By Monica J. Smith

imageWhen David M. Mahvi, MD, finished his residency in general surgery in the mid-1980s, he went into practice feeling confident about the skills he had gained in training and he felt well prepared to perform surgery and care for patients. However, established surgeons today have a sense that the present generation of surgeons-in-training is not ready to assume autonomy and responsibility for patients at the end of their training.

“By the time I was done, I had done a lot of stuff autonomously: I’d managed people in the OR [operating room], I’d managed trauma and I left my training feeling like I was competent, that I could go off and do surgery,” said Dr. Mahvi, professor of surgery, Northwestern University-Feinberg School of Medicine, Northwestern Memorial Hospital in Chicago. “The first couple of years of practice were pretty scary, but I didn’t feel like I didn’t know what I was doing.”

But Dr. Mahvi and other surgeons believe that today’s residents don’t feel quite so secure and, in fact, are not ready to take up the scalpel.

“They’ve dealt with this by doing fellowships, mostly in general surgery, a basic GI [gastrointestinal] surgery, which to me is a warning sign that we are not adequately preparing people,” said Dr. Mahvi. “We need to do something different in the way we are training people so that when they leave [training], they feel comfortable doing surgery.”

Part of the reason for this lack of competence and confidence is the lack of experience that new surgeons obtain in residency. The duty-hour restrictions that came into effect in 2003 and capped residents’ workweek at 80 hours are not the only factor contributing to this problem, but they certainly play a role.

“I’m not supportive of a 120-hour workweek, but there’s something to be said for repetitive involvement, immersive exposure,” said L.D. Britt, MD, MPH, chairman, Brickhouse Professor of Surgery, Eastern Virginia Medical School, Norfolk, who compared the duty-hour restrictions to a Ponzi scheme for their failure to make a return on any investments. Dr. Britt and Dr. Mahvi were both part of a panel discussion, “Crisis in Training and Education,” at the 2012 meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, at which they discussed these and other topics.

“Since duty-hour limitations [were implemented], not one metric has improved. The failure rate on the certifying exam has gone from 14% to 29% or 30% in the past five years. There are more handoff mistakes, and there has been no evidence that patient safety has improved,” Dr. Britt said.

According to Dr. Mahvi, “The residents we’re training now have had very little independence during their five years of surgical training. This is not necessarily because they are better or worse: I think in some ways they are more driven and smarter than we were. But it’s just not acceptable. The patients won’t accept it, the payers won’t accept it and the hospitals won’t accept it. Training needs to change, because every aspect of surgery—from the content of residential programs to what surgeons want and what the public has come to expect—has changed.”

So, what has changed? “I would say the surgeons of the 1990s had a broad-based skills set; they were trained to be the captain of the ship, and they were expected to run things and accept risk,” Dr. Mahvi said. “Surgeons training today, however, want expertise in a narrow area. They want free time and a sane work–life balance. They don’t want to set up a billing system and figure out an EMR [electronic medical record].”

Furthermore, there is no evidence that the skills gained in general surgery training will lend themselves to narrow subspecialties: “If you know how to [perform a small bowel resection], you don’t really know how to do a lower anterior resection; if you know how to do a lower anterior resection, you don’t necessarily know how to do an esophageal resection,” Dr. Mahvi said. “I think this is a critical point when you talk about broad-based or narrow-based training. If there isn’t any evidence for transferability [of skills], the broad basis of general surgery just doesn’t work.”

The public also wants experts, and it wants them next door. “The public doesn’t want competent surgeons finishing five years of training. They want an expert in whatever disease they have,” said Dr. Mahvi.

The quandary is that residents want to specialize and patients want specialists, but there is still a need for surgeons who can take care of the public in general, ones who take the call and save the patient with a ruptured aneurysm. “If we get too subspecialized, it becomes very difficult to do that, especially outside of big cities,” Dr. Mahvi said. “That’s a significant problem that we aren’t really addressing.”

To address the current shortcomings of surgical training, Dr. Mahvi said that residents must be made autonomous at some point in their training and the profession needs to accept the idea of subspecialization and make a decision about what the core of surgery is.

“Everyone should be able to take care of sick people, everyone should be able to deal with GI emergencies, take care of trauma patients, and be competent to do endoscopy,” Dr. Mahvi said. Learning complex minimally invasive surgery should be part of residency so that surgeons leave with straightforward skills, and a fellow shouldn’t be [learning how] to do a Nissen [fundoplication]. “Early specialization is really the first step toward training expert GI surgeons; the key thing we want to develop in our surgeons is autonomy.”

Last year, the Accreditation Council for Graduate Medical Education introduced the Next Accreditation System (NAS), which is due for implementation in general surgery programs by 2014. NAS is based on the concept of achieving specific milestones based on the six competencies of patient care: professionalism, medical knowledge, interpersonal and communication skills, practice-based learning and improvement; and systems-based practice. The question is whether this program will help to ensure that residents develop the skills that would lead to autonomy.

