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.

A med student with issues wants to be a surgeon

An osteopathic medical student writes that she is older than most students, failed a course in her first year of med school, had to take the COMLEX (osteopathic equivalent to USMLE) several times before passing. She has earned good grades in her third-year rotations. 

She said, "I found your blog one night earlier this week while doing research on obtaining a surgical residency. After reading your blog, I thought you might be able to help. What can I say to programs and put in my application to make me stand out as someone who they would value and honestly consider?"

I appreciate your reading my blog. As you have correctly pointed out, you have some problems. I hope you can handle the truth (from the movie "A Few Good Men").

1. You are an osteopathic student, which may adversely affect your ability to obtain a general surgery residency by a little to a lot, depending on where you  apply.

2. You are a non-traditional student (not so bad) but your age of 33 is another issue. Should it matter? No. Does it matter? In my opinion, yes.

3. You had some trouble in the first year of school. That is usually a red flag, and many program directors would not get past that part of your dean's letter and transcript.

4. You have "struggled with the COMLEX and have had to take it multiple times" and you have not taken the USMLE.

With the disclaimer that this is strictly my opinion and I cannot say how you would be viewed by other PDs, your chances of matching to a categorical position in general surgery are slim. 

What can you do to improve the odds? Here's what I would suggest.

To counteract the COMLEX issue, try to take at least USMLE Part I and do very well on it.

In your personal statement, you should own up to the concerns just as you did in your email to me except that you need to condense everything into a much shorter document. You should emphasize that you have conquered these shortcomings. You need to find med school teachers, particularly surgeons, who know you well and are willing to write exceedingly strong letters of recommendation. A letter from someone who a PD might have heard of would not hurt.

You then have to wait and see if you are invited for any interviews. If you are, you need to impress everyone with your charm, work ethic and intelligence.

You also need a "Plan B." Would you take a non-designated preliminary slot hoping for someone to falter or quit so you could transfer into a categorical position? It is risky because you might end up wasting a year or two and have to take a residency in something else anyway. That's not a big deal if you are 26 when you graduate from med school, but for you it would be.

Another option would be to do an internal medicine residency and specialize in GI or cardiology which are procedure oriented. It's not surgery, but it might be satisfying and certainly would be easier to achieve. 

You didn't mention whether you had significant student loan debt or not. That needs to be factored in if you are considering the non-designated prelim choice.

I hope this helps. Let me know how it turns out.

Good luck.

Non-US citizen at a Caribbean med school wonders what his chances are for getting a surgical residency

"Leighton" (not his real name) writes,

I'm a 4th yr medical student hoping to match into general surgery in 2014. The only hurdle is that I'm an international medical graduate (IMG). I'm a non-US citizen at a Caribbean med school.

I have done all my core rotations which include IM, Psych, Gen Surg, Peds and OB/GYN. So far I have all As in my rotations. I did my surgery rotation at Elsewhere General Hospital in the Midwest. It's a community hospital without a surgery residency program.

I have a pretty good USMLE step 1 score (247) and will be writing step 2 in the coming months. Since you have been a residency director, what can I do to improve my chances? What do residency programs look at? What programs might be more IMG-friendly? Surgery is quite competitive, do I have a chance as an IMG or should I focus my electives more for IM or Family med?

Data for the 2012 match (page 5) shows that general surgery filled 1143 (99.7%) of 1146 available categorical positions via the match. Of the 1143 who matched, 57 (4.9%) were non-US citizen IMGs.

While your USMLE score is very good, I don't know if it puts you in the top 5% of all non-US IMGs. 

I'm afraid it is difficult to judge what your grades mean, but that is also a problem with US med school grades. (See a previous blog of mine.) Certainly, all 'A's are better than all 'B's in any school. But how many students in your school get all 'A's?

The only way to find out if a program is IMG friendly is to go to each program's website and see where their current residents are from. Here's a link from ERAS, that gives the web addresses for all of the general surgery programs in the US.

See if your school has any information on how many of its students matched in general surgery over the last two or three years, what their records were like and where they matched. You might also try to contact a couple of those students for advice too.

I'm not sure how to improve your chances. Doing research never impressed me unless it was clinical research that resulted in a published paper in a journal that I had heard of. You might explore elective rotations at some programs that you know have taken non-US IMGs.

The way the match works favors the applicant. You have nothing to lose by trying to match in surgery. If you fail to get a categorical spot, you have two options. You can take a preliminary position and hope to work your way into a categorical one. There were 737 484* surgical prelim positions open after the match last year. However, that can be risky if no categorical spots open up.

Or you could go into internal medicine, which had only 51 unmatched positions or family medicine which had 149. The link to the NRMP match statistics shows all the specialties and how they fared in the 2012 match.

If you decide to pursue surgery, you will need to tailor your electives accordingly. I have written about fourth-year electives.

I hope this helps. Good luck and let us know how it went after next year's match.

[*Number of unfilled prelim positions corrected on 2/27.]

Does OR staff hair cause infections?

“Zlatan” (not his real name) writes:

I just recently found your blog and read about shaving patients and agree with all that you said. My question is about the staff's hair. Sorry if you have addressed this, I couldn't find it. 

