence in such operations. It's just something an attending at my institution mentioned, and it speaks to the trauma and complex laparotomies mentioned in the study I posted. It went from being two residents scrubbed on a case to an attending and a resident. One of the results has to be less resident-teaching, which people tell me is an important way of consolidating the things you've learned.

In light of that, maybe everyone thinks they're doing the best job of anyone considering the restrictions, so their personal belief is that they're turning out relatively excellent surgeons.

 

[JackADeli]

Ironically, I think Serrano wrote several of the practice ABSITE questions in the Johns Hopkins ABSITE Question book, which I read before last year's ABSITE, and which I thought was a really horrible question book.

The funny thing about these super-intellectuals is their inability to answer straight-forward questions. Sometimes they become lost in the minute details and miss the big picture....

The problem here is:
1. I suspect Serano has a track record of studying hard and scoring well on exams and standardized exams. I do not suspect he was a low scorer on the SAT, MCAT, or USMLE. I think he was some sort of honors college grad and an honors med-school grad to boot.
2. Once you take the ABSITE your first year... well the unknown is gone. That exam is pretty much the same exam the following year... with some questions being repeated in identical form every year. You can practice questions. There are question banks. You really can prepare for this exam especially after you get your first experience with what they ask and how they ask.

...I think it's obvious that "Halsted Residents" are very smart, but maybe they don't find the ABSITE to be that important among their multiple other academic endeavors....

That's exactly my point. he chose research and extra cash more important then learning the foundational textbook type knowledge important to becoming a board certified surgeon.... JHU may not have an atmosphere that emphasizes.... but the individual needs to understand they are making a choice that creates a documented score of their fund of knowledge and/or thought process. They make that choice and then ... well, JHU or any other program has it to do with it what they want. In this case they have a score in hand to declare him lacking. In this piece of the case, he handed them this weapon by his choice/s.

JAD

 

[blue2000]

Agree. However, it does mention the decrease in Resident + Resident with attending "supervision," and an increase in Attending + Resident. So that effectively halves the total resident-operation experience on a certain kind of procedure, which would be whatever kind of procedure residents were allowed to do without that much supervision.

If you talk about 50 cases that were done by two residents in a year... that's a rate 100 resident-cases/year. Now an attending is scrubbed. That's 50 resident-cases/year.

It's important also to reflect on the quality of teaching a senior resident can provide to a junior resident. As a junior resident I was often taken through cases by senior residents (who started pre-80 hour work week) and we struggled and flailed. They couldn't expose, struggled to communicate what they wanted me to do. I guess what I'm saying is quantity isn't everything. I also used to double scrub on cases when I could see little, was rarely spoken too, and helped with a very minor part of a long case. Now as a chief, I do the whole case with the attending, and I learn a ton on every case. My two cents.

 

[Winged Scapula]

My comments concerning the quality of Johns Hopkins Hospital residents are restricted to those who went through the Osler Internal Medicine Program. All I know about Hopkins Surgery is what I read or hear.

Geez Danbo...you got a Bat Phone that rings whenever your name is mentioned? 😉

 

[filter07]

While learning should be the primary objective in residency, I don't think studying for the ABSITE truly counts as learning. I took the ABSITE more seriously than most and consequently did better than average. But the questions on at least the junior ABSITE have very little do with good patient care or good judgment. Not only that, but the ABSITE is a truly brainless test that is very easy to study for, with the right materials. Whereas the USMLE exams push you to make reasonable guesses or decide on the best test or treatment, the ABSITE is a "know it or you don't" type of test. You can be tricked by a few buzzwords incorrectly applied on the USMLE, but buzzwords on ABSITE will get you very far. It is a stupid test in my opinion.

The only thing a poor ABSITE says to me is that someone didn't take the test seriously. I don't think that necessarily reflects badly on the resident, because not only is it mostly irrelevant to good patient care, most programs and attendings constantly dismiss its importance for fellowships or jobs.

 

[JackADeli]

While learning should be the primary objective in residency, ...but the ABSITE is a truly brainless test that is very easy to study for, with the right materials. ...the ABSITE is a "know it or you don't" type of test...

