The surgeon had no prestigious named professorship, no N.I.H. grant and no plum administrative position in the hospital’s hierarchy. But to the other surgeons-in-training and me, he was exactly who we wanted to be.
A decade or two earlier, he had started out like us, as a lowly resident in the medical center, but had finished his training elsewhere. When he returned to open a practice, the other doctors in town welcomed him back as one of their own. But they soon discovered that he had become a surgeon like few others. He finished in an hour operations that took most surgeons three or four and had few complications and enviable patient outcomes.
“I know whom I’d call if I ever needed a surgeon,” a friend said to me after watching the surgeon breeze through what we thought would be a particularly challenging case.
One day I finally gathered the courage to ask him for his “secret.” I half-expected him to laugh at my question or decline to respond because the real answer was that he was simply born with such gifts, like an Olympic-level athlete or concert pianist.
Instead, he answered without hesitation. “It’s doing the operations over and over and over again,” he said. He described the hundreds of operations he had participated in during his residency and the final years of training when he felt as if he were “living, breathing and eating surgery. I could have done these operations with my eyes closed,” he said grinning.
“And,” he added with a chuckle, “with one hand tied behind my back.”
I thought of his words often over the next few years as I tried to hone my own surgical skills. And recently I was reminded of them once more when I read a recent study in The Annals of Surgery assessing the skills of young surgeons trained after regulations went into place limiting their work hours in the hospital.
For the past decade, in response to increasing pressure from politicians, unions and sleep experts, the Accreditation Council for Graduate Medical Education, the organization responsible for accrediting American medical and surgical training programs, has been working to cap the hours that residents work. In 2011 the council passed the strictest limits yet. To maintain their accreditation, residency training programs had to abide by a 22-page set of scheduling rules that limited all in-hospital work including any elective “moonlighting” jobs to 80 hours per week, mandated the number of hours “free of duty” after different “duty periods” (eight hours off after 16-hour duty periods and 14 hours off after 24-hour duty periods) and even specified the timing of “strategic napping” in no uncertain terms (after 16 hours of continuous duty and between the hours of 10 p.m. and 8 a.m.).
While most residency programs chafed under the exhaustively detailed regulations, surgical training programs had particular difficulty adopting the new mandates. For nearly a century, surgical residency had been a period of both intensive experience and increasing responsibility under the guidance of more experienced surgeons. More recent research has affirmed that approach, demonstrating the strong link between a surgeon’s operative skill, the number of operations performed and patient outcomes. With limits set on their time at the hospital, young surgeons-in-training had fewer opportunities to care for patients or scrub in on operations. While previous generations of trainees had the luxury of participating in at least one operation a day, new trainees had only enough time to be involved in two or maybe three operations each week.
Calculating the number of hours “lost” by cutting back on in-hospital time, surgical leaders estimated that young surgeons-to-be were now missing out on as much as a year’s worth of experience.
Adding to the challenge, surgery itself was changing, and the number of skills that surgeons now needed to acquire was expanding as never before. The discovery of new medications like anti-ulcer agents rendered once standard operations less common, but not entirely obsolete; so surgeons still had to know how to perform all the operations without getting to practice them as often. Huge advances in minimally invasive and robotic surgery allowed surgeons to remove inflamed gallbladders and deadly tumors with fiber optic telescopes, miniature pliers and robotic tools through incisions small enough to be covered afterward with Band-aids. But they still needed to know how to wield the scalpel and operate the “old way” in case of complications.
Surgical training programs scrambled to make up for less time and cover the ever-expanding body of knowledge by creating online educational tools and offering trainees experiences in simulated operating rooms and trauma resuscitations using electronic mannequins and foam rubber models.
But as The Annals of Surgery study reveals, even the best-equipped simulation labs cannot replace a year’s worth of lost experience.
Researchers sent questionnaires to the directors of subspecialty fellowship training programs and asked them to comment on the bedside and operating skills of the young surgeons enrolling in their programs. These fellowships are a kind of high-level and often prestigious surgical “gap year” where young surgeons who have completed the basic five-year surgery residency can delay independent practice to pursue an additional year or two of training.
The results were abysmal. Fewer than half of the young surgeons could operate or make clinical decisions on their own. Nearly a third of them were incapable of performing even the most basic operations like a gallbladder removal on their own. And a quarter were unable to recognize the early signs of complications.
Even in areas of surgery where the young surgeons had had supplementary online learning modules during their residency, they performed poorly, with more than half unable to perform basic maneuvers.
“It’s hard to compensate for real-world experiences,” said Dr. Samer G. Mattar, lead author of the study and a professor of surgery at Indiana University School of Medicine.
While some observers have criticized the study for being self-serving – most respondents also noted that the young surgeons’ deficiencies resolved after additional training under their auspices — the findings are consistent with previous studies. One earlier study, for example, found that a quarter of young surgeons in their final year of residency felt unprepared to practice independently. Another study found that more and more young surgeons – 80 percent according to recent estimates – were choosing to extend their training by a year or two to bolster their skills.
And in what may be the starkest proof of the link between experience and proficiency, the failure rates on certifying oral exams administered at the end of residency have almost doubled since the duty hour changes went into effect. While 15 percent of would-be surgeons failed a little under a decade ago, nearly 30 percent fall short on the exams now.
“When you take a whole year’s worth of in-hospital experiences out of training, you can’t be surprised that the ‘product’ is not the same,” said Dr. Frank R. Lewis, executive director of the American Board of Surgery, the major credentialing body in surgery that administers the certifying exams.
Still, few surgical leaders are eager to go back to 100-plus hour workweeks for trainees. Instead, many are now focusing on making training more efficient. Some have advocated specialization as early as medical school so that young surgeons-to-be can begin acquiring operating skills even before getting their M.D. Others have worked on creating more mentoring opportunities after the completion of residency to help close the experience gap. Still others believe that what may be most helpful is adding greater flexibility to the current regulations so that trainees can elect to spend more time with a patient or scrubbed up in the operating room without fear of putting their residency program’s accreditation in jeopardy.
“Things needed to change,” Dr. Lewis said, “but not recognizing the potential long-term effects was dangerous. Even issues that seem completely obvious and one-sided can sometimes have significant consequences.”