Should the duration of surgical training be increased?

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PediBoneDoc

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I am just posting a question. Should the duration of surgical training be increased? Let’s put money aside, which we can talk endlessly about, cheap labor etc. But, with some of the restrictions with the 80 work week, will surgeons and other procedurally related subspecialties get enough practice to be competent when the complete training?

The question is already being raised by different medical boards, hospitals and insurance companies. And I can tell you that something that will be coming down the pipeline. Your credentials may be based on you numbers of cases. (Surgery case logs etc)

Numbers are down, but I don't think it has to do with the 80 work week so much, because not a ton of important surgery is done at night (besides trauma, infections, etc). It probably has to more with having to leave early during the week, missing cases. So, it is just a question. All opinions welcome. :)

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I'm not a surgeon, nor do I pretend to want to be one. But the training I've seen at various surgical residencies seems......inefficient. Especially on the technical end of it.
 
I don't think training should be lengthened, just made more relevant. It seems like there is sort of a push to have integrated residency/fellowships, which makes sense. I don't know much about the European system, but I think that you start out in a CT or Vascular program instead of doing general surgery then specialty training.

ENT, Ortho, Urology, and Plastics (some) have done this effectively - why not CT, Vascular, Peds, etc? If you spend more time doing the specialty that you intend on pursuing, you will see and do more cases that are relevant to your field. I still think that the first 2 years should be in a general surgery program. Also, after the first 2 years, a few months a year of general surgery rotations could be included in the sub-specialty training.

This might even attract more people if they knew that they didn't have to do a full general surgery residency before they were able to concentrate on what they really wanted to do.
 
Not a surgeon, either.

The hospital I'm at now has Ortho residents averaging about 40 hours per week (beyond the PGY-2 year). The hospital where I completed medical school had Ortho residents averaging 80 hours per week.

There is no contest over which residents can operate better - which isn't really surprising to me in the final analysis.
 
the european system is different and overall longer training. so i won't go into the specifics.

i am in orthopaedics, so i do know about tailoring to a specialty. and i would agree that the are a lot of inefficiencies in surgery. the problem is how to increase the speed of technical skill developement. for us, it is not until surgeons are well into their 3rd or even 4th year othopaedic (PGY-4 or 5) that they get "the vision." to see without seeing, the foresite, anticipation. the more they operate the quicker this comes. the less, well you get the picture.

i speak about some of the development of a surgeon, I watched Greys anatomy .... Let's Operate ,just to discribe some of the learning process. developing technical skill is different than developing medical knowledge.

i know that more operative time improves this ability. some are quicker than others. and i know when a young surgeon begins to have the vision. ahhhh, everything begins to make sense.
 
I don't think training should be lengthened, just made more relevant. It seems like there is sort of a push to have integrated residency/fellowships, which makes sense. I don't know much about the European system, but I think that you start out in a CT or Vascular program instead of doing general surgery then specialty training.

ENT, Ortho, Urology, and Plastics (some) have done this effectively - why not CT, Vascular, Peds, etc? If you spend more time doing the specialty that you intend on pursuing, you will see and do more cases that are relevant to your field. I still think that the first 2 years should be in a general surgery program. Also, after the first 2 years, a few months a year of general surgery rotations could be included in the sub-specialty training.

This might even attract more people if they knew that they didn't have to do a full general surgery residency before they were able to concentrate on what they really wanted to do.


It's those very first 2 years that are the MOST INEFFICIENT of the years of training. More paperwork than training. There is no way around this unfortunately, because the teaching programs are not that many for those subspecialties. Most subspecialties have become their own specialties... look at vascular surgery.. moving from a subspecialty after general surgery to a specialty of their own, becoming more efficient.
 
hire more pa's and np's so that residents can do more meaningful work...oh wait, that would require institutions spending money.

-tm
 
most institutions have hired more PA's and NP's. I have 2 PA's and an NP. It does not increase the resident case volume though.

people are always complaining about busy work. paperwork, discharges, etc.. you know, i spend more time afterhours on "busy work" than i ever did as a resident. unfortunately it never ends.

but, TxMed, you do have a point.

the thing is you still need to learn how to take care of patients. so, when are you supose to learn that?
 
Wow, I guess I'm out of the loop. I thought 5 years was enough time. How far have the numbers been dropping? Is it that bad that they'd consider adding time?
 
I'm just a 3rd year student but it seems to me like part of the problem is how little freedom surgical residents are given to make mistakes. It seems like they constantly have someone looking over their shoulder or the attending holds the right angle while they bovie, or shows them where to tie or place the suture exactly. I have heard that in the "old days" there was more learning by doing and suffering the consequences of mistakes. Unfortunately, i suppose those mistakes can be huge. Maybe the threat of litigation means attendings must be more hands-on?
 
I've got a novel idea - how about reducing the volumes of paperwork that have somehow grown to take longer than the exam itself. That may open up more cases and allow for more patients to be seen...
 
