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RIPPLES Are We Spending Too Much Time in General Surgery Residency? CPT Jayson D. Aydelotte, MC, USA, Brooke Army Medical Center, Fort Sam Houston, Texas Program chairmen and directors and other surgical educators make decisions about surgical education that will have a ripple effect on residents, and eventually, medical students. This section is designed to show you residents’ perspectives and thoughts about issues in surgical education that affect their lives, their education, and their treatment of patients. In each issue, 3 residents from across the nation will be asked to write their response to a question, given to them by the editorial staff. This issue’s question is “How many years should it take to train a general surgeon?” Surgery residents like to lament the long hours and long years of training. Most interns do not even know they are in a tunnel much less have the where-with-all to see the light at its end. Chief residents cannot even remember when they started, and mid-level residents believe they are ready for anything with or without the next couple of years of residency. So, how long should a general surgery residency be? Is it necessary to spend 5, 6, sometimes 7 years in training to do lap chole’s, hernias, and appendectomies? After all, that’s what general surgeons do after training, isn’t it? I would like to believe that is not all I will do. I still believe general surgery is the greatest specialty in medicine. No one other specialist has the visibility of the entire hospital or the entire patient like we do. We are the end of the line in most cases. When everyone else, who seems to have taken most of our business away through one means or another, has a complica- tion from that procedure, they call us to take care of the patient. Unfortunately, our vast knowledge and the drama that goes with it simply does not pay as well or as quickly as radiology, dermatology, orthopedics, and so on. General surgery is going to change. We have to become more efficient at training our young. The 80-hour workweek is a step in this direction. And now, so is the issue of shortening surgery residencies. I do not know the right answer to the question. People I respect greatly have given me arguments both for and against shortening residency. In the end, I think surgery resi- dency should remain the same, about 1000 cases long. It should be said that cases as described above are people with problems that need help. They are the appropriate preoperative, postoperative, and operative care of patients, not just the con- tact with the patients in the operating room. One would natu- rally assume that along with the thousand or so cases come all the nonoperative patient experiences that shape our decision- making abilities. After all, cases are roughly how we measure residents’ proficiency in everything they do. If 2 people have the same exposure to the same caseload, it should not make a dif- ference if it took 1 person 2 more years to gain that experience. The argument that those 2 years magically add experience does not hold much water. If they each have the same amount of cases and other corresponding nonoperative patient care expe- riences, then what is this other resident doing in the hospital those extra years (research notwithstanding)? I would submit that at the end of both residents’ training, they will each run into things they have not seen and problems they have not yet solved. Those 2 extra years probably would not make a differ- ence. After all, very few of us will have to practice on an island right out of residency. And if one offered a 3-year, 1000-case Correspondence: Inquiries to CPT Jayson D. Aydelotte, MC, USA, Brooke Army Medical Center, General Surgery Service, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234-6200; fax: (210) 916-2202; e-mail: [email protected] CPT Jayson D. Aydelotte, MC, USA CURRENT SURGERY • © 2003 by the Association of Program Directors in Surgery 0149-7944/03/$30.00 Published by Elsevier Inc. 473

Are we spending too much time in general surgery residency?

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RIPPLES

Are We Spending Too Much Time in GeneralSurgery Residency?

CPT Jayson D. Aydelotte, MC, USA, Brooke Army Medical Center, Fort Sam Houston, Texas

Program chairmen and directors and other surgical educators makedecisions about surgical education that will have a ripple effect onresidents, and eventually, medical students. This section is designedto show you residents’ perspectives and thoughts about issues insurgical education that affect their lives, their education, and theirtreatment of patients. In each issue, 3 residents from across thenation will be asked to write their response to a question, given tothem by the editorial staff. This issue’s question is “How many yearsshould it take to train a general surgeon?”

Surgery residents like to lament the long hours and long yearsof training. Most interns do not even know they are in a tunnelmuch less have the where-with-all to see the light at its end.Chief residents cannot even remember when they started, andmid-level residents believe they are ready for anything with orwithout the next couple of years of residency. So, how longshould a general surgery residency be? Is it necessary to spend 5,6, sometimes 7 years in training to do lap chole’s, hernias, andappendectomies? After all, that’s what general surgeons do aftertraining, isn’t it?

I would like to believe that is not all I will do. I still believegeneral surgery is the greatest specialty in medicine. No oneother specialist has the visibility of the entire hospital or theentire patient like we do. We are the end of the line in mostcases. When everyone else, who seems to have taken most of ourbusiness away through one means or another, has a complica-tion from that procedure, they call us to take care of the patient.Unfortunately, our vast knowledge and the drama that goeswith it simply does not pay as well or as quickly as radiology,dermatology, orthopedics, and so on.

General surgery is going to change. We have to become moreefficient at training our young. The 80-hour workweek is a stepin this direction. And now, so is the issue of shortening surgeryresidencies. I do not know the right answer to the question.People I respect greatly have given me arguments both for andagainst shortening residency. In the end, I think surgery resi-dency should remain the same, about 1000 cases long.

