Should the duration of surgical training be increased?

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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.

You are correct. People like yourself have a better perspective of the differences seen between the pre and post-80 hour era. I have no such personal experience and just have to go with what I think is logical.

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What if surgery was more of a consult service. Sort of like ortho. It is almost impossible to get patients admitted to the ortho service. For example, a patient with a broken hip who also happens to have hypertension and is on HCTZ will almost always go to medicine to manage the HTN.

I don't have a problem with this because ortho is trained in operating, not managing medical problems. It seems to me the same could be true for general surgery. Why not have them operate and then let the post-op be managed by medicine or some other service. Honestly, if I had multiple co-morbid conditions in addition to my surgery, I think I would rather have internal medicine following me. That would free up more time for surgeons to operate which is really what they want to do anyway.
 
THP,

that is a good idea, but you are then are going to run into the gen surg EGO. WHEN I WAS AN INTERN, at the turn of the century, when men was men :)... sorry, i got carried away there. as an intern, i was told "we never call the code team, we never call in the fleas, we manage all of our own patients." that was the mentality. now, part of general surgery (and maybe this will change) is intensive care. placing folks on ECMO, managing the SICU, and running traumas, that was typically the general surgeons realm (this varies from hospital to hospital). i think like many things there needs to bean overall attitude change.

as i really can only speak for orthopaedics (because that is what i know), patient care is extremely important. the amount of outpatient care that is require is sometimes stifling. for all surgery, the is both the technical side and the patient care side. most young surgeons get caught up on the technical side, which is the most fun. but, the outpatient and/or inpatient patient care and decision making has to also be learned. the hardest thing for me to teach is when to put the scalpel down. in practice you learn very quickly that you can not fix everything.

there is something that my partner says all the time, "there is nothing that ruins a good surgery like follow up." it's all fun and games until you have a complication. that is the art. that is something that you can not get in residency, most are on a service for 1-3 months (may be more) then they leave. so many times they miss the complication or the final result.
 
we never call in the fleas

the use of this term by surgeons to refer to their internal medicine colleagues is really offensive and part of the huge turn-off that medical students feel towards surgery after doing our 3rd year clerkships. and for the record, i don't plan to go into IM.

however i will add that the notion of general surgery being treated like a consult service, operating and then handing off post-op care to IM, is a bad idea. IM residents don't understand post-op complications the way surgeons should, to say nothing of the fact that many surgical admissions never get operated on (ie, acute cholecystitis).

i'm in the camp that thinks direct matching into subspecialized areas of surgery, as well as IM, peds, and some areas of OB-gyn, is the way to go. exxtending training even further for whatever reason is a tough sell to a 30 year old who just got married and wants to start a family. not just for financial reasons, but also for the time and intrinsic schedule variability that residency and fellowship training entails. if a 4th year med student can decide they want to do a surgical subspecialty such as plastics the rest of their life, why not trauma, colorectal, or pediatric surgery also? the same could be said for a medical subspecialties like endocrinology, pulmonology, or cardiology - on both the adult and pediatric side. i believe that within the next 10-20 years there will be a massive shift in the way graduate medical education occurs in this country to move towards these more integrated training programs. extending surgical training is just going to make it an even tougher sell to medical students.
 
subspecialization early, i don't feel it the answer. my reasoning is then who are going to be the generalists. not every hospital needs all subspecialties and some of the basic patient care aspects of medicine need to be learned first. medical school does not train medical students to take care of patients right out of the blocks, that is why july always scares me. the other thing is if we compartmentalizing everything, would then medical school need to be lengthened to accommodate the ability of every medical student to have the opportunity to see or have access to every subspecialty. or should we go to a system where you do a general internship, practice for 2 years and then apply to your subspecialty (sort of like the old british system)
 
you can still have generalists while allow subspecialization early. just because a med student could choose to go directly into trauma surgery, they could also choose to be a general surgeon. same with endocrinology vs. internal medicine. the early part of the subspecialty-direct training should still include the basics of patient care because you're right that med school does not prepare you to come out and take care of patients completely indepdendently on july 1.

medical school would not need to be lengthened were this to occur. medical students do have access to every specialty and sub-specialty - it's called the 4th year. as it is now, if a student wants to explore an area of medicine that isn't part of the core 3rd year experience of IM, peds, FP, psych, surgery, and ob-gyn they do it at the beginning of 4th year. i don't see dermatology or ortho struggling to fill their programs because med students aren't guaranteed exposure to those fields. we already have such a system in this country with the surgical subspecialties that med students directly match into - why not extend it to other areas of surgery, and then also medicine, pediatrics, OB-gyn, and radiology. go talk to a pediatrician and ask them how hard it is to find a peds endocrinologist, and then ask the general pediatrician why they didn't subspecialize. they'll tell you it's because another 3 years of training is too long when you have a young family. but if they could have done 4 years directly out of med school, that probably is a much more appealing option. same thinking applies to the surgical specialties that are now done as fellowships off general. vascular is figuring this out and coming up with residencies tot allow 5 years total training and then certification in vascular only. but so what? if you want to do vascular surgery, who cares if you're not also BC/BE in general surgery? leave that to the general surgeons - there will still be plenty of them to take out a gallbladder while the vascular surgery resident better utilizes their time gaining more expertise in vascular issues.