The surgery program at my school went from 5 years to 7 years with 2 "research years" - I think they switched 2 years ago or so. It did fill, but I heard concerns voiced that they wouldn't be considered by candidates wanting fellowships, etc, due to the extra time. Since its such a recent change, only time will tell... if they keep enough of them there to see a difference (it seems to be a quasi-pyramidal program with residents with great surgical skills/knowledge who don't test well being eliminated/held back) - enough to be noticable to the casual med student who has absolutely no interest in general surgery:) ).
 
If only they payed residents what a person of that level education deserves, this will not be an issue for debate. For me, an 8 year residency with slave wage falls under the "go f&ck yourself" column.
 
you all have good comments and questions:

first off, dutchman. holland is such a nice calm country. be nice. i stated in the begining we are not going into the wage issue. i think that is a whole lecture series in itself and not simple to answer because it affects more than just the hospitals. it affects medicare as well. most people just look at the costs of how much it cost for one resident ~$75-80,000 depending on the resident year. there are other factors that come into play. if you think about any job, everytime an employee leaves and they have to hire a new emplyee that is attrition and it costs the company money. if you look at a 3 year program, the worker (resident) attrition rate is 33%. the costs would kill most busnesses with the retraining, etc. so the over all costs are more than ~$75-80,000, but the true value some fancy math guy needs to probably figure it out.

tired mom, i think the research thing is truely cheap labor and a way of require folks to help faculty publish and get ahead in the academic world. i thin the research year should be a choice. we have a reseach year. we do get the residents invoved in some clinical activity and they are on the call schedule so it lessens the burden of everyone's call, and it keeps them from becoming clinically stale.

NinerNiner999, i wish there was less paper work. just wait. there are FMLAs, worker comp, school forms, insurance forms, medicare forms, :eek: ... it is endless. if you can fix that we would all be greatful.

THP, the hands on approach that most surgeons have now is for several reasons. you make a mistake, it is our malpractice; so many are less comfortable taking that risk. secondly, the HCFA guidelines require surgeons to be there for the key parts of the surgery. so, staff have to be present and depending on the hospital the rules may be more strict.

finally, Mayhem, the numbers are down. it does depend on the program. the elective case volume goes down. it depends on the call system. is it a night float system (which i particularly hate, because they are babysitters and not much operating occurs) or a regular call system (the people have to leave when the elective cases are being done). some programs are better than others. the problem is that if you don't get a lot of operating time as a junior, then you want to operate more as a senior. the juniors then opertate less and so on.

i don't know thank for all the good input so far
 
you all have good comments and questions:

first off, dutchman. holland is such a nice calm country. be nice. i stated in the begining we are not going into the wage issue.

Sorry if I came accross the wrong way. I was not refering to you BTW. How can you talk about more years of residency without talking about pay? Remember that every single year in residency, residents pay for their training by way of loan interests. Kind of like paying tuition, only to the wrong person. There are limits to the number of hours residents can work in europe(way lower than 80 hours in some cases), but they get their training done in about the same time(give or take 1 extra year). Not to mention that residents in Europe(Like holland and U.K) actually get payed overtime for extra work.
 
I don't see case numbers going down because of the new 80 hour work week. Unless cases go uncovered, the numerator is still the same cases and the denominator is still the same number of residents. The months you are on night float are made up for, but the other busier operative months. It should all even out in the end.

I think cases are down because technology is evolving -- minimally-invasive techniques, IR (percutaneous drainage of abscesses, gastrostomy tubes, etc.), percutaneous angioplasty / stenting / atherectomy for PVD instead of bypasses for example.

I think many graduates feel ill-prepared to enter independent practice and for this reason choose to get further training in fellowship years.

Not only are cases down, but clinical experience in pre and post-op management is suffering as well.
 
i knew holland was a nice country. the reason i didn't want to make this a money forum is because that really is another topic. "how it increase resident wages?" complicated. and the european system is actually down to (i think) 48hr work weeks (for both attending and resident). they are definitely seeing a decrease in the case volume.

as far as decrease in case volume, things i do see. we don't have enough people to cover everything. definitely no double scrubbing cases. this decreases experience of learning from other resident and increases access to rare cases.

i do a number of cases all by myself :(. so lonely. the other thing that suffers is surgical residents obviously prefer the OR. so the clinics go uncovered. this decreases their experience with postop out comes and surgical decision making.

so many things, good feedback, all
 
I actually think that it should be made shorter, perhaps with a mandatory attached fellowship of some sort that makes it the same length again. If board certification came earlier, maybe the threat of litigation for a BC surgeon would be less, and they could actually train with some autonomy. I'd actually be a little bit scared today to be operated on by some of the surgeons just graduating from some of the modern programs. It has nothing to do with the surgeons, but the fact that the programs watched them with such a severe CYA attitude for the entire residency that they don't feel comfortable operating autonomously. People will have to make some mistakes some time. It is better if this happens in the sheltered residency environment, where someone who knows how to fix it is available.
 
I don't see case numbers going down because of the new 80 hour work week. Unless cases go uncovered, the numerator is still the same cases and the denominator is still the same number of residents. The months you are on night float are made up for, but the other busier operative months. It should all even out in the end.

