- Email: [email protected]
What Is Wrong with the Training of General Surgery?
Advances in Surgery j (2014) j–j
ADVANCES IN SURGERY What Is Wrong with the Training of General Surgery? Daniel T. McKenna, MDa, Samer G. Mattar, MDb,* a
Department of Surgery, Indiana University Hospital North, 11725 North Illinois Street, Suite 275, Carmel, IN 46032, USA; bDepartment of Surgery, Oregon Health & Science University, Mail Code L233A, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
Keywords
General surgery training 80-hour work week Residency changes
Key points
There is a perception that general surgery training has been affected by rapid advances in technology, the increasing adoption of nonsurgical management of common surgical conditions, and an overall reduction in trauma volume.
Resident autonomy and operative volume were further reduced as a result of enhanced regulation and work-hour restrictions initiated in 2003.
Future trainees may need early subspecialization, more effective mentorship, a proficiency-based curriculum, and/or a longer residency.
We need a system, and we will surely have it - which will produce not only surgeons, but surgeons of the highest type, who will stimulate the finest youths of their country to study surgery, and to devote their energies and their lives to raising the standards of surgical science. —William Halsted, 1904.
Dr Halsted, more than a century ago, developed the model by which general surgeons have received training until the present time. In it, residents achieve progressive responsibility over a set period of time, requiring availability and opportunity. The Halsted model of training has proved to be a serviceable and beneficial framework for many generations of surgeons. However, many changes have taken place within the realms of both general surgery and residency training that seem to have affected the real and perceived applicability, relevance, and quality of surgical training. There have been an increasing number of *Corresponding author. E-mail address: [email protected] 0065-3411/14/$ – see front matter http://dx.doi.org/10.1016/j.yasu.2014.05.010
Ó 2014 Elsevier Inc. All rights reserved.
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publications and communications in which fellowship directors and practicing surgeons have voiced concerns regarding the preparedness of general surgeons graduating from residency programs. In a recent survey of fellowship directors, 30% could not perform a laparoscopic cholecystectomy, 38% showed a lack of patient ownership, and 66% were unable to perform 30 minutes of a major operation unsupervised [1]. Surgical competency extends beyond technical skills. A good surgeon should possess sound judgment, firm decisiveness, clear and unambiguous communication abilities, and be compassionate; traits that are both inherent but also gained through experience and observation of role-models. The reasons for the lack of preparation are controversial and complex. Profound changes have occurred in the management of surgical diseases, in how residents are more closely supervised, and in resident availability. An additional factor is the change in residents’ expectations. Because of these changes, residents now have less autonomy and a narrower experience in operative procedures, resulting in trainees who may be unprepared for independent practice. CHANGES IN SURGICAL DISEASES The old adage that a chance to cut is a chance to cure reflects only half the truth. To surgeons, every surgical intervention is a rich opportunity to test their judgment, operative skill, knowledge of anatomy, and postoperative management. Although changes have occurred in the management of most diseases in the past 30 years, it is particularly revealing to describe the more dramatic evolution that has taken place within 2 of the commonest disease processes: choledocholithiasis and peptic ulcer disease. Although the adoption of advances in endoscopy and pharmaceutical therapy in these settings has been beneficial in sparing patients operative intervention, these same technologies have detracted from traditional surgical teaching. Open common bile duct exploration cases have traditionally provided ideal opportunities for teaching biliary anatomy, suturing skills, and decision making at a higher level than a simple cholecystectomy can afford. However, over the past 20 years, its frequency has decreased substantially. Chung and colleagues [2] found that from 1988 to 2001 the incidence of open cholecystectomy decreased to 28%, open common duct exploration to 27%, and sphincteroplasty to 20% of baseline levels. Cholecystostomy and choledochoenteric bypass decreased to 70% and 75%, respectively. This decline began before the era of laparoscopic cholecystectomy, but accelerated after its introduction. In a recent survey, graduates preferred nonsurgical, mainly endoscopic, approaches for all bile duct conditions but also increasingly sought the assistance of senior surgeons in the operative management of unexpected events [2]. In many institutions, endoscopic retrograde cholangiopancreatography has replaced common duct exploration, resulting in a marked reduction of complex biliary surgery experience for residents despite the ubiquity of laparoscopic cholecystectomy. This trend similarly applies to peptic ulcer disease. Between 1999 and 2008, Accreditation Council for Graduate Medical Education (ACGME) case logs
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3
showed a significant reduction in the frequency of vagotomy procedures. The number of vagotomies performed by residents decreased from 1778 in 1999 to 463 in 2008 [3]. Two reasons for the marked decrease in procedures for peptic ulcer disease are the discovery of Helicobacter pylori in 1984 and the subsequent development of H2 blockers and proton pump inhibitors, which has led to a substantial shift in the treatment of ulcer disease from surgical to medical therapy. For trainees, this became a disease process that was generally transferred to gastroenterologists and primary care physicians. This situation persisted until the popular adoption of bariatric surgery, eventually resulting in a virtual renaissance of gastric surgery. Other diseases, such as lymphoma, tuberculosis, or portal hypertension, have also seen the mainstay of therapy shift away from surgical interventions. CHANGES IN OPERATIVE TECHNIQUE During the past 20 years, efforts to minimize trauma and stress to the patient led to the development and adoption of minimally invasive techniques in general, vascular, and cardiac surgery. Such was the acceptance of this technology by patients and referring physicians that it rapidly became the standard approach for many procedures, including cholecystectomy. At present, surgeons use minimally invasive techniques for many abdominal and thoracic procedures. An examination of all procedures from 1999 to 2008 found an increase in laparoscopic approaches with a reciprocal decrease in open cases. The number of open appendectomies decreased by 29% (30.7–21.7), whereas the number of laparoscopic appendectomies increased by 278% (8.5–32.1). Open inguinal hernia cases similarly decreased by 12.5% (51.9–45.4) and open colectomy cases decreased by 10.4% (48–43). In contrast, laparoscopic hernia repair and laparoscopic colectomy increased by 87.5% (7.6–15.8) and 550% (2–13), respectively [4]. Although this can be seen as the natural progression of minimally invasive