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.

Why I left academic medicine

A medical student who thinks he wants a career in academic surgery asks, “You were deep into academic medicine and walked away from chairman, program director, etc. Why?"

[Background: For over 23 years, I was a full time surgical chairman and residency program director in three different community hospitals affiliated with medical schools.]

Good question. For many years I had always said something like, “No matter what crisis happens with the residents or the chairman’s job, it pales in comparison to having a patient with a complication.” In other words, non-clinical problems were annoying but manageable.

Then one day I realized that was no longer so. Patients with complications still caused me many sleepless nights and that hadn’t changed. What had changed was that resident issues and administrative hassles finally became intolerable.

The rules set by the accrediting bodies, the ACGME and the Residency Review Committee [RRC] for Surgery, had always been difficult to comply with, especially for a small program. They became more onerous every year or two until it reached the point where I can’t imagine how anyone can stand it. Residents can complain to the RRC anonymously and no matter how factually you refute the complaint, the RRC always believes the disgruntled resident. Add in the work hours rules and the lack of motivation of some of today’s med school graduates and I had had enough.

The position of surgical chairman in a community teaching hospital is like that of a football referee. At any given time, half your constituency is not happy with you. The administration pays your salary and expects you to spout the party line. But you need your attending surgeons to treat the residents well and support the program. Many times you have to make decisions that are guaranteed to alienate many people.

A lot of energy was spent investigating complaints. Families were unhappy with the residents; attending surgeons were unhappy with the residents and conversely; nurses were unhappy with the residents and/or the attendings; someone was rude to someone else; someone shouted; someone cried and on and on.

And the site visits. Drop everything; the state is here to investigate a case or the state is here to interview the residents about their work hours. The Joint Commission is coming in six months. We need to meet twice a week to make up for all the unnecessary but JC-mandated stuff we haven’t been doing for the last two-and-a half years. Countless hours were spent buffing up the paperwork for an RRC site visit. I think that’s where I learned creative writing.

And the meetings. Risk management meetings could last three hours during which time you would have the opportunity to try to explain why a surgical complication occurred to a room full of non-surgeon MDs and non-physician administrators. We used to deal with this sort of thing quite effectively at morbidity and mortality conference.

Then there were the committees. At one of my former hospitals I was either chairman or a member of the following committees: Pharmacy, Critical Care, Infection, Medical Executive, Operating Room, Surgical Performance Improvement, Strategic Planning Work Group, Product Evaluation, Library, Clinical Leadership Group, Cancer, Trauma, Budget, Graduate Medical Education, and Risk Management. I’ll save you the trouble. That’s 15 committees.

For a long time, I enjoyed being a residency program director. I am proud of the more than 50 chief residents I helped train. I view them as my legacy. I regret that running a program and teaching residents stopped being fun a few years ago. I also liked being a chairman until medicine took a turn toward the dark side.

I could go on but this post would reach 20,000 words.

So my young friend, think long and hard about that decision to become an academic chair.