I think cases are down because technology is evolving -- minimally-invasive techniques, IR (percutaneous drainage of abscesses, gastrostomy tubes, etc.), percutaneous angioplasty / stenting / atherectomy for PVD instead of bypasses for example.

I think many graduates feel ill-prepared to enter independent practice and for this reason choose to get further training in fellowship years.

Not only are cases down, but clinical experience in pre and post-op management is suffering as well.

While I agree that the influx of IR and GI doing cases has reduced some for surgical residents, I cannot agree that the 80 hr work week hasn't had an effect. As someone who lived through the transition, it seemed clear to me that by going home post-call, you missed cases...in the old days, we stayed until the end of the work day and did cases, hence the number was higher. We also didn't have night float.
 
i knew holland was a nice country. the reason i didn't want to make this a money forum is because that really is another topic. "how it increase resident wages?" complicated. and the european system is actually down to (i think) 48hr work weeks (for both attending and resident). they are definitely seeing a decrease in the case volume.

as far as decrease in case volume, things i do see. we don't have enough people to cover everything. definitely no double scrubbing cases. this decreases experience of learning from other resident and increases access to rare cases.

i do a number of cases all by myself :(. so lonely. the other thing that suffers is surgical residents obviously prefer the OR. so the clinics go uncovered. this decreases their experience with postop out comes and surgical decision making.

so many things, good feedback, all

My question for you is: How are the Europeans able to acheive good training with that much fewer hours? Seems strange that they are able to train their doctors with half the hours our Academia is whinning is not enough. IMO, the training of residents is not efficient, and a big part of it is exploitation.
 
My question for you is: How are the Europeans able to acheive good training with that much fewer hours? Seems strange that they are able to train their doctors with half the hours our Academia is whinning is not enough. IMO, the training of residents is not efficient, and a big part of it is exploitation.

Because in many cases, their training is can be nearly twice as long.

Everyone does 1-2 years after graduation from medical school doing general medicine - it includes surgery, EM, IM, etc. rotations. After that you become a medical officer (the RMO) and finally the Registrar. During this period, which can extend 3 or 4 (or more) years, you then apply for specialty training which, if you actually get a position the first year you apply (many competitive specialties or those with few spaces, have applicants apply several years in a row), extends for a few more years.
 
tired mom, i think the research thing is truely cheap labor and a way of require folks to help faculty publish and get ahead in the academic world. i thin the research year should be a choice. we have a reseach year. we do get the residents invoved in some clinical activity and they are on the call schedule so it lessens the burden of everyone's call, and it keeps them from becoming clinically stale.

I agree completely - and 2 years of required research seemed pretty darn steep, especially to throw on people who were already in the program when the change went through. A funny twist though, some of the ones doing research years have chosen to do them in an away setting, which still doesn't help with the call situation... just makes them gone for 2 years in the middle of their residency. So I really don't know. There's been some pretty big shakeups in the faculty recently, not sure if this is involved or not.
 
Not a surgeon, but from what I have seen, the people who worked in the old system had a different work ethic and more confidence than the current entrants. It just stands to reason that limiting work hours will slow down your learning curve, for better or worse.
 
I'm just a 3rd year student but it seems to me like part of the problem is how little freedom surgical residents are given to make mistakes. It seems like they constantly have someone looking over their shoulder or the attending holds the right angle while they bovie, or shows them where to tie or place the suture exactly. I have heard that in the "old days" there was more learning by doing and suffering the consequences of mistakes. Unfortunately, i suppose those mistakes can be huge. Maybe the threat of litigation means attendings must be more hands-on?

Not being a surgeon and having friends and family who have undergone surgery, I have to say that I am ok with close supervision and hand-holding for as long as it takes. Yeah, it may take longer that way, but people deserve not to be training grounds for unsupervised inept.
 
Not being a surgeon and having friends and family who have undergone surgery, I have to say that I am ok with close supervision and hand-holding for as long as it takes. Yeah, it may take longer that way, but people deserve not to be training grounds for unsupervised inept.

Understandable, but without some autonomy, it can be very difficult when you are faced with doing those procedures on your own. I think the lack of autonomy is a factor in why so many residents choose fellowships - there is a world of difference between someone holding the tissue for you and boving between it and actually making the decisions and actions yourself.
 
While I agree that the influx of IR and GI doing cases has reduced some for surgical residents, I cannot agree that the 80 hr work week hasn't had an effect. As someone who lived through the transition, it seemed clear to me that by going home post-call, you missed cases...in the old days, we stayed until the end of the work day and did cases, hence the number was higher. We also didn't have night float.

Maybe so, but I know how I am when I've been up for that long and I shouldn't be driving a car let alone cutting open a person.
 
Not a surgeon, but from what I have seen, the people who worked in the old system had a different work ethic and more confidence than the current entrants.

This is a common, albeit contentious, argument. I see a world of difference between the ethic and attitude of my Chiefs when I was a junior resident and the classes now. But of course, none of the current residents will accept that there may be a change - just that the "old guys" always say they had it harder.
 