techniques, it does have an impact on resident education and experience. Minimally invasive surgery can be more challenging to teach than open surgery. It requires the attending surgeon to relinquish control to the trainee. There is no hand or instrument guiding the trainee’s dissection. Thus, the resident must possess the requisite skill and experience before performing many of these procedures, thereby reallocating the assignment of these procedures from the junior-level residents to the more senior residents. When National Surgical Quality Improvement Program (NSQIP) data are stratified by resident level, there is a significant shift in laparoscopic versus open cases. For example, in inguinal hernia repair, residents in their third year or earlier performed 72% of open repairs, whereas junior residents performed only 41% of laparoscopic repairs (P<.0001). In a similar way, 61% of open appendectomies were performed by this same group compared with 48% of laparoscopic appendectomies (P<.0001). Within colorectal surgery, more laparoscopic cases were the domain of senior residents. Junior residents performed 46% of open and 33% of all laparoscopic resections (P<.0001) [5], which is a substantial portion
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of the early experience in tissue handling, suturing, and anatomy that is shifted to the later years. This impact is not limited to 1 area of general surgery, but rather is widely distributed. When the ACGME subcategories were examined, it was found that minimally invasive surgery had affected alimentary tract, abdomen, vascular, thoracic, and pediatric surgery. In all of these categories, there was a significant difference in the volume of minimally invasive operations performed for the most common procedures. As an example, in vascular surgery, not only had the total number of aortic aneurysms that underwent open repair decreased by 1500 cases from 1999 to 2008, but the endovascular repair technique had accounted for 45.4% in 2008, which was up from 0% [3]. An examination of case numbers in the Greenville Hospital System found that there was a significant decline in resident participation in open abdominal aortic aneurysm (22.4 vs 7.7), carotid endarterectomy (37.2 vs 31.1), aortobifemoral bypass (18.6 vs 5.5), and lower extremity bypass (42.8 vs 19.1) between 1991 and 2007. Numbers for dialysis access creation (49.0 vs 57.1) were maintained [6]. Although the operative volume remained stable, the introduction of a fellowship reduced the number of vascular cases performed by residents. The most dramatic impact of the proliferation of minimally invasive techniques is probably the rapid growth of fellowships. Many endovascular, endoscopic, or laparoscopic techniques require extensive and prolonged training to gain proficiency; certainly of a duration that is longer than residency rotations may afford. Examining case logs at 5 intervals between 1989 and 2011, designated pediatric cases declined for each period from an average of 47.7 in 1989 to 1990 to 33.8 in 2010 to 2011. The investigators in that study concluded that the cause of this significant change in general surgery resident experience was multifactorial, including the increase in pediatric surgery fellowships and the adoption of minimally invasive techniques. This decline occurred independently of work-hour restrictions [7]. CHANGES IN MANAGEMENT OF CERTAIN DISEASE PROCESSES Trauma In the past, injuries represented a large portion of training opportunities for general surgeons, and this remains true in many parts of the world. Several factors led to changes in the frequency and management of injuries, including a decrease in the frequency of blunt and penetrating trauma, improvement in radiologic imaging, and nonoperative management of blunt trauma. Penetrating trauma has decreased by 60% to 70% in the United States over the past 20 years, resulting in a marked reduction in the need for abdominal surgery. Exploratory laparotomies in penetrating trauma have historically provided the trainee with the development of skills for the systematic inspection of the abdomen, complex exposure techniques, expediency in decisiveness, and the acquisition of a range of technical maneuvers. The incidence of automobile-related blunt trauma has also declined by about 20% over the
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last 30 years because of the use of seat belts, the availability of airbags, and other improvements in automobile safety. Although most cases of blunt trauma do not require operative intervention, a 20% reduction led to an even further loss of surgical training opportunities. Improvements in body imaging and its increased availability have also resulted in a reduction in exploratory surgery over the past 20 years. Computed tomography (CT) scanning has improved greatly with resolution levels so discreet that it is possible to detect minute injuries. The availability of more accurate, and rapid, diagnostic modalities has resulted in a reduction of nontherapeutic laparotomies that were in the past triggered by positive diagnostic peritoneal lavage. Improvements in imaging have also contributed to the nonoperative management of blunt trauma to the spleen, liver, pancreas, or kidneys. At present, most blunt trauma to these organs is managed nonoperatively. Nonoperative management and improvements in radiologic imaging have led to a generation of surgeons who have little experience in diagnostic peritoneal lavage. Operative trauma case requirements have been reduced to only 10 cases for current residents, representing an 80% reduction. In addition, a category of nonoperative trauma management has been created. Although these advances in trauma management have been beneficial to patients and to society, they have markedly reduced the experience of surgical residents in performing open abdominal surgery, and decreased their breadth of experience. When ACGME aggregate data collected from general surgery residency programs from 1990 to 2010 were examined, the effect of the 2003 work-hour reform on resident operative trauma volume seemed negligible. Overall trauma cases per year declined from 78.28 in 1990 to 38.73 in 2010. From 1990 to 2003, laparotomy, burn, and upper-gastrointestinal trauma cases decreased at least 50%, from 9.97 to 4.85 cases per resident, 10.05 to 3.30 cases per resident, and 3.34 to 1.01 cases per resident, respectively. After 2003, laparotomy and burn cases began to increase by 0.23 cases per year. Vascular trauma cases continued to decline from 8.63 cases per resident before the reform, but stabilized after the reform [8]. Graduating residents are now performing 40 cases less than residents in 1990. Outpatient surgery There has also been a substantial shift in the evaluation and postoperative management of patients. In the past, patients who were undergoing surgery were admitted to the hospital a day, and sometimes 2 days, before surgery. The advent of minimally invasive techniques and the pressure for cost containment have resulted in the extensive use of outpatient surgery and ambulatory centers. Three common operations have now become standard outpatient procedures: cholecystectomy, herniorrhaphy, and breast biopsy. Such paradigm changes limit residents’ ability to evaluate the patient before and after the procedure, effectively eliminating the ability to form substantive rapport with the patient, and impairing continuity of care. The end result is the severe limitation
