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.

Houses of Cards

Between Internal last block and Psychiatry this block, social factors have featured pretty prominently. It's been a good demonstration of the importance of having a support system and personal resources in maintaining health, as well as a fairly meaningful lesson on the limits of modern healthcare when these social factors are absent.

What struck me was how someone who seemed to be leading a reasonably complete life could have that life fall into complete disarray if just one critical support piece is taken away. That support might have been a job, a vehicle, a family member, a friend, any number of things - but once it was gone, health started to decline quickly. Many times it was a snowball effect, where losing one support would result in other supports falling away either directly (eg spouse dies and they used to be the driver in the family) or indirectly (eg person loses job, has episode of depression, loses interest in activities, loses supportive friends associated with those activities).

Listening to some patients' stories, I can't help but see us all as giant houses of cards, seemingly well-constructed when everything's going well and each piece is in place, but quickly collapsing into a big heap of nothingness when just one piece is pulled away.

Granted, I've seen many instances where a patient recovers quite well despite losing a major support in their lives, where the other supports they have simply fill in the gaps or new supports are marshaled to help. Still, take away one more support from some of these patients and it's a short path to being in a very difficult situation. It's important - critical, I would say - from an individual perspective to develop social supports and to have personal resources available. Yet, even well-supported patients can falter if their life sustains just the right combination of minor insults.

My reaction to this is to push for adequate institutional supports. When everything goes south, what should we have in place to pick people up? And to what degree should the healthcare system be involved with these institutional supports, particularly in Canada, where healthcare is one of our primary institutional support systems? We've got a pretty complex network of publicly and privately funded resources for patients or people in general when they need help. These resources do a lot of good. But they have their limitations too, and plenty of people fall through the cracks. Those cracks could use some filling in.

Education Levels and Medical Compliance

Came across a comment that patients with lower education levels were more significantly likely to make poor medical decisions. It's not the first time I've heard a statement along those lines, not by a long shot.

However, in my admittedly limited experience, I've found this to be completely, 100% false.

Sure, there are people with less education who make dumb medical decisions. Plenty are non-compliant with medical advice. But there are also a good number of people with LOTS of education who make dumb medical decisions or who are non-compliant with medical advice. This is especially true of healthcare workers. They say doctors make the worst patients, and so far as I can tell, this is absolutely true!

I'm speaking in generalities of course, as I've met many healthcare workers and physicians who took excellent care of themselves and made intelligent, carefully considered medical decisions. Still, in general, people of all education levels can make idiotic decisions when it comes to their health or their medical care, just as people making good medical decisions can have any level of education.

We pre-judge people a lot in medicine. It's part of our training, not without reason. However, this element is one when I try not to make too many assumptions. Education is a poor guide to medical decision-making, so far as I've seen.

Sick Luck

So I'm sick. Again. On my week off. Again.

This seems to be happening regularly now, every time I get a break I start feeling awful soon afterwards. Not even sure how this one happened - at least before I was in the middle of a rotation where I was under a fair bit of stress and had regular exposure to people with communicable disease. I'm on break from Psychiatry right now, which has been a pretty relaxed experience so far, and the patients don't have so much as a sniffle. No idea where this is coming from - no one's sick at home either.

Guess I'm just that lucky...

March Break

March Break started today! I get a full week off and, unlike my winter break, I have virtually no other commitments, so it's a real week off.

That means I get to do things I've been neglecting, like clean the apartment, exercise (somewhat) and eat healthy foods (also somewhat). I've also had a chance to read things that aren't super-related to medicine. One book I've been very slowly working on is Aldous Huxley's Brave New World. It's weird. Really weird...

One element to the story that comes up frequently is the nature - and specifically the downsides - of indoctrination. Indoctrination is obviously a very bad thing, implanting often skewed or flat-out wrong thoughts into impressionable people, typically children, and suppressing independent thought. However, in my warped medical student mind, I couldn't help but recognize that the indoctrinated people really had that indoctrinated information memorized!

It's probably not best to find life-lessons in a fictional account of population-wide abuse, but when it comes to learning, there's something to be said for frequent repetition in a moderate time frame, which is what is employed in the novel. Studying, in general, is an attempt to replicate this approach. Teaching, I think, should also deliberately incorporate repetition on time scales (several days to about two weeks) that are more likely to promote long-term retention.

However, if the first half of Brave New World is any indication, these techniques should not be used to instill a rigid order onto society, something to maybe keep in mind with Mr Combover gaining an ever-larger following south of the border (I also have more time to keep up with the news on my week off!)