Understandable, but without some autonomy, it can be very difficult when you are faced with doing those procedures on your own. I think the lack of autonomy is a factor in why so many residents choose fellowships - there is a world of difference between someone holding the tissue for you and boving between it and actually making the decisions and actions yourself.

Agreed. I am definitely for residents learning autonomy and having to make decisions and live with the consequences. But there still needs to be someone there to nix the really dangerous stuff and clean up the inevitable messes.
 
Agreed. I am definitely for residents learning autonomy and having to make decisions and live with the consequences. But there still needs to be someone there to nix the really dangerous stuff and clean up the inevitable messes.

I don't disagree with you - the total lack of supervision is wrong. But what is happening in surgical residencies is that, even at the Chief level, residents may stand on the "operating side" but are essentially just following the moves of the attending. It isn't all about learning to make decisions (albeit that is an important step), but actually physically learning to do the procedures and THEN, also learning to teach the procedures to junior residents. More and more Chief residents are finding that the lack of autonomy makes for a difficult transition to a surgical practice.
 
I'm not a surgical resident but I don't think extending surgical residency is the answer. It should be more subspecialized - and if anything, shorter. I found that most surgical residencies have 4th-5th years doing all the cases while the 1st-3rd years manage the floors. It seems no more than 1 year should be spent managing the floors, if that, as it doesn't prepare anyone for actual surgery.
Britian's system is completely different than ours and medical school/postgrad training is longer, but they go to med school right out of high school - so 12+ years of more schooling (all in medicine) is not really unreasonable.
Here, many people don't go to med school until much later, and if training length was equal to that in Britain, someone who starts med school at age 28 wouldn't practice until 40, if not later. I think this would be a major obstacle and would drive students away from surgery.
 
looking at the discussion there are some wonderful things being discussed and it is why i started the thread.

first off, dr. cox brings up something i see as well, the young surgeons do not know any different and when told they will not get as good of training, they say, "oh, so we have to spend all our time here and have no life to be a good surgeon." if you are a young surgeon or surgery wannabe, and you have said that statement, YOU HAVE MISSED THE POINT.
This is a common, albeit contentious, argument. I see a world of difference between the ethic and attitude of my Chiefs when I was a junior resident and the classes now. But of course, none of the current residents will accept that there may be a change - just that the "old guys" always say they had it harder.
this is the point they miss. it is about work ethic. and work ethic does not mean you have to spend hours in the hospital. it means when you are in the hospital, you actually work hard..

second there is the discussion about autonomy. this started to change in the mid 90's with HCFA and increases in malpractice. away went true resident clinics and cases. now we have to be present for the "keyu portions of the procedure". those are the rules. have a resident make a mistake and it may cost you millions. i personally believe that there are true resident cases. cases that they can not do harm and if they get into trouble you can bail them out. i believe this is when you let them struggle. figure it out how to get out of a tough situation. i won't scrub unless they call mercy. i said in another forum that i heckle and they really got on me for saying that, may be i should have said teased. the purpose is to take soe of the pressure off and make light of the situation. i just did a case with a chief level resident. simple case, but it humbled him. he learned and you can almost feel his growth. i fear that the more resident that become attendings out of the new system, the more hands on they will be and this means even the less experience.

so these are difficult questions to answer. the growth of a surgeon and not be forced. you can not read about it. simulations do not do it justice. you have to do it.
 
Besides assumptions and speculations, is there anecdotal evidence suggesting 80hr/week residents are not well prepared to practice? All this sounds like academic medicine is once again strapping on her dildo, and looking for who to screw.
 
Besides assumptions and speculations, is there anecdotal evidence suggesting 80hr/week residents are not well prepared to practice? All this sounds like academic medicine is once again strapping on her dildo, and looking for who to screw.


I'm afraid that until the first class of 80/hr week residents graduates from surgical training (class of 2008), we won't really know, and everything is anecdotal at this point.

Recent article regarding operative experience as a function of the reduced work hours:

Carlin AM, Gasevic E, Shepard AD. Effect of the 80-hour work week on resident operative experience in general surgery. Am J Surg, 193 (2007), 326-330.
 
The surgery program at my school went from 5 years to 7 years with 2 "research years" - I think they switched 2 years ago or so. It did fill, but I heard concerns voiced that they wouldn't be considered by candidates wanting fellowships, etc, due to the extra time. Since its such a recent change, only time will tell... if they keep enough of them there to see a difference (it seems to be a quasi-pyramidal program with residents with great surgical skills/knowledge who don't test well being eliminated/held back) - enough to be noticable to the casual med student who has absolutely no interest in general surgery:) ).

just wondering if the rumors about "this program which will not be named" having 17 go unmatched are true? it seems like the **** has really hit the fan as of late. i also heard they went much, much, much further down their rank list to fill than in years past. if residency is indentured servitude, then 2 years of "research" is slavery. sad times


-tm
 
...most people just look at the costs of how much it cost for one resident ~$75-80,000 depending on the resident year. there are other factors that come into play. if you think about any job, everytime an employee leaves and they have to hire a new emplyee that is attrition and it costs the company money. if you look at a 3 year program, the worker (resident) attrition rate is 33%. the costs would kill most busnesses with the retraining, etc. so the over all costs are more than ~$75-80,000, but the true value some fancy math guy needs to probably figure it out...