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of observing the natural history of disease processes as they progress and run their course in individual patients. CHANGES IN WORK HOURS Restrictions have twice been imposed on the working hours of residents in the past 10 years. The first change occurred in 2003 when residents were limited to work 80 hours per week, no more than 30 hours in a shift, and mandated they have 1 day off every 7 days. In 2012, interns underwent further restriction, being limited to 16 hours in a shift, and were to have 10 hours off between shifts. Both of these changes have affected the autonomy and experience of patient continuity of surgical residents. Many clinicians think that this arrangement has bred a shift-work mentality in a specialty that demands continuity of care. Before the implementation of these work-hour restrictions, it was thought that surgery residents averaged 90 to 100 hours of work per week. Since their implementation, these restrictions have resulted in a reduction of more than 5000 hours of potential experience. Examining data from the ACGME following the implementation of the 80-hour work duty restrictions, the number of total major operations reported by residents, as surgeon, decreased from 930 to 909 (2.3% decrease; P<.0001), surgeon chief operations decreased from 252 to 231 (8.3% decrease; P<.0001), and surgeon junior operations remained essentially unchanged, from 677 to 678. From academic year 1992 to 1993 through 2005 to 2006, the median number of first-assistant and teachingassistant cases declined from 231 to 49 (79% decrease) and from 67 to 23 (66% decrease), respectively [9]. Assisting on a reduced number of cases and performing a third of the teaching cases must have a significant impact on technical skill and judgment. Similar findings have been found at individual programs. At the University of Mississippi, during a 7-year period, resident first-assistant cases declined significantly, as did total operative cases [10]. Although the total number of cases declined modestly, a greater impact has been on the accrual in the experience gained from urgent or emergent surgical cases. The on-call experience has historically been considered a valuable opportunity for the development of judgment and autonomy. At present, night float arrangements and complex call systems have replaced the traditional call structure. Many residencies have a night float system that is incorporated into most years of training. The problem with this concept is 3-fold. Often, the night float is a third-year or fourth-year resident acting as the most senior resident, precluding learning opportunities that may have been gained by observing chief residents in action. This setup precludes junior residents from learning from their chiefs how to develop judgment and autonomy. The second factor is that many night float systems provide little operative experience, except when covering a busy trauma center or emergency department. The third factor is that it undermines continuity of care, by effectively dismantling the traditional sequence of residents seeing the patient before surgery, performing the surgery, and following the patient throughout their hospital stays as they recover.
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Recent work-hour changes may be particularly detrimental to interns’ experience. When interns were surveyed before implementation of recent restrictions, most interns stated that the new duty-hour regulations would decrease continuity with patients (80.3%), time spent operating (67.4%), and coordination of patient care (57.6%), whereas approximately half thought that the changes will decrease their acquisition of medical knowledge (48.0%), development of surgical skills (52.8%), and overall educational experience (51.1%) [11]. This proved to be a prophetic survey. Compared with the preceding 4 years, the 2011 to 2012 interns recorded a 25.8% decrease in total operative cases (65.9 cases vs 88.8 cases; P ¼ .005), a 31.8% decrease in major cases (54.9 cases vs 80.5 cases; P<.001), and a 46.3%decrease in first-assistant cases (11.1 cases vs 20.7 cases; P ¼ .008) [12]. In another survey of interns who were working within these restrictions, 57% of respondents thought that it compromised their opportunities in the operating room but did not relieve fatigue [13]. Not only is it clear that the effect of these changes has had a negative effect for training surgeons but there may also be a potential detriment in patient care. Because of work-hour restrictions, there are now multiple hand-offs during the day. Great effort is put into conveying all the necessary patient care information, but it is impossible to communicate everything about that patient, particularly nonverbal observations. The ACGME performed a metaanalysis in 2013 of studies of its impact on patient care. The investigators determined that the recent changes had no positive impact on patient care, with mortality and complications remaining unchanged [14]. CHANGES IN SUPERVISION AND DOCUMENTATION Many seasoned surgeons recall a time when chief surgical residents evaluated patients, determined the operations needed, called the attending staff, and then performed the operations assisted by only a junior resident. For better or worse, this scenario is now practically nonexistent. Because of regulatory requirements, billing criteria, and institutional rules, the attending surgeon must be intimately involved throughout all phases of the care of the patient. Rather than making decisions independently, many residents (even chief residents) have been indoctrinated to seek approval for most decisions (management and operative) from the attending surgeon. It is this lack of autonomy that is thought by many educators to be greatly undermining the full ability and confidence of residents to enter practice. CHANGES IN RESIDENT EXPECTATIONS An additional complex issue, interwoven in work-hour restrictions and generational changes, is that there may be a trend toward changes in resident expectations. Residents expect to have a controllable and predictable lifestyle. A survey of program directors, after the institution of the 80-hour work week, found that the total attrition rate increased from 0.6 residents lost per program per year to 0.8 residents per program per year (P ¼ .0013). Lifestyle concerns were the most commonly reported reasons for residents who voluntarily
