We need to start a revolution in surgical education

A few months ago I read an essay by Dr. Herbert Fred of Houston, Texas. After reading his essay, “Medical Education on the Brink,” I was inspired to start a revolution in surgical education.

His essay ends with the following recommendation:

“…raise the bar of performance in all training programs to a distinctly higher level, with excellence as the perpetual goal.”

As the Fourth of July approached, I began to view his remarks as a call to arms for a revival of classic medical education.

Coming from Massachusetts, I felt that I could take some liberties in re-writing the original call to arms document – the Declaration of Independence.

I decided to rewrite it after reviewing Medical Education on the Brink as well as several articles bemoaning the increasing board failure rates in internal medicine, surgery and thoracic surgery.

To their credit, influential members of the American College of Surgeons reviewed the current state of surgical education and revealed that the exam failure rate had increased to almost 30 %.

Their assessment was:

1.”This is a scary situation.”

2. “We have a problem. I maintain that we have to stop being bullied by naive, public, politically driven agendas and by some of our own graybeard pundits – and I think we all know who those groups are – and once again take over the control of educating our successors.”

3. “During the past decade the failure rate on the American Board of Surgery’s oral exam has climbed steadily from 16% to 28%.”

After reading this I came across another article analyzing the increasing failure rate of my colleagues in internal medicine. I then read an article about the American Board of Thoracic Surgery’s oral board examination.

The failure rate of that exam has doubled between 2000 and 2011 (14.4% to 28.1%).

I believe that there has been an overall loosening of educational demand on resident physicians in all specialties.

Many of my colleagues share the same view. A rigorous knowledge of human pathology has been subordinated to a constant drumbeat of respect for resident self-esteem.

One must deliver every essential medical lesson in a warm and nurturing manner paying full attention to the psycho-social and ethno-cultural needs of the resident.

This kinder, gentler educational environment has resulted in many residents feeling better and better about knowing less and less.

The result may be a doctor who feels great about knowing nothing.

Unfortunately for future patients, human pathology did not get the hostile work environment memo.

After reviewing the shackles that have been placed on medical educators by various regulatory and governing committees, I began to think about my New England roots. I thought about the citizens of Boston in the 1700’s who were trying to forge a new existence in the Colonies.

Their progress was thwarted by shackles placed upon them by regulating bodies many miles away.

So what did they do?

They figured they could do it better on their own, so they declared their independence and put it in writing.

Thomas Jefferson wrote it and 56 patriots signed it. The rest, as they say, (and I am semantically correct here) is history!

So one Saturday afternoon, I carefully reviewed the Declaration of Independence.  I decided that classically educated surgeons (and all classically educated physicians) should do the same thing – declare their independence from a far removed governing body that was hindering their growth and prosperity.

My generation, classically educated, produced some weird and unusual people.  But they were great educators and marvelous surgeons.

They were characters with character!

Many of these physicians were politically incorrect. Some were tired and occasionally insensitive. But they could dig out a necrotic colon at 3am. They could control exsanguinating hemorrhage after leaving their anniversary party. They could crack a chest, save a gunshot wound victim then regale the resident with a few Halsted and Billroth anecdotes.

These physicians were, in a word, inspiring.

I suppose that most of my surgical heroes if they were in the current system would be referred to various well-being committees. They would have to undergo gender and cultural counseling. Many might have even been suspended or had their privileges amended.

But they had all passed their boards and they could all do their job.

So here it is – a Declaration of Surgical Independence:

I hope, in some small way, that this will “raise the bar of performance in all training programs to a distinctly higher level.”

Leo Gordon is a surgeon. This article originally appeared in General Surgery News. For a copy of the Declaration of Surgical Independence, contact Dr. Gordon at SurgicalIndependence@gmail.com.

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  • FFP

    I think oral boards are highly subjective and together with college admission interviews should go the way of the dinosaurs.

    • Suzi Q 38

      I would think that the oral boards would have some merit.
      A multiple choice exam is fine, but is it real?
      I see the merits of both.
      You can get the highest test scores throughout medical school and beyond, but are you a good diagnostician?
      Are you good with working with real people?
      Do you get so nervous that you can not think or speak?
      I would think that the oral boards might add another challenge or dimension to the evaluation of a physician.

      • FFP

        What other challenges would you like, Suzi Q? A decathlon maybe?

        I mean, seriously, stop assuming that the graduate medical education programs let just anybody graduate.

