Resident autonomy

Discussion in 'Surgery and Surgical Subspecialties' started by SteadyEddy, Dec 27, 2008.

  1. SteadyEddy

    SteadyEddy Senior Member
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    For the 3's and up, do you guys perform major operations (ie. whipple procedure) with other residents or only staff? Good to speak with you all again.

    SE
     
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  2. Winged Scapula

    Winged Scapula Cougariffic!
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    Depended on the service and what needed coverage.

    As an example, I did a fair few Whipples as a 3rd year because my Chief was off interviewing for fellowships. On other services, I might double scrub with the Chief and the attending, or do the case with the attending alone. It really varied from service to service and what else was going on. As a rule though, we had little autonomy (ie, no doing cases without an attending around).
     
  3. Smurfette

    Smurfette Antagonized by Azrael
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    Hi SE!

    Well, it depends on what you consider a major operation. Whipples---no way, none of our attendings would be comfortable letting residents do that on their own, and would definitely be scrubbed. (that being said, I've been left alone in a whipple but did not do any major resections or anastomoses until the attending came back) Other cases, it depends on the attending and which hospital we're at.

    Trauma ex laps and thoracotomies residents do on their own; if the patient is in extremis or if the residents struggle, the attending will scrub in. The attending is *usually* in the OR throughout a case, although not always, depending on the situation (i.e. multiple major traumas going on).

    Choles, hernias, straightforward cases (bowel resections, etc.) at one of the institutions we rotate at are usually 5s retracting for the 3s and helping the 3s through it. Depending on the attending and the surgical indication, we would start an ex lap and the attending would scrub only for the "crucial" part of the case or to "take a quick look".

    At our other hospital, it is attending dependent but 90+% of the time the attending is there the whole time. Exceptions are port a caths or breast cases (including mastectomies) which usually a senior resident will do either by themselves or with a junior resident.
     
  4. thunder hawk

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    I have been in a couple of residency interviews recently and most of them were community hospitals. One thing which they were selling about their program was the fact that their residents start operating earlier as compared to residents in university programs. They say that at university hospitals there are a lot of fellows who tend to do all the major cases and residents do not get the same autonomy as residents in community hospitals where there are no fellows. I went to a hospital where residents scrubbed in OB/GYN, ENT and ortho cases. Residents in community hospitals mostly do private general surgery practice in small areas after graduation and they want hands on experience on every clinical case which they may encounter during their private practise.so in a way it helps them ........So do you think that resident autonomy and especially how early residents get autonomous depends upon the type of program they are in i.e community vs university hospitals???
     
  5. SLUser11

    SLUser11 CRS
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    Here is a recent similar thread.

    In my experience, there isn't a cut and dry difference between community and academic autonomy. Both categories contain good and bad apples.

    There are community programs where you operate from day one, but you are truly a first assist until PGY-3, or even later, and your level of autonomy is limited by your private practice doc's level of comfort with their patients. There are other programs where the resident has excellent autonomy, and does not rely heavily on the staff for complicated cases.

    There are academic programs where the PGY-3 is walking the intern through a hernia while the attending reads a book. There are other programs where the PGY-3 is retracting while the staff does the hernia. In a program I'm familiar with from away rotations, a PGY-5 couldn't do a simple hernia without the staff coming in to help.

    I guess overall the academic programs will have a dichotomous mix of programs with low operative caseloads and poor autonomy....and programs with crazy high caseloads, and scary, probably inappropriate levels of autonomy.

    Community programs will generally provide you with more operative cases and better overall hands, but as mentioned previously....many times.....you can teach a monkey to operate. You need to focus on the quality of surgical education at the different programs.
     
  6. ESU_MD

    ESU_MD Old School
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    So very true...

    In my experience at a community program, there was seldom a time when a resident was left in the OR alone for any significant part of an operation. The interns are in the OR all the time, but they are first assistants. This gives the wrong impression to alot of applicants, who tend to be disappointed after realizing that this. It is not uncommon for interns to log 30 carotids, but they have never dissected the plaque or sewed a patch in.

    Of course, PG 3,4,5 will open, setup the booky and close solo.

    Now that I'm done gen surg, weirdly enough it is probably actually BETTER to scrub with staff while you are still training.

    Private surgeons have private patients, plus not to be underestimated is the culture of the institution. In my old joint, if an attending TRIED to leave the OR during the case, they would make a big deal about it, write-ups, etc.. In fact, the nurse beaurocrats are trying to make it so that the attending has to be scrubbed prior to skin incision!

    If you want to be alone in an OR as a resident, the best place is a VA hospital. but even that is starting to change
     
  7. SLUser11

    SLUser11 CRS
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    I agree 100%. As an intern at a university-affiliated community program, I participated in 452 procedures, including everything from CVLs or chest tubes to liver resections (although I'm didn't log several of the smaller things, so probably more like 500). However, in my "Defined Category Surgeon Junior" role, I had 112 cases. I think it is because I'm relatively anal about what I need to do to consider it my case. In particular, I needed to be doing the entire dissection to count certain things...not just 51% of the case. So, for a lot of the cases, including almost all the colons, and several of the vascular cases, I logged them as first assist.

    Bovie-ing between the attending's right angle is not doing the case, obviously, but some people still log these, or are even forced to log them in order to get their numbers.

    As a PGY-2, my comfort level increased, as did my autonomy in the OR. I logged 578 procedures. Four months of Trauma ICU means that a lot of these were lines, tubes, bolts, etc, so they don't count toward a defined category, but I also logged 279 defined category surgeon junior cases, including basic and complex laparoscopy, thyroids, colons, carotids, etc. Still, when I didn't feel that I did the critical portions of the case, I wouldn't count it.

    So my personal experience in the OR included an appropriate level of graduated autonomy up to this point. I am sure that there are other residents in the same program that get more and less autonomy, and it's probably based on the amount of trust you develop with your staff.

    I am a firm believer in the quality of my program, so I can't say that my experience is the community program norm, but I would be doubtful of residents from academic programs who claimed similar numbers. If they do, then I congratulate them on finding "one of the good ones."


    As for the VA, I spent time there this year as a PGY-3, and I agree that there is a lot of autonomy, but I don't find the experience as necessary here as I did in St. Louis because we're not lacking that autonomy in the private sector. I do, however, believe it is invaluable due to it's abundance of advanced and sometimes neglected pathology.
     
  8. Agreed that the VA or county hospital systems are where most residents gain the most autonomy.
     
  9. sponch

    sponch Senior Member
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    I'm at one of those programs on the west coast and logged similar numbers to yours. If you're going to an academic program, try to get one with university, county, VA, and community rotations. That way you get a good mix. At our university hospital, there are very few choles but tons of complex hepatobiliary. On the other hand, the community hospital where we rotate does 700-800 choles a year and the county does about 600. At the county there are so many trauma laps that chiefs are walking second years through them while the attending hangs out.

    When interviewing, ask the residents what they're actually doing in the OR. Firing the Endo-GIA after the attending or chief does the dissection on a nasty stuck down appendix requires only the ability to squeeze.
     
  10. Agreed that for a good mix, a strong program should have:

    *University hospital
    *County hospital
    *Children's hospital
    *VA
    *Community/private hospital
     

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