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discontinued their surgical training. Most (56%) of those who left surgery entered other fields of medicine (most commonly anesthesia and family medicine). The investigators concluded that residents migrate to specialties that are conducive to a more controllable lifestyle despite improvements in work hours and lifestyle during surgical training [15]. Although environmental, technical, and administrative changes have altered the environment in which residents have trained, the residents have changed also. The millennial generation (born in the 1980s or 1990s) has a different set of characteristics than previous generations. They have been termed optimistic, engaged, and team players. They have also been criticized as having great expectations with a sense of entitlement and narcissism [16]. Perhaps the old standard of service leading to experience and education is not the best way for them to learn. LACK OF MENTORSHIP The underlying causes for such gaps in general surgery training cannot rest solely with the administrative, technical, or management changes. It is not a generational gap. Part of the responsibility rests with the surgical attending who is unable or unwilling to mentor residents. The cause of this is multifactorial and nebulous. The combination of work-hour restrictions and administrators has shifted greater responsibility to the attending surgeons for documentation, undoubtedly taking time away from teaching rounds and mentorship. Academic health systems seem increasingly to devalue education and research with a troubling increase in emphasis on clinical production. Productivity decreases when trainees perform major portions of complex operations, compared with experienced surgeons. The structure of surgical training has not changed despite changes in work hours, increasing number of residents within many programs, and further subspecialization. There has been less adaptation to the current reality of training surgeons. The old model continues to be applied to the new reality. A more individualized approach to training surgeons with mentorship would allow the development of trust, autonomy, and better readiness to enter practice. IMPROVING GENERAL SURGERY TRAINING Current and future technology and training protocols may be able to address these shortcomings. Advances in simulation technology provide opportunities that previous generations did not have. Simulation can be helpful in teaching laparoscopic, robotic, endoscopic, or endovascular procedures. Although this can never replace standard operative interventions, it allows the trainee to practice before performing a case, endowing them with fundamental skills that allow them to maximize their learning opportunities [17]. There needs to be a shift in how the readiness of a trainee to enter practice is determined. Instead of a time-based or volume-based residency, there should be a proficiency-based curriculum. There has been a trend toward this in laparoscopy and endoscopy with the introduction of Fundamentals of
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Laparoscopic Surgery (FLS) and Fundamentals of Endoscopic Surgery (FES). In addition, many centers use the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) to help track residents’ progress and attainment of proficiency in flexible endoscopy. A similar assessment tool, Global Assessment of Advanced Laparoscopic Skills (GOALS), has been adopted by The Fellowship Council for augmenting the training of residents for a wide spectrum of operations [18]. Current efforts to promote and implement early subspecialization may help resolve issues of scope of practice and lack of mentorship. Narrowing a trainee’s practice may optimize development of expertise and proficiency within a specific area by allowing the trainee to work with a smaller group of surgeons that may foster mentorship. Moreover, trainees are more likely to become integrated into the operational practices of surgeons within a similar specialty, thereby providing them with early practice management skills [19]. One of the consequences of implementing work-hour restrictions may be the need to extend the length of residency. It already seems to have occurred voluntarily, because 80% of residents are entering fellowships. The American College of Surgeons has recently established Transition to Practice fellowships at several institutions, which may be a viable option to bridge the deficiencies in general surgery training until the current gaps are addressed, although several barriers to its widespread implementation exist [20]. SUMMARY The practice of surgery has undergone tumultuous changes over the last 30 years. Disease management, trauma volume, operative techniques, supervision requirements, and allocation of work hours have all changed, resulting in a substantial impact on general surgical training. Changes need to occur in the structure, assessment, and mentorship of future residents to prepare them to enter the marketplace and practice safe medicine with confidence and authority. References [1] Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg 2013;258:440–9. [2] Chung RS, Wojtasik L, Pham Q, et al. The decline of training in open biliary surgery: effect on the residents’ attitude toward bile duct surgery. Surg Endosc 2003;17:338–40. [3] Carson JS, Smith L, Are M, et al. National trends in minimally invasive and open operative experience of graduating general surgery residents: implications for surgical skills curricula development? Am J Surg 2011;202:720–6. [4] Alkhoury F, Martin JT, Contessa J, et al. The impact of laparoscopy on the volume of open cases in general surgery training. J Surg Educ 2010;67:316–9. [5] Hedrick T, Turrentine F, Sanfey H, et al. Implications of laparoscopy on surgery residency training. Am J Surg 2009;197:73–5. [6] Joels CS, Langan EM 3rd, Cull DL, et al. Effects of increased vascular surgical specialization on general surgery trainees, practicing surgeons, and the provision of vascular surgical care. J Am Coll Surg 2009;208:692–7. [7] Gow KW, Drake FT, Aarabi S, et al. The ACGME case log: general surgery resident experience in pediatric surgery. J Pediatr Surg 2013;48:1643–9.
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[8] Patel MB, Guillamondegui OD, May AK, et al. Twenty-year analysis of surgical resident operative trauma experiences. J Surg Res 2013;180:191–5. [9] Kairys JC, McGuire K, Crawford AG, et al. Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg 2008;206:804–11. [10] Picarella EA, Simmons JD, Borman KR, et al. ‘‘Do one, teach one’’ the new paradigm in general surgery residency training. J Surg Educ 2011;68:126–9. [11] Antiel RM, Van Arendonk KJ, Reed DA, et al. Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: views of surgical interns compared with program directors. Arch Surg 2012;147:536–41. [12] Schwartz SI, Galante J, Kaji A, et al. Effect of the 16-hour work limit on general surgery intern operative case volume: a multi-institutional study. JAMA Surg 2013;148:829–33. [13] Antiel RM, Reed DA, Van Arendonck KJ, et al. Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA Surgery 2013;148(5):448–55. [14] Jamal MH, Doi SA, Rousseau M, et al. Systematic review and meta-analysis of the effect of North American working hours restrictions on mortality and morbidity in surgical patients. Br J Surg 2012;99(3):336–44. [15] Everett CB, Helmer SD, Osland JS, et al. General surgery resident attrition and the 80-hour workweek. Am J Surg 2007;194(6):751–6. [16] Twenge JM. Generation me: why today’s young Americans are more confident, assertive, entitled–and more miserable than ever before. New York, NY: Simon and Schuster; 2006. [17] Sachdeva AK, Buyske J, Dunnington GL, et al. A new paradigm for surgical procedural training. Curr Probl Surg 2011;48(12):854–968. [18] Gumbs AA, Hogle NJ, Fowler DL. Evaluation of resident laparoscopic performance using global assessment of laparoscopic skills. J Am Coll Surg 2007;204(2):308–13. [19] Nasca TJ, Philibert I, Brigham T, et al. The next GME accreditation system–rationale and benefits. N Engl J Med 2012;366(11):1051–6. [20] Richardson JD. ACS transition to practice program offers surgical residents additional opportunities to hone skills. Bull Am Coll Surg 2013;98(9):23–7. Available at: http: //www.facs.org/fellows_info/bulletin/bullet.html. Accessed November 17, 2013.