Mental Health and Resources - Addendum

Since my last post, I've had a few opportunities to chat about the state of mental healthcare in the area, particularly what could be done to improve the situation. It's in the news a fair bit now, so it's come up in conversation a lot, particularly while on my Psych rotation. One idea that came up was increasing Psychiatrist work hours.

It's a valid thought. Psychiatrists do work fewer hours than most other physicians, especially hospital-based physicians. If any physician can be told that they need to work longer hours, it may be Psychiatrists. However, I'd like to push back against that notion for a few reasons.

First, while Psychiatrists work fewer hours than many other physicians, is that because Psychiatrists are working too few hours, or because other physicians are working too many? I'd argue it's the latter. Psychiatrist hours still average over 45 a week, not much below that of other specialties, particularly office-based practices. Given overall rates of physician burnout and unhappiness with work-life balance, asking Psychiatrists to work longer hours would likely help one problem by causing another.

Second, while no physician works optimally when tired, tired Psychiatrists can be particularly troublesome. Psychiatrists have to be careful not just with their clinical decisions, but their words as well. Emotional lability increases with exhaustion or chronic mental fatigue - a bad thing for all physicians, but particularly for one who has to stay mindful of their phrasing whenever they interact with a patient. With non-psychiatric patients, words matter of course, but the margin for error is much greater - a poorly phrased statement can typically be apologized for, clarified, or otherwise explained without enduring consequences. Not so with some psychiatric patients.

Lastly, there's only so much additional hours from Psychiatrists will do to help. It wouldn't help with inpatient services. It wouldn't help with community supports. It wouldn't help with long-term care availability. At best, it would help reduce outpatient wait times. That's still a desirable outcome, though I doubt that longer hours for Psychiatrists would be anywhere near enough. If wait times could be reduced from 1 year to, say, 9 months, that would be a positive change, but 9 months is still far too much time. 

It's a tough situation. As our society increasingly accepts mental health as an important priority, demand for mental health services will also increase. Realistically, all options should be on the table, including longer working hours for Psychiatrists. However, we need to avoid band-aid solutions and "work harder" is pretty close to my definition of a band-aid solution. Other approaches are necessary and, I believe, should be explored first before simply asking current workers to do more.

Mental Health and Resources

I'm on my Psych block now. I'll give my final thoughts on the rotation when I'm further into it, but for now, I'd like to take a minute to express my deep frustration with the availability of medical services in this country and my area in particular. Long story short, we need more beds, more services, and more resources in general.

I have plenty of frustrations about the medical system in general. That's kind of the point of this blog, to get those frustrations out constructively. A lot of my concerns relate to the actions of physicians as a group, as well as physician-dominated organizations including medical schools. I think we, as a profession, hold a lot more blame for the problems in medicine than we're generally willing to admit, and that we have a lot more power to push forth positive change than we currently exercise. I try to advocate for internal changes within the profession of medicine ahead of or in conjunction with changes outside of the medical profession. I especially try to avoid lobbying for more money to be thrown at any particular problem, because resources are finite and while money can paper over a lot of structural problems, they don't solve them either. Those structural issues need to be tackled regardless and doing so may remove the need for more funding.

Not so much when it comes to mental health. The state of mental healthcare in my region is receiving a lot of scrutiny, justifiably, due to a number of frankly horrible situations that have occurred recently or not-so-recently. A lot of these criticisms have been directed towards the government, particularly the provincial government, and I largely agree with those criticisms. Some of the criticism has been directed towards the hospital I'm training at, the physicians and other healthcare workers involved in care for those with mental health, as well as the school I attend. For once, I can't agree with these criticisms. The hospital has clearly tried to prioritize mental health. Employees and physicians have largely just tried to make the best of a bad situation, accepting what is objectively a poor situation because no better alternatives exist. Even the school has gone out of their way to increase the number of Psych residents to help with the workload and encourage more Psychiatrists to stay in the area.

When valuable 1-on-1 therapy is virtually impossible to achieve without insurance or significant independent funding, when long-term care facilities are routinely unavailable, when the mental health ward is operating above 100% capacity (even after accounting for those waiting for long-term care), when wait lists to see an outpatient psychiatrist are on the order of months or years... even monumental changes in the organization of services aren't going to cut it.

Psychiatry does have its share of problems that can be laid at the feet of physicians, of that I have no doubt. However, it's pretty clear that more resources are needed. I don't see mental health being substantially improved without more inpatient beds as well as more supports both in and out of the hospital.