I work at a VA hospital in surgery. I have been in the OR environment for 30 years and have seen quite a lot and been through many inspections. We had an independent nurse evaluate us for upcoming JCAHO inspection. We 'failed' due to not covering facial hair and chest hair with scrub attire and in addition were told folks with hairy arms needed long-sleeve scrub tops. Of course this comes from the all powerful AORN. Being an evidence-based person at heart, I began to look for some evidence regarding covering up (that is how I stumbled onto your blog). Do you have any knowledge of evidence based practice regarding hair covering and infection rates? I appreciate your time.

Thanks!

Great question. Where do they come up with these things? Chest hair? Arm hair? Long-sleeve scrub tops?

For the record, I am against wound infections. I would do anything reasonable to try to prevent them.

I suspect your independent nurse evaluator may have over-interpreted the rules. My distaste for the Joint Commission (by the way, it’s no longer called “JCAHO”) runs deep, but I don’t think even they have thought of those wrinkles to the hair issue.

It is possible though as the JC and the AORN seemed to be obsessed with hair.

How does one define "hairy arms"? I assume long sleeve scrub tops would be for the circulating nurse only. If the surgeon and the scrub tech wore long sleeves, they wouldn’t be able to properly wash their hands and arms.

Regarding the chest hair, are we talking male or female staff? (Just kidding.)

As far as I know, there is not one shred of evidence linking shed skin or hair on the head, face, chest or arms of OR staff to patient infections. This is after an exhaustive search of PubMed, CDC, and holding nothing back, I even crowd-sourced the question on Twitter.

In case some readers missed my post on the ritual of clipping the hair of patients before surgery, the link is here. The post was about rules that people make up without any justification to drive us all crazy.

I collected several such rules related to presumed infection prevention in the comments section of that post and elsewhere. Here they are.

No forced-air warming until patient is draped.
No briefcases in the OR.
No one may enter the room without the circulator's permission.
No room warming as it may cause condensation on surgical instruments. (Children and burn victims who may become hypothermic be damned!)

Remove masks every time you leave the OR. And no letting them hang down with just the lower tie done.

Masks must be worn by anyone in the scrub sink area even if that person is not scrubbing but just walking by.

All OR personnel must wear long sleeves because of the potential for "shedding skin."

But the independent nurse reviewer has spoken. I’m betting that long sleeve scrub tops and chest and arm hair police will soon appear in your OR.

A patient wants to know when to speak up

Matthew writes:

My only experience with the medical profession is strictly as a patient. I'm wondering what is an appropriate balance between being an educated patient (willing to ask questions, make observations, etc.) versus being one of those supposedly "self-educated" know-it-all patients that I'm sure are one of the banes of a doctor's existence.

We've all heard the stories of the patient whose doctor didn't listen to their concerns until it was too late, but on the other hand, I don't deny that my doctor knows worlds more about my body than I do, or ever will.

I want to trust my doctor, but without having to blindly accept whatever he tells me. Yet I've dealt with members of the medical community who see anything BUT blind acceptance as a personal affront.

As such, is there ever a time to research symptoms online before making an appointment? Is there ever a time to disagree with a diagnosis? Is there ever a time to request or ask about alternate treatments? And if so, how can this be done in a way that is respectful to my physician?

You ask some excellent questions.

I’m not sure I have all the answers. I hope some of my physician colleagues will comment. 

There is a fine and very fuzzy line between asking good questions and being a pain in the ass. And that line is drawn in different places by different doctors. It ranges from zero tolerance for questions (See Dr. Sung on “Monday Mornings,” who, when asked a question about a procedure he recommended, said, “Not do—dead.”) to the most open-minded, usually a primary care doc or psychiatrist. There are issues of time, urgency, the physician’s perception of the patient’s level of understanding, the complexity of the disease or operation and many more.

I had no problem with patients who researched their symptoms online. However, I would hate it when a patient brought a portfolio with 100 pages of downloaded material for me to comment on. There is a lot of garbage on the Internet.

I think you should always ask what your options are. Informed consent discussions should include the risks, benefits and alternatives for any procedure. The doctor should also tell you what the risks and benefits of the alternatives are too.

Go with your gut. If what the doctor says to do does not sound right, say you will think it over. Don’t be afraid to get a second opinion. Run away quickly from any doctor who discourages second opinions. I always encouraged second opinions for patients who were reluctant to have surgery I recommended. I felt that if I was proposing the right thing, the second opinion doctor would support me.

One of the worst things a patient can do is be too acquiescent to the physician. I used to tell patients “Don’t worry about hurting your doctor’s feelings. This is your life we are talking about. The doctor will get over it. If she doesn’t, you don’t want her as a doctor anyway.”

Another question about choosing a specialty, this time from a wife

I recently came across your blog, and I have found it very insightful. What you can recommend in terms of advice for my husband and me. My husband is a 3rd year medical student, and he is not sure what type of residency he wants to go into. He has finished most of the required clerkships (peds, surgery, surgery sub-specialty, and family). Currently, he is finishing up internal med, and will do psych next, then obgyn. We constantly check in on what he is interested in, and weigh the pros can cons of each in terms of possible residency choices. He loves ped surgery, surgery, emergency med, and certain aspects of internal med. What he and I find most challenging, is how does he pick between medicine and surgery, when you've only had limited exposure to both, and enjoy both? What type of advice can you give regarding this aspect?