ADVANCES IN SURGERY What Is Wrong with the Training of General Surgery? Daniel T. McKenna, MDa, Samer G. Mattar, MDb,* a
Department of Surgery, Indiana University Hospital North, 11725 North Illinois Street, Suite 275, Carmel, IN 46032, USA; bDepartment of Surgery, Oregon Health & Science University, Mail Code L233A, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
Keywords
General surgery training 80-hour work week Residency changes
Key points
There is a perception that general surgery training has been affected by rapid advances in technology, the increasing adoption of nonsurgical management of common surgical conditions, and an overall reduction in trauma volume.
Resident autonomy and operative volume were further reduced as a result of enhanced regulation and work-hour restrictions initiated in 2003.
Future trainees may need early subspecialization, more effective mentorship, a proficiency-based curriculum, and/or a longer residency.
We need a system, and we will surely have it - which will produce not only surgeons, but surgeons of the highest type, who will stimulate the finest youths of their country to study surgery, and to devote their energies and their lives to raising the standards of surgical science. —William Halsted, 1904.
Dr Halsted, more than a century ago, developed the model by which general surgeons have received training until the present time. In it, residents achieve progressive responsibility over a set period of time, requiring availability and opportunity. The Halsted model of training has proved to be a serviceable and beneficial framework for many generations of surgeons. However, many changes have taken place within the realms of both general surgery and residency training that seem to have affected the real and perceived applicability, relevance, and quality of surgical training. There have been an increasing number of *Corresponding author. E-mail address: [email protected] 0065-3411/14/$ – see front matter http://dx.doi.org/10.1016/j.yasu.2014.05.010
Ó 2014 Elsevier Inc. All rights reserved.
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MCKENNA & MATTAR
publications and communications in which fellowship directors and practicing surgeons have voiced concerns regarding the preparedness of general surgeons graduating from residency programs. In a recent survey of fellowship directors, 30% could not perform a laparoscopic cholecystectomy, 38% showed a lack of patient ownership, and 66% were unable to perform 30 minutes of a major operation unsupervised [1]. Surgical competency extends beyond technical skills. A good surgeon should possess sound judgment, firm decisiveness, clear and unambiguous communication abilities, and be compassionate; traits that are both inherent but also gained through experience and observation of role-models. The reasons for the lack of preparation are controversial and complex. Profound changes have occurred in the management of surgical diseases, in how residents are more closely supervised, and in resident availability. An additional factor is the change in residents’ expectations. Because of these changes, residents now have less autonomy and a narrower experience in operative procedures, resulting in trainees who may be unprepared for independent practice. CHANGES IN SURGICAL DISEASES The old adage that a chance to cut is a chance to cure reflects only half the truth. To surgeons, every surgical intervention is a rich opportunity to test their judgment, operative skill, knowledge of anatomy, and postoperative management. Although changes have occurred in the management of most diseases in the past 30 years, it is particularly revealing to describe the more dramatic evolution that has taken place within 2 of the commonest disease processes: choledocholithiasis and peptic ulcer disease. Although the adoption of advances in endoscopy and pharmaceutical therapy in these settings has been beneficial in sparing patients operative intervention, these same technologies have detracted from traditional surgical teaching. Open common bile duct exploration cases have traditionally provided ideal opportunities for teaching biliary anatomy, suturing skills, and decision making at a higher level than a simple cholecystectomy can afford. However, over the past 20 years, its frequency has decreased substantially. Chung and colleagues [2] found that from 1988 to 2001 the incidence of open cholecystectomy decreased to 28%, open common duct exploration to 27%, and sphincteroplasty to 20% of baseline levels. Cholecystostomy and choledochoenteric bypass decreased to 70% and 75%, respectively. This decline began before the era of laparoscopic cholecystectomy, but accelerated after its introduction. In a recent survey, graduates preferred nonsurgical, mainly endoscopic, approaches for all bile duct conditions but also increasingly sought the assistance of senior surgeons in the operative management of unexpected events [2]. In many institutions, endoscopic retrograde cholangiopancreatography has replaced common duct exploration, resulting in a marked reduction of complex biliary surgery experience for residents despite the ubiquity of laparoscopic cholecystectomy. This trend similarly applies to peptic ulcer disease. Between 1999 and 2008, Accreditation Council for Graduate Medical Education (ACGME) case logs
GENERAL SURGERY TRAINING
3
showed a significant reduction in the frequency of vagotomy procedures. The number of vagotomies performed by residents decreased from 1778 in 1999 to 463 in 2008 [3]. Two reasons for the marked decrease in procedures for peptic ulcer disease are the discovery of Helicobacter pylori in 1984 and the subsequent development of H2 blockers and proton pump inhibitors, which has led to a substantial shift in the treatment of ulcer disease from surgical to medical therapy. For trainees, this became a disease process that was generally transferred to gastroenterologists and primary care physicians. This situation persisted until the popular adoption of bariatric surgery, eventually resulting in a virtual renaissance of gastric surgery. Other diseases, such as lymphoma, tuberculosis, or portal hypertension, have also seen the mainstay of therapy shift away from surgical interventions. CHANGES IN OPERATIVE TECHNIQUE During the past 20 years, efforts to minimize trauma and stress to the patient led to the development and adoption of minimally invasive techniques in general, vascular, and cardiac surgery. Such was the acceptance of this technology by patients and referring physicians that it rapidly became the standard approach for many procedures, including cholecystectomy. At present, surgeons use minimally invasive techniques for many abdominal and thoracic procedures. An examination of all procedures from 1999 to 2008 found an increase in laparoscopic approaches with a reciprocal decrease in open cases. The number of open appendectomies decreased by 29% (30.7–21.7), whereas the number of laparoscopic appendectomies increased by 278% (8.5–32.1). Open inguinal hernia cases similarly decreased by 12.5% (51.9–45.4) and open colectomy cases decreased by 10.4% (48–43). In contrast, laparoscopic hernia repair and laparoscopic colectomy increased by 87.5% (7.6–15.8) and 550% (2–13), respectively [4]. Although this can be seen as the natural progression of minimally invasive techniques, it does have an impact on resident education and experience. Minimally invasive