The only thing a poor ABSITE says to me is that someone didn't take the test seriously...

Exactly my points.... Yes, numerous programs declare and/or demonstrate how little they take it seriously.... but, it exists and can be taken seriously at their discretion. Obviously, if JHU has a track record of poor performance on the exam and poor emphasis on the exam... his score will potentially be washed out in the court fight. But, it really is a point of pride and to the lay person it may represent just that.... 1. he didn't take it seriously, 2. anyone, and especially someone with his caliber should and could perform on this "objective"/"standardized" exam... the only excuse being.... he didn't take it seriously, and when all is said and done, that is tarnish, cause he did select working for extra cash over putting forth the little effort to get a decent score!

Further, this is the scenario, suppose he wins, suppose he CHOOSES to not complete surgery residency. There still exists the JHU claim he lacked knowledge and there is the "objective exam" that supports that claim combined with the fact that he ultimately "dropped out".... it's all perception.

Finally, as I mentioned, a resident that believes the PDs and atmosphere that devalues the importance of the ABSITE does at their own peril. Plenty of PDs, that decide they don't like you (and maybe likes this other resident seeking transfer with publications, accolades.... and stellar ABSITE), have been known to suddenly "find" value in the ABSITE score. Also, ACGME when reviewing programs and considering adequate "academics" always asks about why are the inservice scores so low?????

JAD

 

[SocialistMD]

Let me start by stating that, while I have several friends at the BCM GS program, this is not based on anything they've told me and is rather my critical reading of an article.

Agree. However, it does mention the decrease in Resident + Resident with attending "supervision," and an increase in Attending + Resident.

As I stated, that is a problem. However, that wasn't the conclusion drawn from the initial article you posted based on the results of this study. I'm not denying that there have been some unfortunate consequences and compromises in our training as a result of the 80-hour workweek, I'm simply stating that the conclusion drawn by the article you cited and that you put in your post can't be made based on the article cited as the source of said conclusion.

Now an attending is scrubbed.

This is a separate issue, as the attending is, by law, required to be scrubbed for the "critical portions" of the procedure if s/he is to bill for it. Fifteen years ago, many residents operated with residents and the attending may be somewhere in the hospital. Some programs in my home state were slow to enforce that rule and have been reprimanded for it, as that is no longer allowable in today's world.

Interesting. The conclusion the paper came to was that the seniors were pinching from the juniors.

I disagree. See below.

Would it make sense that the seniors weren't doing the cases as primary surgeon but the juniors were?

In a word, yes. As I stated, there is no way an attending is operating without a junior on a big trauma lap. They corrected for total numbers of trauma explorations- that means one of two things happened. Either (a) there were fewer advanced cases that came in (be it from more conservative management of liver and spleen blunt trauma or just people being nicer in Houston [doubtful]) or those cases are being done with someone not an R-5 or R-4. Since they didn't look at the R-1 to R-3 data in this paper and didn't hire a new fellow in this time period, it is most likely that the R-3's were doing more trauma cases. In the past, it was most likely that an R-4/5 did every trauma lap. Now, the R-3's (and, possibly R-2's) are added into that pool. It is conceivable that an R-3 was the most senior resident available to do a trauma laparotomy.

I remember at my medical school, chief residents took in-house trauma call on a rotating schedule with the R-4s. Similarly, when I was an intern, the chief residents at my current program rotated taking in-house trauma call on Saturday. Now, our chief residents do not take trauma call at all (an adjustment made to help keep them 80-hour compliant). As a result, all of our trauma exposure comes as an R-3 and R-4. Since only 50% of those residents are actually part of this study's demographic, I'm sure the R-4/5 trauma numbers of our residents would look down when compared to the year before my intern year and my intern year, but that would be expected, as our R-5s will log, by design, zero trauma laparotomies this year.

I'm not sure how, though, if the seniors are directly pinching cases from the juniors.

Again, I don't think they are. It is tough to pinch a case when you aren't there.

...back when I started my GSurgery internship, the program coordinator logged our cases. We provided her with little slips of paper/mini-forms we completed with the name of patient, med-number, and what the case was and what our level of participation was. We were specifically instructed that as PGY1/intern you can NOT take credit as more then first assist (FA). We were told as a PGY1 is was not conceivable you could cognitively or techniquely meet the requirements as spelled out by ABS to take credit as primary/surgeon (I think it is "surgeon junior" or something).