I am not a "fancy math guy" but I do understand business and your comments on the cost of retraining are wrong. First of all, you are confusing the business aspects of residency training with the educational aspects. It is perfectly obvious that surgical residents are next to useless for the first several years of their training as they need constant supervision in the OR. They are lacking in education for the job of a surgeon and need the five or six years to get up to speed.

But they are not being paid to be surgeons. Aside from the educational aspects of the job, the hospital wants the warm body to fill a slot on the call schedule and handle the huge volume of pedestrian but intricate clerical duties for which they would otherwise have to hire another doctor or a mid-level. There is no "Cost to Retrain" for those duties as the recent medical school graduate shows up legally ready to stand call, sign orders, and make decisions. If this weren't the case then you would never run the risk of pulling call your very night as an intern (which I did). As there is a natural progression from intern to second year and so on, the hospital, barring the usual attrition, has a steady stream of low-paid physicians in the pipeline to cover the duties assigend to them comensurate with their level of training (their actual degree of training is irrelevant for the most part because if they meet the minimum standard, they can be a warm body).

A "Cost to Retrain" implies that the hospital is footing the bill for the initial training (which they are not as medical school tuition is paid by the resident) or that there is some unusual or unlooked for cost in losing an employee who cannot be replaced except by hiring somebody and training him from scratch which is not the case in residency training (especially because, as you are so fond of pointing out, if a program loses a resident the other residents are forced to cover the work that needs to be done).

In short, there is no "retraining cost" for a residency program incurred by either losing residents through attrition or graduation. There may be a training cost (lost productivity, extra support staff) but as we have discussed before, this is more than covered by the average of $110,000 per year that a typical hospital gets for every resdent, not even taking into account the economic advantages to the hospital of paying a physician 10 bucks an hour for work that they would otherwise have to pay a mid-level or another physician 50 to 120 dollars per hour.

The attrition you talk about doesn't exist. In the case of residency training it is people who are a commodity and are therefore fungible, meaning that to your hospital, one intern is no different from another and for the economic duties they are assigned, they might as well be clones.

It's even worse for non-surgical specialties like mine where on top of saving the hospital money, we actually generate revenue almost from the beginning.
 
I don't disagree with you - the total lack of supervision is wrong. But what is happening in surgical residencies is that, even at the Chief level, residents may stand on the "operating side" but are essentially just following the moves of the attending. It isn't all about learning to make decisions (albeit that is an important step), but actually physically learning to do the procedures and THEN, also learning to teach the procedures to junior residents. More and more Chief residents are finding that the lack of autonomy makes for a difficult transition to a surgical practice.

Definitly agree with this point. I too, trained with the transition of pre-80hr work week to post-80-hr work week. One of the great benefits that I enjoyed pre-80 hours was being able to do loads of cases with my chief resident teaching me the case (most often in the middle of the night). There were more residents in the hospital during the day (no night float which takes residents out of the day pool) and if you are the night float, you are going home and missing cases during the day.

I have my case numbers but as a chief, I rarely get to be the teaching resident to the junior resident but many of my attendings have actually required that I "teach" the case to them as they corrected me along the way. Some won't do much and let me totally handle the case with a medical student. It's rocked my world a couple of times but I understand the transition that I have to make and I actually do feel some trepidation at being an attending (and autonomous) in a few months.
 
Panda Bear, welcome.

as i said at the begining, this was not a forum for discussing something you really like to talk about. the discussion about payment for residents and what a resident is worth. i can tell you i true fact, when there is resident turn over and new residents come, there is a slow down in the basic working of the hospital. "don't get sick in july." this is because of all the new hires. call it whatever you want. i don't disagree that residents salary should be increased. ok, an off the money subject again.

back to the topic at hand. for the sugical specialties, the first year really is to help with your understanding of patient care. in orthopaedics, we switched to a transitional type year, because the gen surgeons use to take advantage of those not in categorical positions and would place them on transplant for months and on services which did not help out in orthopaedics. as a surgeon, it is extremely important to understand both how to evealuate a patient and then learn surgical technique.

the question then becomes when are they ready to operate .... i will finish this thought later. i have to go operate. my residents are literally trying to work me to death.
 
From talking to several attendings I know I have heard an interesting theory about changing surgical training. Instead of making everyone do 5 years of general surgery and then X years of fellowship, there is apparently a move to make surgical residency 2-4 (different people use different numbers) years long, and then make the fellowship period much longer. This won't change the number of years required to become a CT/Trauma/whatever surgeon, but will mean that future CT surgeons don't have to spend 5 years playing in the belly. They will get the 2-4 years required to learn the basics of that body cavity and the general "theory" of surgery, and then the rest of their time will be spent learning their trade. I would love to hear thoughts on this from people who know more than I do, but as a prospective surgeon, this is an idea I like.
Thanks in advance for your comments...
 