surgery can be more challenging to teach than open surgery. It requires the attending surgeon to relinquish control to the trainee. There is no hand or instrument guiding the trainee’s dissection. Thus, the resident must possess the requisite skill and experience before performing many of these procedures, thereby reallocating the assignment of these procedures from the junior-level residents to the more senior residents. When National Surgical Quality Improvement Program (NSQIP) data are stratified by resident level, there is a significant shift in laparoscopic versus open cases. For example, in inguinal hernia repair, residents in their third year or earlier performed 72% of open repairs, whereas junior residents performed only 41% of laparoscopic repairs (P<.0001). In a similar way, 61% of open appendectomies were performed by this same group compared with 48% of laparoscopic appendectomies (P<.0001). Within colorectal surgery, more laparoscopic cases were the domain of senior residents. Junior residents performed 46% of open and 33% of all laparoscopic resections (P<.0001) [5], which is a substantial portion
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of the early experience in tissue handling, suturing, and anatomy that is shifted to the later years. This impact is not limited to 1 area of general surgery, but rather is widely distributed. When the ACGME subcategories were examined, it was found that minimally invasive surgery had affected alimentary tract, abdomen, vascular, thoracic, and pediatric surgery. In all of these categories, there was a significant difference in the volume of minimally invasive operations performed for the most common procedures. As an example, in vascular surgery, not only had the total number of aortic aneurysms that underwent open repair decreased by 1500 cases from 1999 to 2008, but the endovascular repair technique had accounted for 45.4% in 2008, which was up from 0% [3]. An examination of case numbers in the Greenville Hospital System found that there was a significant decline in resident participation in open abdominal aortic aneurysm (22.4 vs 7.7), carotid endarterectomy (37.2 vs 31.1), aortobifemoral bypass (18.6 vs 5.5), and lower extremity bypass (42.8 vs 19.1) between 1991 and 2007. Numbers for dialysis access creation (49.0 vs 57.1) were maintained [6]. Although the operative volume remained stable, the introduction of a fellowship reduced the number of vascular cases performed by residents. The most dramatic impact of the proliferation of minimally invasive techniques is probably the rapid growth of fellowships. Many endovascular, endoscopic, or laparoscopic techniques require extensive and prolonged training to gain proficiency; certainly of a duration that is longer than residency rotations may afford. Examining case logs at 5 intervals between 1989 and 2011, designated pediatric cases declined for each period from an average of 47.7 in 1989 to 1990 to 33.8 in 2010 to 2011. The investigators in that study concluded that the cause of this significant change in general surgery resident experience was multifactorial, including the increase in pediatric surgery fellowships and the adoption of minimally invasive techniques. This decline occurred independently of work-hour restrictions [7]. CHANGES IN MANAGEMENT OF CERTAIN DISEASE PROCESSES Trauma In the past, injuries represented a large portion of training opportunities for general surgeons, and this remains true in many parts of the world. Several factors led to changes in the frequency and management of injuries, including a decrease in the frequency of blunt and penetrating trauma, improvement in radiologic imaging, and nonoperative management of blunt trauma. Penetrating trauma has decreased by 60% to 70% in the United States over the past 20 years, resulting in a marked reduction in the need for abdominal surgery. Exploratory laparotomies in penetrating trauma have historically provided the trainee with the development of skills for the systematic inspection of the abdomen, complex exposure techniques, expediency in decisiveness, and the acquisition of a range of technical maneuvers. The incidence of automobile-related blunt trauma has also declined by about 20% over the
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last 30 years because of the use of seat belts, the availability of airbags, and other improvements in automobile safety. Although most cases of blunt trauma do not require operative intervention, a 20% reduction led to an even further loss of surgical training opportunities. Improvements in body imaging and its increased availability have also resulted in a reduction in exploratory surgery over the past 20 years. Computed tomography (CT) scanning has improved greatly with resolution levels so discreet that it is possible to detect minute injuries. The availability of more accurate, and rapid, diagnostic modalities has resulted in a reduction of nontherapeutic laparotomies that were in the past triggered by positive diagnostic peritoneal lavage. Improvements in imaging have also contributed to the nonoperative management of blunt trauma to the spleen, liver, pancreas, or kidneys. At present, most blunt trauma to these organs is managed nonoperatively. Nonoperative management and improvements in radiologic imaging have led to a generation of surgeons who have little experience in diagnostic peritoneal lavage. Operative trauma case requirements have been reduced to only 10 cases for current residents, representing an 80% reduction. In addition, a category of nonoperative trauma management has been created. Although these advances in trauma management have been beneficial to patients and to society, they have markedly reduced the experience of surgical residents in performing open abdominal surgery, and decreased their breadth of experience. When ACGME aggregate data collected from general surgery residency programs from 1990 to 2010 were examined, the effect of the 2003 work-hour reform on resident operative trauma volume seemed negligible. Overall trauma cases per year declined from 78.28 in 1990 to 38.73 in 2010. From 1990 to 2003, laparotomy, burn, and upper-gastrointestinal trauma cases decreased at least 50%, from 9.97 to 4.85 cases per resident, 10.05 to 3.30 cases per resident, and 3.34 to 1.01 cases per resident, respectively. After 2003, laparotomy and burn cases began to increase by 0.23 cases per year. Vascular trauma cases continued to decline from 8.63 cases per resident before the reform, but stabilized after the reform [8]. Graduating residents are now performing 40 cases less than residents in 1990. Outpatient surgery There has also been a substantial shift in the evaluation and postoperative management of patients. In the past, patients who were undergoing surgery were admitted to the hospital a day, and sometimes 2 days, before surgery. The advent of minimally invasive techniques and the pressure for cost containment have resulted in the extensive use of outpatient surgery and ambulatory centers. Three common operations have now become standard outpatient procedures: cholecystectomy, herniorrhaphy, and breast biopsy. Such paradigm changes limit residents’ ability to evaluate the patient before and after the procedure, effectively eliminating the ability to form substantive rapport with the patient, and impairing continuity of care. The end result is the severe limitation