Also, what advice could you offer to the spouses of a medical student? I want my husband to be happy in his chosen field, but I just want to make sure that I AM happy as well. For instance, my husband LOVES peds surgery; however, it is a long road to get there and extremely competitive. If he did decide to go this route, then it would be years of general surgery residency, fellowships, research and with only 30 pediatric surgery spots in the nation, it might be near impossible to get into. If he did decide to do this, I would never see him (and I'm already finding medical school difficult because we hardly see each other). So, I'm hoping you have some insight or words of wisdom regarding what kind of advice and support will be beneficial for both of us during this difficult time? I don't want him to go through years of medical school, only to "settle" for a specialty that will not give him any joy or purpose. However, I want to make sure that I will be happy, and I know "settling" for certain specialties gives you a decent work/family balance. Is there any advice you can provide regarding this very important decision in his medical career, and any possible next steps?

Good questions and I'm afraid there are no simple answers.

Here's a link to a blog I wrote (which contains a link to yet another) on the subject. Both pertain more to the situation with married female doctors but much is universal.

Peds surgery is pretty competitive with about 2+ applicants for every slot. Last year there were 40 positions offered. Here's a link to the data:

Go to page 61 for the peds surgery stats. All other fellowships that are NRMP matched are in this report.

Unless your husband does something that's a 9 to 5 specialty like derm (also very competitive) or radiation oncology, long hours are part of the deal. Also, the degree of boredom of a specialty is inversely proportional to the hours. For example, PM&R is very boring but the hours are short.

I have always maintained that one must choose a specialty that one likes and not base the choice on money, prestige or hours. Your husband will have to go to work every day for 35-40 years. It's hard to do that if you hate it. There are a lot of unhappy docs out there and many of them did not choose their specialties wisely.

I wish I had a magic solution for you and him. I regret I do not.

Choices: University program with research or not?

I am a 4th year medical student who is going into general surgery, and I wanted to ask you a question as I'm getting my rank list in order for the upcoming match.

I've been a good student and hopefully have a lot of doors open for me for my rank list. I had a few interviews at some "top-tier" programs (more research heavy, but also big names) and plenty at very good "middle" programs. I'm pretty confident that I want to be a community surgeon when all is said and done, but I most definitely will want to do a fellowship. At this point, I think that would be in colorectal surgery.

I feel conflicted about my rank list, though. Several people have told me that it would be stupid not to rank the top-tier programs first, and part of me feels like I should go for these big names. However, at this point I don't think I want to do 2 years of dedicated research during my residency, which is a requirement at these top-tier programs. Unless, of course, colorectal fellowships are getting more and more competitive and that's what it will take to get in them.

Plus, I feel deep down that some of these middle programs actually have a better operative experience, as there are busy county hospitals (giant trauma centers) affiliated with them where I feel the residents get unparalleled opportunities to operate more and with more autonomy.

Honestly, I think I really want to rank some of these "middle" programs over the "top-tier" ones, but I keep on trying to convince myself that I want to "go-for-the-gold," as it is.

I fully plan on being productive in clinical research during my residency (I have 3 publications already) so I'll [hopefully] garner more publications during residency, but, in your opinion, are 2 years of dedicated research something that I should really be thinking about? Are more and more surgeons doing that type of dedicated research work in order to get fellowships? At the end of the day, I just want to be able to operate confidently, get the fellowship I want (no plans for surg onc or peds at this point), and help patients. Any advice or comments you have  would be extremely helpful and appreciated.

I posted this email with a bit of editing for length and confidentiality but wanted other readers to see what is going through your mind. It is a difficult decision.

Let’s take the easy part first. The 2012 colon and rectal fellowship match statistics show that there were 129 applicants for 90 positions and 73% of US med school grads matched. With three published papers (two of which are in respected surgery journals) already and probably more to follow during your residency, I can say with confidence that you will have little or no trouble obtaining a fellowship in colon and rectal surgery. Statistics are available here for most of the other specialty matches too.

Now, let’s look at your personal situation. I share your concern regarding the two major issues you raise.

If you are fairly certain you don’t want an academic career, is spending two years doing research worth it? As noted above, it is not a sina qua non for colorectal training. Also, should you change your mind and decide later that you do want an academic career, you can do extra research time in many fellowships.

Operative experience generally begins earlier and is more extensive in non-university programs. This is not just my opinion. As I explained in a blog last year, a survey showed that residents in community hospital programs were “statistically significantly more satisfied with their operative experience and less likely to worry that they will not be confident operating by themselves after they finish training than university trainees. Surprisingly, they were also happier with the level of didactic teaching than university-based residents.”

You did well in medical school, have excellent scores on USMLE Parts I and II and have less than $50,000 in student loan debt. You are in a position to do exactly what you want.

I think you will probably match at every program on your list. General surgery residency is a long and difficult time. You should pick the program that you think you will be most happy in.

I hope this helps.