From talking to several attendings I know I have heard an interesting theory about changing surgical training. Instead of making everyone do 5 years of general surgery and then X years of fellowship, there is apparently a move to make surgical residency 2-4 (different people use different numbers) years long, and then make the fellowship period much longer. This won't change the number of years required to become a CT/Trauma/whatever surgeon, but will mean that future CT surgeons don't have to spend 5 years playing in the belly. They will get the 2-4 years required to learn the basics of that body cavity and the general "theory" of surgery, and then the rest of their time will be spent learning their trade. I would love to hear thoughts on this from people who know more than I do, but as a prospective surgeon, this is an idea I like.
Thanks in advance for your comments...


I think in theory this sounds good, and a few integrated programs for those dead set on becoming a ______surgeon right out of medical school is probably a more effective way to go. The problem is that somebody coming out of Medical school with 3 months (on the high side) of trauma may think its the greatest thing in the world but may have never seen a CABG or a parathryroidectomy. Now you're locked in to a track to become a trauma surgeon when really you don't know your ass from a hole in the ground. If you had a seperate match after 2 years of GS this could be avoided but I haven't heard anyone talking about this.
Also, what do you do for those first two years? Are you expecting University programs to start getting people in the OR right away, It'll never happen. Now all of a sudden you have spent ZERO time "playing" in the belly developing operative technique and hopefully a sense of responsibility and you're moving on to a specialty. Now this may be doable but imagine the transition where we have a current fellow after 5 years of GS trying to gain operative experience in his field and some 3rd year that can't do ANYTHING comes along and starts trying to get cases under his belt at a snails pace.

I think condensing training is going to be the trend but I also think its unfortunate and may not work out quite the way people want it to.
 
From talking to several attendings I know I have heard an interesting theory about changing surgical training. Instead of making everyone do 5 years of general surgery and then X years of fellowship, there is apparently a move to make surgical residency 2-4 (different people use different numbers) years long, and then make the fellowship period much longer. This won't change the number of years required to become a CT/Trauma/whatever surgeon, but will mean that future CT surgeons don't have to spend 5 years playing in the belly. They will get the 2-4 years required to learn the basics of that body cavity and the general "theory" of surgery, and then the rest of their time will be spent learning their trade. I would love to hear thoughts on this from people who know more than I do, but as a prospective surgeon, this is an idea I like.
Thanks in advance for your comments...

Right now, we are still making the transition from pre-80-hour work week to post-80-hour work week and evaluating the effects of that change. It is likely that once complete evaluation of the surgical training experience under new work hours system is done, there may be some changes in the wind. As Dr. Cox so eloquently stated, "The 2008 class" will be the first class to be completely under the 80-hour work week system.

There are plenty of programs out there that are not even in compliance with the 80-hour work week system and thus the "jury is still very out" as to how the system NEEDS to be changed or IF the current system needs to be changed.

Currently, most categorical surgical residents do their major abdominal cases in their fourth and fifth clinical years. If for example, my program went to a 3 + 2 training program for vascular surgery, I would have missed many major abdomial cases because I would have moved over to vascular surgery.

Now one could argue that my vascular attendings could teach me the techniques of doing major abdominal cases but not to the extent that operating with an experienced colo-rectal or general surgery attending any more than a colo-rectal or general surgeon would enjoy teaching the techniques of thoracic surgery. As time passes, things will change as change is the nature of medicine. Right now, I am happy that I have the experiece that I have gotten before I head off to fellowship.
 
just wondering if the rumors about "this program which will not be named" having 17 go unmatched are true? it seems like the **** has really hit the fan as of late. i also heard they went much, much, much further down their rank list to fill than in years past. if residency is indentured servitude, then 2 years of "research" is slavery. sad times


-tm

PMing you!
 
Panda Bear, welcome.

as i said at the begining, this was not a forum for discussing something you really like to talk about. the discussion about payment for residents and what a resident is worth. i can tell you i true fact, when there is resident turn over and new residents come, there is a slow down in the basic working of the hospital. "don't get sick in july." this is because of all the new hires. call it whatever you want. i don't disagree that residents salary should be increased. ok, an off the money subject again.

back to the topic at hand. for the sugical specialties, the first year really is to help with your understanding of patient care. in orthopaedics, we switched to a transitional type year, because the gen surgeons use to take advantage of those not in categorical positions and would place them on transplant for months and on services which did not help out in orthopaedics. as a surgeon, it is extremely important to understand both how to evealuate a patient and then learn surgical technique.

the question then becomes when are they ready to operate .... i will finish this thought later. i have to go operate. my residents are literally trying to work me to death.

Except that I submit to the rules of SDN and am properly contrite when chastised by the moderators, I pretty much post where I want on SDN. Most people do. I'll stack my close to 8000 posts against your 53 and note that there is probably something here or there in some of my posts that a few people might want to read.
 
