Why do we teach surgery the same way we did 40 years ago?

When I was a surgical residency program director, I often wondered what the establishment, you know those guys who ran surgical education, was thinking. Some may remember the rule that a resident had to see at least 50% of the patients he operated on in the clinic or the private surgeon’s office in order to claim credit for having done the case.

There was the emphasis that still exists today on making sure every resident did research. At last, some are questioning the value of this for the average clinical surgeon. Contrary to the prevailing wisdom, there is no evidence that a resident who is dragged kicking and screaming through a clinical research project or who spent a year in someone’s lab really learns anything about research or how to read and understand a research paper. Then there is the obsession with a transplant rotation, recently noted to be a waste of time in the opinion of surgical residency program directors.

And what’s with all the emphasis on basic science? Shouldn’t the residents have learned all the basic science they need (and more) in medical school? With all that is new in clinical surgery, why are residents forced to relearn basic science that they will not ever use in practice? When you stand at the bedside of a sick patient, do you ask yourself, “How is lactic acid formed”? Or do you simply order a lactate level?

Why do we teach surgery the same way we did 40 years ago? Instead of teaching residents how to think, we still force them to memorize large volumes of information that they can carry in their smart phones.

Now I am wondering what is going on with clinical training. A recent paper found that residents are concerned that their operative skills are inadequate.

Last year in a blog reviewing that paper, I wrote, “A significant number of all residents surveyed worried that they would not feel confident to perform surgery by themselves when they finished training. A similar number were not satisfied with their operative experience.”

Many graduates of residency take fellowships to gain extra experience. Especially interesting is the proliferation of so-called “advanced” laparoscopic fellowships. There was a time when we taught residents all they needed to know in five years. Why can’t residents learn advanced laparoscopy during a five-year surgical residency? Are they too busy memorizing the Glasgow Coma Scale?

I recently heard of a new proposal: there may be a plan to offer “open surgery” fellowships. Details are sketchy, but the idea would be to train surgeons to do old-fashioned laparotomies. It’s not yet clear which of the surgical disciplines (such as vascular, colorectal, hepatobiliary) would be involved or which hospitals have enough volume of open surgery to support such a fellowship.

Maybe we should skip most of general surgery residency altogether and just let them go to their fellowships after a year or two of basic training.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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    These feelings of inadequacy are based on the fact that they do not operate independently as residents. 30 years ago, as chief resident, I took patients to the OR without attendings present in appropriate cases.
    Surgeons need confidence and that is gained by letting them do things and push the envelope. When I was in academics and head of a fellowship program, the fellows learned to take care of the patients. However, times being what they were, I had to be present. But I sat by and let them do their thing.
    There is no substitute for the real thing. No simulation for being responsible. Until you are the person who is on the firing line for that patient, you will never know. That is where surgical education has failed. Time to go back to having chief residents with privileges and the responsibility to take care of people. What is the difference between June 30 and July 1 anyway.
    Yeah, those were the good old days.
    And btw, the call schedules need to go back to the one in 3–stamina, working when tired, under pressure and all that jazz was what made us into surgeons–a different breed. And that was good.
    P.S. I am a woman surgeon, and mother, and wife and rabble rouser extraordinaire.

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