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of observing the natural history of disease processes as they progress and run their course in individual patients. CHANGES IN WORK HOURS Restrictions have twice been imposed on the working hours of residents in the past 10 years. The first change occurred in 2003 when residents were limited to work 80 hours per week, no more than 30 hours in a shift, and mandated they have 1 day off every 7 days. In 2012, interns underwent further restriction, being limited to 16 hours in a shift, and were to have 10 hours off between shifts. Both of these changes have affected the autonomy and experience of patient continuity of surgical residents. Many clinicians think that this arrangement has bred a shift-work mentality in a specialty that demands continuity of care. Before the implementation of these work-hour restrictions, it was thought that surgery residents averaged 90 to 100 hours of work per week. Since their implementation, these restrictions have resulted in a reduction of more than 5000 hours of potential experience. Examining data from the ACGME following the implementation of the 80-hour work duty restrictions, the number of total major operations reported by residents, as surgeon, decreased from 930 to 909 (2.3% decrease; P<.0001), surgeon chief operations decreased from 252 to 231 (8.3% decrease; P<.0001), and surgeon junior operations remained essentially unchanged, from 677 to 678. From academic year 1992 to 1993 through 2005 to 2006, the median number of first-assistant and teachingassistant cases declined from 231 to 49 (79% decrease) and from 67 to 23 (66% decrease), respectively [9]. Assisting on a reduced number of cases and performing a third of the teaching cases must have a significant impact on technical skill and judgment. Similar findings have been found at individual programs. At the University of Mississippi, during a 7-year period, resident first-assistant cases declined significantly, as did total operative cases [10]. Although the total number of cases declined modestly, a greater impact has been on the accrual in the experience gained from urgent or emergent surgical cases. The on-call experience has historically been considered a valuable opportunity for the development of judgment and autonomy. At present, night float arrangements and complex call systems have replaced the traditional call structure. Many residencies have a night float system that is incorporated into most years of training. The problem with this concept is 3-fold. Often, the night float is a third-year or fourth-year resident acting as the most senior resident, precluding learning opportunities that may have been gained by observing chief residents in action. This setup precludes junior residents from learning from their chiefs how to develop judgment and autonomy. The second factor is that many night float systems provide little operative experience, except when covering a busy trauma center or emergency department. The third factor is that it undermines continuity of care, by effectively dismantling the traditional sequence of residents seeing the patient before surgery, performing the surgery, and following the patient throughout their hospital stays as they recover.
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Recent work-hour changes may be particularly detrimental to interns’ experience. When interns were surveyed before implementation of recent restrictions, most interns stated that the new duty-hour regulations would decrease continuity with patients (80.3%), time spent operating (67.4%), and coordination of patient care (57.6%), whereas approximately half thought that the changes will decrease their acquisition of medical knowledge (48.0%), development of surgical skills (52.8%), and overall educational experience (51.1%) [11]. This proved to be a prophetic survey. Compared with the preceding 4 years, the 2011 to 2012 interns recorded a 25.8% decrease in total operative cases (65.9 cases vs 88.8 cases; P ¼ .005), a 31.8% decrease in major cases (54.9 cases vs 80.5 cases; P<.001), and a 46.3%decrease in first-assistant cases (11.1 cases vs 20.7 cases; P ¼ .008) [12]. In another survey of interns who were working within these restrictions, 57% of respondents thought that it compromised their opportunities in the operating room but did not relieve fatigue [13]. Not only is it clear that the effect of these changes has had a negative effect for training surgeons but there may also be a potential detriment in patient care. Because of work-hour restrictions, there are now multiple hand-offs during the day. Great effort is put into conveying all the necessary patient care information, but it is impossible to communicate everything about that patient, particularly nonverbal observations. The ACGME performed a metaanalysis in 2013 of studies of its impact on patient care. The investigators determined that the recent changes had no positive impact on patient care, with mortality and complications remaining unchanged [14]. CHANGES IN SUPERVISION AND DOCUMENTATION Many seasoned surgeons recall a time when chief surgical residents evaluated patients, determined the operations needed, called the attending staff, and then performed the operations assisted by only a junior resident. For better or worse, this scenario is now practically nonexistent. Because of regulatory requirements, billing criteria, and institutional rules, the attending surgeon must be intimately involved throughout all phases of the care of the patient. Rather than making decisions independently, many residents (even chief residents) have been indoctrinated to seek approval for most decisions (management and operative) from the attending surgeon. It is this lack of autonomy that is thought by many educators to be greatly undermining the full ability and confidence of residents to enter practice. CHANGES IN RESIDENT EXPECTATIONS An additional complex issue, interwoven in work-hour restrictions and generational changes, is that there may be a trend toward changes in resident expectations. Residents expect to have a controllable and predictable lifestyle. A survey of program directors, after the institution of the 80-hour work week, found that the total attrition rate increased from 0.6 residents lost per program per year to 0.8 residents per program per year (P ¼ .0013). Lifestyle concerns were the most commonly reported reasons for residents who voluntarily