Except that I submit to the rules of SDN and am properly contrite when chastised by the moderators, I pretty much post where I want on SDN. Most people do. I'll stack my close to 8000 posts against your 53 and note that there is probably something here or there in some of my posts that a few people might want to read.

dr. bear, thank you for pointing out that you have posted more than i. you have put me in my place like so many of those attendings you so detest. i quiver in your presents.

you know i have no issues with you. post what you want. i'm tired, my residents have worked me to the bone. oh, see in my program, the residents kind of double team their poor attending. adding cases on, making me run 2 rooms, then leaving for lecture and taking their wife to dinner. damn those residents. my typical summer day, a morning run, 9 cases, and a resident lecture (where i actually expected them to have read before lecture and i asked i think 6 questions, i'm a malignant pimper :) ).

to all, those who thing i am here on some ego trip (particularly mr. bear). i am here to learn from you all. i have minimal access to medical students, because pediatric othopaedics is not a core (i am not sure why). so, i have questions. there are things passed from faculty to faculty that are most likely wrong. i have recently discovered these forums (i am usually on orthogate). so i post. i ask questions. i respond. i realize i do not know everything. i don't pretend to be an expert at everything. i know what i know and that's about it.

for me, i am proud of my profession. i love what i do. i love teaching and learning. i smile everyday i come to work. i laugh at myself everyday. i learn something everyday, even from that panda guy. he brought up resident salaries. he's got me looking up things and questioning our GME to figure out where they get the salary numbers from. hmph ... and who would ever listen to that panda guy.

all of you who have posted, you all rock (even dr. bear). it's time for bed, goodnight moon .... :sleep:
 
Definitly agree with this point. I too, trained with the transition of pre-80hr work week to post-80-hr work week. One of the great benefits that I enjoyed pre-80 hours was being able to do loads of cases with my chief resident teaching me the case (most often in the middle of the night). There were more residents in the hospital during the day (no night float which takes residents out of the day pool) and if you are the night float, you are going home and missing cases during the day.

I have my case numbers but as a chief, I rarely get to be the teaching resident to the junior resident but many of my attendings have actually required that I "teach" the case to them as they corrected me along the way. Some won't do much and let me totally handle the case with a medical student. It's rocked my world a couple of times but I understand the transition that I have to make and I actually do feel some trepidation at being an attending (and autonomous) in a few months.

If you have a night float system, then, yes, perhaps the 80 hour rule does cause residents to lose numbers. However, in my program, we don't have nightfloat, are pretty much in compliance with the 80 h rule, and, as an intern, I have done quite a few cases. For example, one hernia, one masectomy, two breast biopsies, all yesterday. And, I got do most of the case with the teaching of the attending. It was awesome. So, maybe your programs just aren't structured right. In our program, our residents go on out rotations and do a TON of cases. Blaming your numbers on the 80 hour rule is pathetic. You guys just need to change your structure. Period.

And, more than 5 years, please, give me a break. :thumbdown: It's more than enough. All it takes is some sacrifice on the part of the HOSPITALS and the freaking administration to provide midlevel help to residents so that they spend less time on bull**** paperwork and more on meaningful work. Just one PA to help out with discharge notes, social work issues, putting in orders, and you would save so much time every ****ing day. When are people going to stop lowering their heads and taking the abuse and start thining progressively to change this miserable system. If you people who are seniors still have this viewpoint, of course, why would PDs or administration would ever want things to change.

Take the issue of women's right to vote. I'm sure you could have heard people whining about how women now were too liberated and had too much freedom, and the amount of time they spent in the kitchen was reduced after having been given the right to vote. I'm sure a study could have come out to say that yes, they did spend less time in the kitchen cooking, because, they were out voting. So, that proves that voting makes women less skilled at cooking, because, hey, they just aren't getting the numbers in the kitchen. Do you people get it now, is it simple enough? Does voting now have decreased your skills in the kitchen? Let's vote to this. Anybody want to go back to the old days?
 
...as an intern, I have done quite a few cases. For example, one hernia, one mastectomy, two breast biopsies, all yesterday.

While I agree that we can't place the blame for falling cases totally on the 80 hr workweek, those of us that have lived through "the change" do see that residents, especially the junior ones, are doing fewer cases. And yes, the structure of the programs do need to change to accomodate the changes in the work environment.

It is great that you are operating and I hate to be the bearer of bad news, but only the mastectomy "counts" towards your case total for the ACS/ACGME if you were Surgeon Junior (ie, did more than 50% of the case). That's the trouble with a lot of junior resident cases :hernias, appys, biopsies, etc. - they don't count for ACS. Hernias only count if they are laparoscopic and breast biopsies not at all. Your program coordinator should be able to give you the list of what counts and what does not, or you can look at it here:
http://www.acgme.org/acWebsite/downloads/oplog/440CatMin.pdf
 
While I agree that we can't place the blame for falling cases totally on the 80 hr workweek, those of us that have lived through "the change" do see that residents, especially the junior ones, are doing fewer cases. And yes, the structure of the programs do need to change to accomodate the changes in the work environment.

