Tuesday, July 30, 2013

Are program directors the reason that surgical residency training is a mess?

A resident writes: "You have been a program director (PD). I read your article about residents not being confident about surgical skills and you conveniently blamed resident work hours limits/resident work ethic for this. I ask you how come PDs are not responsible for the training they provide? How can they get away with telling residents/fellows on what the residents/fellows can say/write on evaluations that accredit the program? How can they get away without providing adequate training/exposure in lap/robotic surgery? How come we don't teach surgeons how to teach surgical skills? Just because one is a good surgeon does not mean they can teach surgical skills to others. After all Michael Jordan was a great basketball player, but that does not necessarily imply he would make a good coach. In fact I would argue that average basketball players make better coaches."
Great questions. Let's see what I can do to answer them.

I "conveniently blamed resident work hours limits/resident work ethic" for the lack of confidence in their skills that >25% of general surgery residents have. That problem was not created by program directors. Most PDs hate it. It certainly is a contributing factor to the lack of resident confidence.
We are responsible for the training we provide. We must sign a form attesting to the competence of our graduating residents. I cannot speak for current PDs, but I felt very responsible for the residents when I was a PD.

I never told a resident what to write on an evaluation. I understand that may happen, but the evaluations are submitted on line anonymously to the accrediting body, the Residency Review Committee for Surgery. The residents are free to say whatever they want and no one will be able to trace it back to an individual. In my experience, the residents did not hold back on their complaints.

I agree with you that we are obviously not training residents well enough in some areas such as advanced laparoscopic surgery. That is difficult to understand and explain. It must be true because so many graduates of five-year programs feel the need to take extra training. I think it is somewhat harder to teach minimally invasive surgery. I always felt I could control what the resident was doing during open operations; for laparoscopic procedures, not so much. But we should be doing a better job in that area.

And it's not just laparoscopy or the American College of Surgeons wouldn't have established "Transition to Practice" fellowships. See my previous blog about this. There is also the problem of too much supervision which I mention in that blog.

I have news for you. In most cases, surgeons are not taught how to teach anything, let alone surgical skills. For many years, it has just been assumed that any surgeon (or any doctor in any specialty) is an excellent teacher. Of course, this is not so.

However, teaching is not particularly valued or rewarded an academic medicine. On the other hand research is, especially research that brings in grant money.

Teaching is also a problem in community hospital programs because attending surgeons are busy trying to stay afloat financially.

I agree with you that Michael Jordan and most other superstars of sport would not make good coaches. It may be similar in surgery. I don't think that has been investigated, nor is such a study likely.

In case you haven't read any of my previous posts (search "surgical education" on the Skeptical Scalpel blog) on this subject, I am pessimistic about the future of surgical education.