Poorly Trained Surgeons

Wanted to share this post, about concerns with surgical resident competencies. This is presented in a US context, but I've heard many of the same worries in Canada. Put simply, a good portion of fellowship directors (and other attending surgeons) believe that a fairly significant number of graduating surgical residents are not competent to perform important surgeries independently. Worse, many of these surgical residents agree.

The kicker for me, however, is this paragraph:

"The lack of confidence stems from the gradual increase in supervision of residents over the last 15 to 20 years. In yet another blog post, I pointed out that many of today’s residents rarely if ever operate independently during residency training. To realize you are on your own as a full-fledged surgeon without ever having performed a case by yourself must be frightening."

I've had a few glimpses of this myself - residents, even residents far along in their training, rarely get a chance to operate in a truly independent manner. It's all dependent on the attending surgeon of course, some are more comfortable letting residents take a larger role than others, but the overall proportion seems skewed against letting residents really gain independence. I've seen first-hand a PGY-5 start off leading a surgery, only to be bumped when the first, relatively minor complication arose. That's not a great way to get that PGY-5 to a point of competency when they graduate in a year (for the record, the PGY-5 was excellent from a surgical perspective relative to their peers, I really can't fault the resident here).

More junior residents had it even worse. For the most part they were assisting with the odd opportunity to do some small parts of the surgery, but opportunities were generally based on whoever else was in the room (fellows and senior residents getting priority), attending comfort, and other considerations beyond the resident's control such as timing. The skill level or educational requirements for the resident only rarely seemed to factor into things... they mostly just got left with whatever scraps of learning they were lucky enough to gather.

When it comes to a procedure - any procedure - the only way to gain competency is to do it, on your own, over and over. Sure, supervision is essential, especially in high-risk procedures, which includes pretty much any surgery, but supervision could be a lot more arms-length than it currently seems to be for surgical residents. More importantly, progression could be a lot more deliberate and standardized, rather than set by the whims of the attending on the day, whims that could hold a resident back from performing tasks they're fully able to complete - or tasks where trying to complete it is the next step in their education - while on the flip side, could push a resident to attempt a task they're not ready to try, yet they do because it may be their only chance at it in quite some time.

Back to the article - the author makes a suggestion that, while logical given the current constraints, hits at the profound dysfunction in a lot of medical education:

"All you can do as a surgical resident is to try to scrub on as many cases as possible and take care of as many patients as you can. With luck, you may have faculty who have enough confidence in themselves to allow you some autonomy and decision making in the OR and when managing patients pre-and postoperatively."

In short, work harder. Hope your superiors let you learn.

Time and time again, I see this pattern, and it's far from being unique to surgery - medical education providing ineffective or inefficient instruction, with the only proposed solution being sheer volume of exposure. Residents dutifully follow this approach, doing everything they can to gain competency, but their options are often limited - too many learners, not enough procedures to help with, many other responsibilities and only so much time in a day. Volumes can only go up so much.

At some point, those doing the instructing need to be held accountable for poor outcomes of their learners, but even they are typically victims of this dysfunctional model of medical education. They weren't often taught in an effective or efficient manner and, more importantly, few are ever taught how to teach. The system perpetuates itself, unfortunately.