Wednesday, August 13, 2014

Applicant worries about the future of surgery

A medical student writes:

I am a few weeks away from applying for residency training in general surgery. Lately I've been lamenting that I was not born in the 1950s. I worry that the physician that I became enamored with so early in life is looking more and more like the surgeon I may never become.

Increasing enthusiasm for innovation in surgical technology is subtly paving a road toward a time in which a surgeon may be rendered obsolete. The rise of the two M's—machines and mid-levels—may herald a very different future from that which I ever imagined.

I love to solve problems and stand (not sit!) above an anesthetized patient making use of my hands and tools directly. There has never been a higher challenge than surgery which involves clinical skills in diagnosis, peri- and intraoperative disease management, and a sense of duty, service, and sacrifice. And now, robotics calls into question why hands might ever need to be laid on patients, and time-honored sutures are replaced with Silicon Valley-prescribed tinker toys.

Many articles call into question the relevance of physicians, particularly surgeons, in the not-too-distant future.

Will mid-level providers take away many general surgery cases? Will opportunities to function as a surgeon be threatened by the relentless emergence of technological or perhaps financial pressures? Are surgical societies actively confronting these issues?

I see you have thought about this in depth.

The PAs I have worked with did a lot of rounding, H&Ps, clinic work, and discharge summaries. In the OR, they assisted and closed skin. In some specialties, they do more such as harvesting vein grafts and closing fascia.

Here's an interesting anecdote about a PA who excised a neck mass by himself. He smelled it, said it was a benign sebaceous cyst, and threw it away. When the mass recurred, a surgeon biopsied it and found squamous cell carcinoma.

I don't see robots operating independently for quite a while, if ever, although NASA apparently has a robot that can be inserted into the abdomen and perform an appendectomy while being controlled remotely.

There is much variability in the location of the appendix, the inflammatory response, and the location of surrounding structures. How can a robot can ever be programmed to do this supposedly simple operation without human guidance?

If NASA has a miniature robot, it may be possible to control it while standing next to the patient. Having never seen it, I just don't know.

Surgery will undoubtedly change a lot in the next 40 or 50 years. As I wrote here, it certainly has since the 1970s. It might change at a faster rate too. But surgeons have adapted well, and they will continue to do so.

Surgical societies have not exactly shined during all of these changes. When laparoscopic general surgery was introduced in about 1990, mainstream surgical leaders called it heresy and were slow to catch up. Conversely, few said anything about the introduction and widespread acceptance of the da Vinci robot, which has not been shown to improve outcomes despite all the fanfare and expense.

Someone (the feds?) will have to put the brakes on unproven technologies or the country will go broke.

So if you want to be a surgeon, go for it, but be prepared for change.

Tuesday, August 5, 2014

Board passage rates and residency program quality

I am 3rd year med student thinking of surgery programs to apply to next year. I came across this document on the American Board of Surgery website. It shows the qualifying exam and certifying exam first-time pass rates for general surgery residents between 2008-2013.

Is this a worthwhile marker for evaluating surgery programs and identifying top programs? Also, is first-time pass/fail on the QE/CE a measure of preparation to practice as a general surgeon upon graduation or is it poorly correlated with a graduate's ability to function independently?

I have a moderately competitive Step 1 score and I want to choose a program that would make me a general surgeon without needing to take a fellowship upon graduation.

[Note: The email was edited for length.] 

Thanks for asking a couple of really good questions. The answers are not black and white. On page 23 of its requirements, the Residency Review Committee (RRC) for Surgery states that board passage rate is one measure for evaluating program effectiveness, and "At minimum, for the most recent five-year period, 65% of the graduates must pass each of the qualifying and certifying examinations on the first attempt."

A quick look at the board passage rates in the ABS document shows that 31% of programs, most of which are community hospital-based, did not reach the magic 65% quota.

Two years ago, I blogged about the two major reasons why the 65% board passage threshold on the first try discriminates against community hospital programs. You can read the full piece here, but briefly one issue is that university hospitals attract smarter residents who are better test takers, and the other is that smaller programs are statistically more likely to have test result outliers.

I am unaware of any correlation between passing the boards on the first try (or the second or third tries) and a surgeon's ability to practice independently. In fact, another post I wrote discussed a paper that surveyed 4882 surgical residents. It found that community hospital trainees were more satisfied with their operative experience and more confident that they could work independently than those who trained in university programs.

But there is another consideration. Fair or not, programs with first-time board passage rates chronically below 65% are at some risk for both RRC probation, which is detrimental to recruiting, and possible discontinuation. It is difficult to quickly turn around a low board passage rate because the number of graduates is small in most community programs and the stain left by a failed first-time taker lasts five years.

So what should you do?

Perhaps you should play it safe and apply to community hospital programs with adequate first-time board passage rates.

Comments from surgical educators, current residents or recent graduates of surgical training are welcome.