It is great that you are operating and I hate to be the bearer of bad news, but only the mastectomy "counts" towards your case total for the ACS/ACGME if you were Surgeon Junior (ie, did more than 50% of the case). That's the trouble with a lot of junior resident cases :hernias, appys, biopsies, etc. - they don't count for ACS. Hernias only count if they are laparoscopic and breast biopsies not at all. Your program coordinator should be able to give you the list of what counts and what does not, or you can look at it here:
http://www.acgme.org/acWebsite/downloads/oplog/440CatMin.pdf

That's not the point here. The argument against the 80 hour rule is that it decreases resident case load which would then generate less skillful surgeons. I don't care if the cases don't count and I'm well aware of it, no links needed, thanks. All I"m saying is that I'm already getting cases (not to show off, just making a point) regardless of working less than 80 hours and it's helping me develop skills early on. Ultimately, my level of skill upon graduation will be dependent on my level of aptitude, willingness to learn, and natural talents, if there are any (which I am not saying there are). I don't even understand how tired residents post call are supposed to develop skills.

As a bodybuilder, I apply the rules of training to everyday life. It's well accepted that athletes develop better when given optimal rest and nutrition. I would think that well rested residents that come to work ready to learn with a healthy mind and body are better geared towards learning the fine surgical techniques and acquire dexterity required to do well during operative procedures. I think most would agree with that.
 
In respect to residents not graduating with the correct skills to become a comfortable attending that isn't a product of "only" working 80 hours. I think it is a product of faculty not adjusting to the 80 hour week. Not the 80 hours, not lazy residents. I wonder if any curriculum, not schedule, but actual curriculum changes have been implemented because of the 80 hours? I'm guessing not many. Once the residency curriculum has adjusted to 80 hours then I think that graduating residents will be more confident.
 
i think many people get caught up in the whole 80 hr work week issue. i don't think that is a major issue. most things should be able to be done well with in the 80 hr work week. most programs, at least the 4 programs that i have been involved with on resident selection committees and curriculum committees, have developed ways of compensating for the restrictions with in the 80 work week. what we have done is hire PA's to help on the floor and in clinic as well as take some of the call load off of the residents. my department covers 3 hospitals (a university, a children's, and a private hospital); the residents cover the university and children's (as part of their trauma and peds rotations) and the private hospital is covered by PA's and residents come in only for OR cases.

as far as faculty adjusting, we (my department) have not really had any issues. it's a 630am to 530pm service for the most part during the week. lecture time is protected (the faculty get scolded if residents miss lecture because of clinic or cases).

i think that most programs (in my field) have some sort of curriculum set up (formal or informal).

the reason i have the question of increasing years is because of the lost OR days and clinic days secondary to having to leave during the week. there are cases missed. this is a certainty. those who where not in the previous system can't really say that there experience it the same, but it may be adequate. it also takes away some of the teaching cases which are in my opinion extremely important in a surgeons growth.

in many university programs, because of the lack of initial OR time, there is a lag in surgical skills. now, programs which have case loads which are very senior heavy will have to adjust. but, that also has to come within the resident ranks. chiefs handing down cases. sometimes this may require the chiefs to participate in floor work or clinic (which i do feel is still helpful as a chief and fellow, you need to see when and more importantly when not to operate).

this is definitely is a work in progress. i think it is a good change, because like when the insurance companies began to only pay for x number of days in the hospital, it forced a change which was long needed.
 
That's not the point here. The argument against the 80 hour rule is that it decreases resident case load which would then generate less skillful surgeons. I don't care if the cases don't count and I'm well aware of it, no links needed, thanks. All I"m saying is that I'm already getting cases (not to show off, just making a point) regardless of working less than 80 hours and it's helping me develop skills early on. Ultimately, my level of skill upon graduation will be dependent on my level of aptitude, willingness to learn, and natural talents, if there are any (which I am not saying there are). I don't even understand how tired residents post call are supposed to develop skills.

As a bodybuilder, I apply the rules of training to everyday life. It's well accepted that athletes develop better when given optimal rest and nutrition. I would think that well rested residents that come to work ready to learn with a healthy mind and body are better geared towards learning the fine surgical techniques and acquire dexterity required to do well during operative procedures. I think most would agree with that.

I wasn't attempting to join the "argument" and am glad that you are getting cases and that you know what "counts" and what doesn't: many junior residents do not, and I was trying to be helpful.

I have no doubt that you will get enough cases to make the ACS minimum - its set pretty low and who's to say what is adequate and what isn't in regards to num,bers. And despite not wanting to get into the discussion, for those who never worked in the pre-80 hr workweek, its not really fair to discuss whether or not we were capable of learning post-call. Some of us need less sleep than others, some of us may not have been 100% post-call but were still learning. I don't defend the old days, but I think it will be inescapable that the current group of residents will have less cases logged than in the pre-80 hrs days. It remains to be seen whether or not that translates into less skilled surgeons right out of residency (I have no doubt that a few years in practice will even things out). But as noted above, its not just the reduction in work hours, but the lack of efficiency in most programs and the relative lack of interest by faculty to change things. Residents, especially junior ones, could be in the OR a lot more if there was less busy work on the floors. Mind you, learning pre and post-op management is exceedingly important and I don't think we should be turning all of this work over to allied health care providers, but much of the work is not educationally useful and junior residents are missing surgical learning opportunities in favor of sitting in front of a computer or phone.
 
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