subspecialization early, i don't feel it the answer. my reasoning is then who are going to be the generalists. not every hospital needs all subspecialties and some of the basic patient care aspects of medicine need to be learned first. medical school does not train medical students to take care of patients right out of the blocks, that is why july always scares me. the other thing is if we compartmentalizing everything, would then medical school need to be lengthened to accommodate the ability of every medical student to have the opportunity to see or have access to every subspecialty. or should we go to a system where you do a general internship, practice for 2 years and then apply to your subspecialty (sort of like the old british system)
 
subspecialization early, i don't feel it the answer. my reasoning is then who are going to be the generalists. not every hospital needs all subspecialties and some of the basic patient care aspects of medicine need to be learned first. medical school does not train medical students to take care of patients right out of the blocks, that is why july always scares me. the other thing is if we compartmentalizing everything, would then medical school need to be lengthened to accommodate the ability of every medical student to have the opportunity to see or have access to every subspecialty. or should we go to a system where you do a general internship, practice for 2 years and then apply to your subspecialty (sort of like the old british system)

I guess I don't see the difference in matching directly into CT, Vascular, Peds, etc. vs. matching into Ortho, ENT, Urology, Plastics, and Neurosurgery. What would the difference be? I still think that general surgery would still be a residency to choose.
 
we can go into length why there are not many pediatric subspecialists and the training only has part to do with it, pediatrics is the red headed step child as far as reimbursements are concerned. and the income difference is not that different.

as far as more sub specialized programs, again most have to start somewhere. i think the 3+2 programs will probably be more prevalent in the future as mentioned in some of the above posts. although the fourth year is great, it will not expose you to everything prior to interviewing for a residency. most of the other sub specialty programs, people already know that they want to go into them before their 4th year.

i fear with the whole sub specialization is that we will require the medical student to then choose a area before they actually get exposure to it. :scared:aahhh, to many things need to be changed, so little time.
 
I guess I don't see the difference in matching directly into CT, Vascular, Peds, etc. vs. matching into Ortho, ENT, Urology, Plastics, and Neurosurgery. What would the difference be? I still think that general surgery would still be a residency to choose.

there really isn't, although the technical skill set of the CT, Vascular, and pediatric surgeon is very similar. The skill set for Ortho (my love), ENT, Plastics, and Neurosurgery are very different. There is some cross over between gen surg and Urology. doing ling bone and spine work is very different than doing head&neck cases, which is different from doing free flaps, which is different from messing around with peoples memories.

listen, i am no fan of the old general surgery mentality of training methods. they hurt my feels :(, and i may have one or 2 resentments.
 
i fear with the whole sub specialization is that we will require the medical student to then choose a area before they actually get exposure to it.

That's a good point, but many medical students are making decisions on future careers with little to no exposure at this time, too. Many subspecialties of medicine at my school were only able to be experienced as fourth year electives...Pathology, Anesthesiology, Radiology, Dermatology, Ophthomology. And one could only choose a single IM fellowship subspecialty (two weeks) during the entire course of the IM rotation. I picked Cardiology, but lost out on GI, Renal, Pulm, Hem/Onc, etc.

Plus, it was impossible to rotate through every single surgical subspecialty. You could choose three separate areas (for a mere two weeks apiece) as a third year (for instance...I chose Neurosurgery, ENT, and CT) but you lost out on the others (for me...Urology, Plastics, Ortho, Vascular etc).

In the meantime, I was required to do six weeks of General Surgery and eight weeks of Internal Medicine.
 
That's a good point, but many medical students are making decisions on future careers with little to no exposure at this time, too. Many subspecialties of medicine at my school were only able to be experienced as fourth year electives...Pathology, Anesthesiology, Radiology, Dermatology, Ophthomology.

you've got it right - and those fields are all pretty competitive and i would venture they all have a lower rate of residents leaving the specialty than many of the core MS3 clerkships everyone experiences. as young adults we med students want to get our training and then work, make a living, have set work hours, etc. things that shorten the total duration of training by eliminating unused knowledge and skills (does someone who ultimately goes into CT surgery need to be a master of the lap chole?) while emmphasizing the skills that doctor will need are good things.
 