    • Leo Gordon, MD

      I think that you can get a better overall assessment of an individual with an oral examination. An examiner can present several if/then scenarios and gain a much better picture of the individual’s ability to think during a changing medical landscape.

      • FFP

        I don’t see any increase in iatrogenic mortality or morbidity in the 90+% of the medical specialties which do not require oral boards. Not only that, but even in specialties that still require oral boards, ~99% of the practitioners will end up passing them before becoming unemployable. So who benefits from this many million dollar industry?

        As of now, the (oral) board certification exams don’t make much difference in predicting a physician’s knowledge and value; all of us know enough medical morons who are board-certified.

        • EmilyAnon

          I think you contradicted yourself.

          In one post you say you “know enough medical morons who are board-certified”. Then in another post you say “stop assuming that all the graduate medical education programs just let anybody graduate.” So how did those “medical morons” you know graduate from their medical education programs in the first place.

          • FFP

            Because some doctors have great people (read “sales”) skills that can easily fool other PEOPLE. They can bullshit their way through most situations, including oral exams.

            It’s much tougher to bullshit a good multiple-choice or simulation exam. The computer has no likes or dislikes. The higher one puts the passing score, the more bullshiters one catches.

            Anyway, the main problem with the system is that it does not do what it was designed to do: keep the good, filter out the bad. If the (oral) boards were a lab test, nobody would use it (insufficient sensitivity, specificity, and predictive value, in my very subjective opinion).

          • EmilyAnon

            This doesn’t bode well for the unconnected patient whose only option is to trust.

          • FFP

            Not even I, as a doctor, know whom to trust in an unconnected specialty. Not one single thing has a reasonable predictive value: (lack/type of) board certification, academic title, research, books, word of mouth, people skills etc. My family had negative outcomes with all of these. The only thing that made a difference was true passion.

            Trust your gut and don’t be afraid to ask questions and to shop around for the best doctor.

  • Dave

    I wonder if part of the problem is this: for a great many residents, the oral board exam is the first non-multiple-choice exam of their medical training. The skills involved in an oral vs. written multiple choice exam are very different. I would be curious what percentage of those who failed the orals would be able to pass a multiple choice test covering the exact same material. Is the problem a lack of knowledge or a lack of ability to think on one’s feet?

    • PollyPocket

      Not sure if general surgery oral exams are the same as ortho, but a substantial portion of the latter is simply case review: what did you do in this case and why, what was the outcome, what are some alternatives, etc. the exam is not only dynamic, it is tailored to the individual physician and his or her experience.

    • Rebecca SA

      I agree it’s a different skill set. Everyone who got to the oral boards passed the multiple choice written,. So I don’t think failing is a knowledge problem. It’s about knowing how to present the information in the way the examiners expect it to be delivered.

  • rbthe4th2

    I think my scare is that I’ve seen some of the older crowd. While they can do their stuff, they made some “assumptions” that could have used a bit of “personality adjustments”, since those assumptions made a difference in patient care. What about maybe a combination of both those styles? Do we really need to try to obliterate a persons’ character for a minor mistake or can we try a softer approach? It might be possible to get the velvet glove to teach without resorting to stronger measures. Then again, depends on the person. I could be told no and be fine with it. My cousin needed a spanking about 5 times before he got it.
    How about a happy medium?

    • FFP

      One of the problems with healthcare nowadays is that it’s so corporate, that it takes a mount of time/paperwork to “correctly” discipline an incompetent employee. One cannot just truly discipline a stupid person on the spot (so that s/he will remember not to do it EVER AGAIN), because nowadays everybody belongs to some minority, it’s not politically correct, not due process, “disruptive” and other BS.

      It’s almost unbelievable that we as doctors accept a situation where we are the ones legally responsible for 99% of our patients’ outcomes, but we cannot hire and fire not even our own secretary, not to speak about choosing the nurses, techs etc.

      • rbthe4th2

        Thank you for that very insightful comment. I’ve seen few people willing to speak about it like this. Much like the government huh?

  • Karen Sibert MD

    Great piece, Dr. Gordon! If you’re not able to take criticism as a resident, you have no business being responsible for anyone’s life. The best physician-teachers I had were also the toughest. You earn self-esteem by performance and hard work, not by false praise when it’s not warranted. You succeed as a physician by what you know and what you can think of in time, not by what you can look up quickly on Wikipedia.