It should be said that cases as described above are people withproblems that need help. They are the appropriate preoperative,postoperative, and operative care of patients, not just the con-

tact with the patients in the operating room. One would natu-rally assume that along with the thousand or so cases come allthe nonoperative patient experiences that shape our decision-making abilities. After all, cases are roughly how we measureresidents’ proficiency in everything they do. If 2 people have thesame exposure to the same caseload, it should not make a dif-ference if it took 1 person 2 more years to gain that experience.The argument that those 2 years magically add experience doesnot hold much water. If they each have the same amount ofcases and other corresponding nonoperative patient care expe-riences, then what is this other resident doing in the hospitalthose extra years (research notwithstanding)? I would submitthat at the end of both residents’ training, they will each runinto things they have not seen and problems they have not yetsolved. Those 2 extra years probably would not make a differ-ence. After all, very few of us will have to practice on an islandright out of residency. And if one offered a 3-year, 1000-case

Correspondence: Inquiries to CPT Jayson D. Aydelotte, MC, USA, Brooke Army MedicalCenter, General Surgery Service, 3851 Roger Brooke Drive, Fort Sam Houston, TX78234-6200; fax: (210) 916-2202; e-mail: [email protected]

CPT Jayson D. Aydelotte, MC, USA

CURRENT SURGERY • © 2003 by the Association of Program Directors in Surgery 0149-7944/03/$30.00Published by Elsevier Inc.

473

program, and the other a 5-year, 1000-case program, which onewould likely get the better applicant?

I am not sure of the right answer. As it is, I am in a military5-year general surgery residency. I value every minute I spend intraining because I believe I may find myself doing any opera-tion. I am content with my program. But given the opportunityto finish early with the same caseload, I would likely take it.

I look forward to the years to come. The residents today aregoing to shape general surgery tomorrow. I do not think thefuture is as gloomy as everyone expects. I think we will makegeneral surgery more efficient and restore it to its rightful placeat the front of the line.

doi:10.1016/S0149-7944(03)00106-5

Length of Surgical Education

Julie Maurer, MD, Baptist Health System, Birmingham, Alabama

There are many issues currently challenging surgical education,and length of training contributes integrally with work hoursand lifestyle. This essay will address length of training in thecurrent system, rather than in a “perfect world” scenario. Train-ing length should remain 5 clinical training years. Shorteningthe length of training is undesirable because residents need timeto develop character traits required of a surgeon. Lengtheningthe training, although on the surface seems necessary to accom-modate expanding curricula and shortened work hours, wouldbe deleterious. Providing the needed training in the establishedperiod of time does not require lengthening of training, but itdoes require a change in the historical “immersion” techniqueof training surgeons.

The job of creating a good surgeon requires developing theskills and the character of an infant doctor. Some of these sub-jective traits include judgment, dexterity, maturity, profession-alism, communication skills, self-analysis, and self-education.These character traits require direct teaching, role modeling,and consistent feedback for the individual residents, over yearsof exposure to many attending surgeons with varying opinionsand practices. Trainees must have sufficient time to developthese traits and incorporate them, or change themselves overtime to become a mature, professional, ethical surgeon. Themetamorphosis from wide-eyed medical student to confident,knowledgeable surgeon requires the 5 years of learning andgrowth. Technical skills and patient management from a med-ical standpoint can be learned much faster using directed tech-niques, but the personal growth cannot be rushed, or cut short.Our system of apprenticeship works well in this regard, andshortening the 5-year training time would hinder the process.

The study and practice of medicine and surgery are becom-ing more technical, and new, complex, scientific knowledge isfound every day. Learning all the old information, all the newfields of study, and mastering new technologies, such as intra-operative ultrasound and laser use, stereotactic, advanced lapa-

roscopy, endoscopy, and endovascular techniques, requiresmore time. Two examples suffice. Laparoscopic cholecystec-tomy is standard of care now, but the open technique is stillrequired for every surgeon to master. Two techniques instead ofone are required.1 Endovascular aortic aneurysm repair is rap-idly replacing the open technique for elective repair, but onecannot be comfortable out in practice without knowing how torepair the aorta if needed. Thus, a case can be made for extend-ing the length of residency to provide sufficient time to masterthese new techniques and practices, while maintaining the es-tablished ones.2

In addition to the expanded curriculum is a required decreasein daily, weekly, and yearly hours. The mandatory 80-hourweek for trainees decreases the total hours available for learning,mastering cases, and apprenticing. The issue of benefit to theresidents is not questioned; one negative impact is to make an

Correspondence: Inquiries to Julie Maurer, MD, Baptist Health System, 701 PrincetonAvenue, SW, 4 East, Birmingham, AL 35211; fax: 205-783-3136; e-mail: [email protected]

Julie Maurer, MD

474 CURRENT SURGERY • Volume 60/Number 4 • July/August 2003