That's a good point, but many medical students are making decisions on future careers with little to no exposure at this time, too. Many subspecialties of medicine at my school were only able to be experienced as fourth year electives...Pathology, Anesthesiology, Radiology, Dermatology, Ophthomology. And one could only choose a single IM fellowship subspecialty (two weeks) during the entire course of the IM rotation. I picked Cardiology, but lost out on GI, Renal, Pulm, Hem/Onc, etc.

Plus, it was impossible to rotate through every single surgical subspecialty. You could choose three separate areas (for a mere two weeks apiece) as a third year (for instance...I chose Neurosurgery, ENT, and CT) but you lost out on the others (for me...Urology, Plastics, Ortho, Vascular etc).

In the meantime, I was required to do six weeks of General Surgery and eight weeks of Internal Medicine.


I never had exposure to being a crane operator, attorney, engineer, or cruise ship singer before I applied to medical school. All people have to make decisions without practicing everything for a month. At $30k/year for med school, and a ~$80k+/year opportunity cost for every lost year in residency, the process really can't take forever. I almost think that the solution might be to replace fourth year with a medical, surgical, or rotating internship, place the basics in third year, and leave sprinkle some specialty exposure into the first two years. Everyone can't know everyhing, but everyone should know some things, and we do a poor job of distinguishing between the two.
 
I almost think that the solution might be to replace fourth year with a medical, surgical, or rotating internship, place the basics in third year, and leave sprinkle some specialty exposure into the first two years. Everyone can't know everyhing, but everyone should know some things, and we do a poor job of distinguishing between the two.

My suggestion would be less core rotation time in IM and GS and more specialty time.

You might not need alot of experience to know you don't want to be a crane operator, but if you're undecided and trying to distinguish between multiple fields then it gets dicey in the third and fourth years with a truncated timetable...especially if you are forced to do core rotations yet again as a fourth year.

Remember too, lots of students want to do more than one away rotation in a single subject. I don't think the process should take alot longer, but I do think more economy and variety of exposure is warranted.
 
I never had exposure to being a crane operator, attorney, engineer, or cruise ship singer before I applied to medical school. All people have to make decisions without practicing everything for a month. At $30k/year for med school, and a ~$80k+/year opportunity cost for every lost year in residency, the process really can't take forever. I almost think that the solution might be to replace fourth year with a medical, surgical, or rotating internship, place the basics in third year, and leave sprinkle some specialty exposure into the first two years. Everyone can't know everyhing, but everyone should know some things, and we do a poor job of distinguishing between the two.

i don't really think there is a simple solution to the whole system. i don't think you need to be exposed to everything. there are surgeons and non-surgeons. there are clinicians and non-clinicians. there are people who like taking care of patients and those that don't. the 3rd year is to give you a base from which to build upon. the problem, i see, with the 4th year is that you need to know what you want to do before you start your fourth year because you have to set up your schedule for that year and apply for residency during the 1st 6 months of that 4th year.

now, the system could be set up that 4th year was sort of a internship (like many of the 3+3 medicine or family medicine programs). the problem see with that is most 3rd year med studs are not ready for that responsibility. so, maybe it should go to a more old european style, graduate medical school, do a rotation internship, work in gen med for a couple years and then apply for a residency. gets people to develop their on style of taking care of patients etc.

i think there needs to be change in the system, splitting up into a ton of subspecialties i don't think is the optimal answer. there may be a change to a 3+ 2 or 3 type of program (in surgery). i do feel that there every resident physician needs to build a base for understanding the basics of patient care and basic surgical techniques. in general surgery, you have multiple aspects that have to be learned other than lap chole's and whipple's; you still have to learn about acute patient care, ICU, and trauma care. so the first 2 or 3 years would be learning these things and basic surgical techniques. then, like with plastics, you apply for your subspecialty (gen surg, CT, vasc, transplant, etc.)

i do think there may need to be an adjustment of the amount of time in the surgical subspecialties because the number of procedures is increasing and each is requiring an increase in surgical skill. with surgeon educator being required to be more hands on secondary to some government regulations (HCFA), non-government regulations (JACHO), and outside influences (malpractice), the amount of time that a young surgeon has to learn his/her craft with out adult supervision is less. also, with money being an issue, the surgeon educator is also influenced by the number of cases s/he an perform and therefore, may step into a case much sooner to get don quicker.

i think prior to the 80 work week, young surgeons operated so much and saw so many patients, that is was not a issue. you would eventually get good at it just because of shear volume. now that the volume will be reduced, how can we as educators improve the amount of education with a shorter time frame. example, it is trauma season, we have had a number of cases added on to the end of my elective schedule (not uncommon). there have been a number of days that i have operated completely by myself. don't get me wrong, i and the staff love it because the cases go much faster; but, these are lost cases to the residents. you may argue, well they don't need those cases. my argument is from what i have seen, yes the do.

ok this is definitely getting too long sorry ... happy easter all
 
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