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discontinued their surgical training. Most (56%) of those who left surgery entered other fields of medicine (most commonly anesthesia and family medicine). The investigators concluded that residents migrate to specialties that are conducive to a more controllable lifestyle despite improvements in work hours and lifestyle during surgical training [15]. Although environmental, technical, and administrative changes have altered the environment in which residents have trained, the residents have changed also. The millennial generation (born in the 1980s or 1990s) has a different set of characteristics than previous generations. They have been termed optimistic, engaged, and team players. They have also been criticized as having great expectations with a sense of entitlement and narcissism [16]. Perhaps the old standard of service leading to experience and education is not the best way for them to learn. LACK OF MENTORSHIP The underlying causes for such gaps in general surgery training cannot rest solely with the administrative, technical, or management changes. It is not a generational gap. Part of the responsibility rests with the surgical attending who is unable or unwilling to mentor residents. The cause of this is multifactorial and nebulous. The combination of work-hour restrictions and administrators has shifted greater responsibility to the attending surgeons for documentation, undoubtedly taking time away from teaching rounds and mentorship. Academic health systems seem increasingly to devalue education and research with a troubling increase in emphasis on clinical production. Productivity decreases when trainees perform major portions of complex operations, compared with experienced surgeons. The structure of surgical training has not changed despite changes in work hours, increasing number of residents within many programs, and further subspecialization. There has been less adaptation to the current reality of training surgeons. The old model continues to be applied to the new reality. A more individualized approach to training surgeons with mentorship would allow the development of trust, autonomy, and better readiness to enter practice. IMPROVING GENERAL SURGERY TRAINING Current and future technology and training protocols may be able to address these shortcomings. Advances in simulation technology provide opportunities that previous generations did not have. Simulation can be helpful in teaching laparoscopic, robotic, endoscopic, or endovascular procedures. Although this can never replace standard operative interventions, it allows the trainee to practice before performing a case, endowing them with fundamental skills that allow them to maximize their learning opportunities [17]. There needs to be a shift in how the readiness of a trainee to enter practice is determined. Instead of a time-based or volume-based residency, there should be a proficiency-based curriculum. There has been a trend toward this in laparoscopy and endoscopy with the introduction of Fundamentals of
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Laparoscopic Surgery (FLS) and Fundamentals of Endoscopic Surgery (FES). In addition, many centers use the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) to help track residents’ progress and attainment of proficiency in flexible endoscopy. A similar assessment tool, Global Assessment of Advanced Laparoscopic Skills (GOALS), has been adopted by The Fellowship Council for augmenting the training of residents for a wide spectrum of operations [18]. Current efforts to promote and implement early subspecialization may help resolve issues of scope of practice and lack of mentorship. Narrowing a trainee’s practice may optimize development of expertise and proficiency within a specific area by allowing the trainee to work with a smaller group of surgeons that may foster mentorship. Moreover, trainees are more likely to become integrated into the operational practices of surgeons within a similar specialty, thereby providing them with early practice management skills [19]. One of the consequences of implementing work-hour restrictions may be the need to extend the length of residency. It already seems to have occurred voluntarily, because 80% of residents are entering fellowships. The American College of Surgeons has recently established Transition to Practice fellowships at several institutions, which may be a viable option to bridge the deficiencies in general surgery training until the current gaps are addressed, although several barriers to its widespread implementation exist [20]. SUMMARY The practice of surgery has undergone tumultuous changes over the last 30 years. Disease management, trauma volume, operative techniques, supervision requirements, and allocation of work hours have all changed, resulting in a substantial impact on general surgical training. Changes need to occur in the structure, assessment, and mentorship of future residents to prepare them to enter the marketplace and practice safe medicine with confidence and authority. References [1] Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg 2013;258:440–9. [2] Chung RS, Wojtasik L, Pham Q, et al. The decline of training in open biliary surgery: effect on the residents’ attitude toward bile duct surgery. Surg Endosc 2003;17:338–40. [3] Carson JS, Smith L, Are M, et al. National trends in minimally invasive and open operative experience of graduating general surgery residents: implications for surgical skills curricula development? Am J Surg 2011;202:720–6. [4] Alkhoury F, Martin JT, Contessa J, et al. The impact of laparoscopy on the volume of open cases in general surgery training. J Surg Educ 2010;67:316–9. [5] Hedrick T, Turrentine F, Sanfey H, et al. Implications of laparoscopy on surgery residency training. Am J Surg 2009;197:73–5. [6] Joels CS, Langan EM 3rd, Cull DL, et al. Effects of increased vascular surgical specialization on general surgery trainees, practicing surgeons, and the provision of vascular surgical care. J Am Coll Surg 2009;208:692–7. [7] Gow KW, Drake FT, Aarabi S, et al. The ACGME case log: general surgery resident experience in pediatric surgery. J Pediatr Surg 2013;48:1643–9.
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[8] Patel MB, Guillamondegui OD, May AK, et al. Twenty-year analysis of surgical resident operative trauma experiences. J Surg Res 2013;180:191–5. [9] Kairys JC, McGuire K, Crawford AG, et al. Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg 2008;206:804–11. [10] Picarella EA, Simmons JD, Borman KR, et al. ‘‘Do one, teach one’’ the new paradigm in general surgery residency training. J Surg Educ 2011;68:126–9. [11] Antiel RM, Van Arendonk KJ, Reed DA, et al. Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: views of surgical interns compared with program directors. Arch Surg 2012;147:536–41. [12] Schwartz SI, Galante J, Kaji A, et al. Effect of the 16-hour work limit on general surgery intern operative case volume: a multi-institutional study. JAMA Surg 2013;148:829–33. [13] Antiel RM, Reed DA, Van Arendonck KJ, et al. Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA Surgery 2013;148(5):448–55. [14] Jamal MH, Doi SA, Rousseau M, et al. Systematic review and meta-analysis of the effect of North American working hours restrictions on mortality and morbidity in surgical patients. Br J Surg 2012;99(3):336–44. [15] Everett CB, Helmer SD, Osland JS, et al. General surgery resident attrition and the 80-hour workweek. Am J Surg 2007;194(6):751–6. [16] Twenge JM. Generation me: why today’s young Americans are more confident, assertive, entitled–and more miserable than ever before. New York, NY: Simon and Schuster; 2006. [17] Sachdeva AK, Buyske J, Dunnington GL, et al. A new paradigm for surgical procedural training. Curr Probl Surg 2011;48(12):854–968. [18] Gumbs AA, Hogle NJ, Fowler DL. Evaluation of resident laparoscopic performance using global assessment of laparoscopic skills. J Am Coll Surg 2007;204(2):308–13. [19] Nasca TJ, Philibert I, Brigham T, et al. The next GME accreditation system–rationale and benefits. N Engl J Med 2012;366(11):1051–6. [20] Richardson JD. ACS transition to practice program offers surgical residents additional opportunities to hone skills. Bull Am Coll Surg 2013;98(9):23–7. Available at: http: //www.facs.org/fellows_info/bulletin/bullet.html. Accessed November 17, 2013.