The problem of fellows in surgical training

One of my Physician’s Weekly posts last month was on the subject of surgeons possibly losing proficiency for doing open cases because of the ever-increasing popularity of laparoscopic and other minimally invasive techniques resulting in declining numbers of open operations for residents during their training.

Although some suggested that knowing how to do open cases would be unnecessary in the future, to me that is wishful thinking.

Another commenter said, “We are seeing the result of this in one of our hospitals with a new surgeon. He frequently aborts cases when he cannot complete them laparoscopically because he does not know how to do the open procedure. Worse, instead of seeking the help of someone who does, he transfers the patient to a medical center.”

A resident said, “Observing the big name academic center that I train at, it seems that the massive cadre of fellows has led to an extremely low and less interesting case load for the rest of the general surgery trainees. Overload of floor management onto the trainees seems to exacerbate the problem. Why not substitute some of the current residency training with more focused experience with mentors — maybe even community mentors outside of academic centers — who perform the cases they’re lacking?”

The presence of fellows is a huge problem that academic centers and both the Residency Review Committee (RRC) and the American Board of Surgery have glossed over for years. Fellows are usually not present in large numbers at community hospital programs; therefore, the residents get to do more surgery. Last year, I wrote about the fact that community hospital residents are more satisfied and do more cases.

The suggestion about mentors from outside of academic centers seems logical. However, it assumes that there are large numbers of community hospital surgeons who are dying to have residents around. In my opinion, that simply is not so. This is also a concern regarding the new surgical residency programs that are being established. I think some of them have been the result of initiatives by hospital administrators (residency programs still bring in government cash) and not the surgeons themselves.

I find it hard to believe that a hospital that has previously not had a residency program and has private practice surgeons who do nothing but operate can turn itself into an setting where surgical education is important.

Who is going to let the residents operate? Who will give didactic lectures? Who will write the research papers that are required by the RRC to prove that the faculty engages in scholarly activity? And so on.

I don’t think it will work very well. What’s your opinion?

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

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  • David Gelber MD

    I can tell you that if there were residents working at the hospitals where i operate I would be reluctant to let them do the cases. My patients come to me because they want me to do their surgery. They often ask me if I am the one who will be doing the operation. If I wanted to work with residents i would practice at the nearby academic center, not in the community.

    • Skeptical Scalpel

      David, thanks for commenting. Your situation is exactly what I am talking about.

  • guest

    As a physician whose child was a surgical patient, I can assure you I made doubly and triply sure that the attending was the one doing the surgery, not the fellow. I do not mind fellows or residents assisting or even rounding, but I am paying for the attending (and yes, I am paying). I have offered physicians and surgeons cash outside of my insurance to assure good treatment. I suppose this is what it has come to.

    • Skeptical Scalpel

      Guest, interesting comment. I guess if everyone felt the way you do, we would never train another surgeon.

      • guest

        Point noted. My next question: would you let a resident or fellow do your surgery? Seems that most of us are honest that while residents and fellows need to learn on SOMEONE, that someone will not be us or our families.

        • Skeptical Scalpel

          Yes. Residents and fellows have operated on me and members of my family. I was a residency program director for 23+ years. You can’t have it both ways.

          • EmilyAnon

            But Skeptical, you being a surgeon know who the star residents or interns are, maybe you even trained them. At the very least you have the resources to vet them and refuse their participation if they don’t meet up to your standards. That has to give you at least a little peace of mind. Average patients don’t know who does what to them in the operating room. Most of the time we don’t even meet the trainees who will be in our care, or know their names, let alone where they are in their training. The only reference we have to operating rooms is that they are secret, potentially dangerous places.

            It’s obvious patients are needed to facilitate the new crop of surgeons, but isn’t our hesitation understandable?

          • Skeptical Scalpel

            That would be true if I had undergone my recent shoulder surgery at a hospital where I was on staff. That was not the situation. I was at a another institution. I had a fellow on my case for that and also my trigger finger surgery a few years ago.

            Two of my children had appendectomies at the hospital where I was chairman of surgery. Residents took part in every aspect of their cases. I never asked the attending surgeon to do the case. I have found that it is better not to upset the routine of the hospital by imposing one’s influence.

            I try not to tell people at the hospital that I am a surgeon.

          • rbthe4th2

            Why not? Most of the time your care will be better.

          • Skeptical Scalpel

            Not necessarily. When routines are changed for presumed VIPs, bad things happen.

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