Now, by the time I was a chief resident, ALL residents including PGY1/interns were taking full credit on all cases.... I even ran into conflicts on numerous occasions were PGY1s that scrubbed with me logged the case before I did and took full credit!!! It became common practice for some to even alter med-number on cases they double scrubbed so they could snatch credit for cases they joined/double scrubbed with a senior resident.

This is something else entirely. When I operate with an attending, no other resident is present and I'm "doing" the case (including being walked through it rather than doing it independently with an occasional suggestion from the attending), I log it. There have been several cases I've been in with a rather "handsy" attending that I didn't log. I've never poached a case from a senior resident-I simply log them in my book but don't put them in the computer. The only issue I've had was when I was doing the lower extremity of a skin graft with the attending while the senior was doing the upper extremity (solo) and plastics was doing a rotational flap/graft on the other leg. In that case, we all had to alter the MR number by 1 to each take credit for the case that each of us did. Otherwise, I personally haven't had this issue (like you said, it is lying, and I try to avoid that).

 

[dienekes88]

Let me start by stating that, while I have several friends at the BCM GS program, this is not based on anything they've told me and is rather my critical reading of an article.

As I stated, that is a problem. However, that wasn't the conclusion drawn from the initial article you posted based on the results of this study. I'm not denying that there have been some unfortunate consequences and compromises in our training as a result of the 80-hour workweek, I'm simply stating that the conclusion drawn by the article you cited and that you put in your post can't be made based on the article cited as the source of said conclusion.

Got it. There's the trauma confounding variable.

I took the following quote at face value:

"First, our results show that under the new regulatory environment, senior residents perform significantly less advanced, technically demanding, emergency procedures. At the same time, simpler cases traditionally delegated to the junior members of the team are now taken over by the upper level resident on call. This fundamental shift in the distribution of operative experience between senior and junior residents has not been previously reported, yet its effect is clear from our data."

However, your explanation was pretty thorough, and I see where you're coming from. Thanks.

This is a separate issue, as the attending is, by law, required to be scrubbed for the "critical portions" of the procedure if s/he is to bill for it. Fifteen years ago, many residents operated with residents and the attending may be somewhere in the hospital. Some programs in my home state were slow to enforce that rule and have been reprimanded for it, as that is no longer allowable in today's world.

I disagree. See below.

In a word, yes. As I stated, there is no way an attending is operating without a junior on a big trauma lap. They corrected for total numbers of trauma explorations- that means one of two things happened. Either (a) there were fewer advanced cases that came in (be it from more conservative management of liver and spleen blunt trauma or just people being nicer in Houston [doubtful]) or those cases are being done with someone not an R-5 or R-4. Since they didn't look at the R-1 to R-3 data in this paper and didn't hire a new fellow in this time period, it is most likely that the R-3's were doing more trauma cases. In the past, it was most likely that an R-4/5 did every trauma lap. Now, the R-3's (and, possibly R-2's) are added into that pool. It is conceivable that an R-3 was the most senior resident available to do a trauma laparotomy.

I remember at my medical school, chief residents took in-house trauma call on a rotating schedule with the R-4s. Similarly, when I was an intern, the chief residents at my current program rotated taking in-house trauma call on Saturday. Now, our chief residents do not take trauma call at all (an adjustment made to help keep them 80-hour compliant). As a result, all of our trauma exposure comes as an R-3 and R-4. Since only 50% of those residents are actually part of this study's demographic, I'm sure the R-4/5 trauma numbers of our residents would look down when compared to the year before my intern year and my intern year, but that would be expected, as our R-5s will log, by design, zero trauma laparotomies this year.

Again, I don't think they are. It is tough to pinch a case when you aren't there.

Side note: is your co-resident publishing that data about the operative numbers? Esp. including analysis of post-op morbidity (the hip-replacement paper talked about increased rate of morbidity post-80 hours in teaching vs. non-teaching hospitals)? I'd like to read about it.