“Milestones are surgeons’ aspects,” said Dr. Britt. “Scouts get merit badges if they achieve certain goals, say, build a campfire. We’re looking at the same thing in surgery, certain benchmarks you have to meet. There’s not necessarily a time limit. If you meet those benchmarks, maybe you can finish sooner than three or four years. The only problem is if you had to stagger with some people finishing sooner than others,” Dr. Britt said. “It would be a nightmare for program directors, but it’s really merit-based. You’re advancing someone based on competency, on their reaching a benchmark.”

Residents will be evaluated on the achievement of specific tasks, for instance, the number of times they put in a central line without complications. “It’s easy to validate, and I like the approach,” Dr. Britt said. “There will need to be more monitoring and recordkeeping, but it’s the right way to do things compared with saying ‘you’ve been in the program for four years and should be able to do certain things,’ but without validating it. We’ve identified what surgeons need to accomplish, and if they haven’t met those benchmarks, maybe they shouldn’t be advanced.”

There is no doubt, Dr. Britt said, that surgery and surgical training are going through a type of renaissance, and that as attractive as merit- and achievement-based training may be, there are still a lot of unanswered questions.

“Will educational standards be met? Will there be specific metrics? The milestones are generic at best. What happens to residents who don’t meet the milestones? Resident retention? Will it be burdensome and costly? Can the milestones be accomplished within duty-hour limitations? Will all these things improve outcomes? Do we have the resources?” asked Dr. Britt.

“NAS could be either a disaster or a home run.”

Does the fourth year of medical school adequately prepare students for residency?

Some of the variables that make surgical residency more difficult, for example the laparoscopic revolution and more complicated patient cases, may have an effect on students as well as residents, but the argument that the fourth year of medical school does not adequately prepare students who plan to enter a surgical residency is nothing new.

“If you go back to J. Roland Folse—I think it was 1996 in his presidential address to the Central Surgical Association—he said that ‘we have failed to use the fourth year of medical school effectively to prepare our students for … residency education,’” said L. Michael Brunt, MD, Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, St. Louis. “So, that was 16 years ago.”

Whereas two decades ago medical students would have been embedded in the overnight call rotation, now they rarely accompany residents to handle acute on-call problems. They spend less time on surgical rotations and, with general surgery being more complex, may be exposed to only a narrow component of general surgery rather than the broad-based exposure received a generation ago.

“As a result, we have to be innovative in our educational program for students to be able to bridge that gap, although I think we’ve been slow to recognize that and make those changes,” Dr. Brunt said.

The fourth year of medical school—when students are not as pressed for time, and are eager to learn the fundamental skills that can help them hit the ground running as residents—may be just the time to address some of these shortcomings. To that end, the Washington University School of Medicine established an accelerated skills preparation for surgical internship in 2006, based largely on Dr. Brunt’s observations of gaps in intern performance and knowledge base.

As of 2012, more than 100 surgical students have participated in the program, which consists of seven, weekly two- to three-hour sessions in the spring of senior year. The sessions’ content includes a short didactic lecture followed by hands-on training and practice. “The other thing we thought was important was to build assessment into the program, because assessment helps drive learning and performance,” Dr. Brunt said.

The sessions covered basics that Dr. Brunt and his colleagues agreed are essential in surgical training, with a heavy emphasis on suturing and knot tying, knowledge of surgical instruments, basic laparoscopic skills and on-call management problems. A popular feature is the animal labs at the end of the program, where students can practice the techniques they’ve been learning, on live tissue.

“We have them do a laparoscopic access, a lap chole, how to open and close the abdomen and do intestinal resections,” Dr. Brunt said. “They get to do a lot of suturing, cutting, clamping and tying.”

The pre- and post-course skills assessments showed that students significantly improved on all five of the assessed tasks. Videotaped assessments showed that their technical proficiency consistently improved. “What was interesting was that when we compared them to end-of-year R2 residents, the students’ times were not significantly different from the residents’ in three of the five tasks,” Dr. Brunt said.

Although the students rated their confidence as low in each of the five domains before the course, they indicated significant growth in confidence scores for 28 of 45 survey questions after the course. The one area in which they did not improve much was in managing on-call difficulties. “I think that’s because they don’t have the opportunity to do that in their rotations,” Dr. Brunt said.

Representatives of the American College of Surgeons, the Association for Surgical Education and the Association for Program Directors of Surgery formed a task force to develop a national curriculum for fourth-year medical students modeled on the month-long courses offered at a handful of universities, such as Southern Illinois, the University of Michigan and the University of Minnesota.

“There’s been a tremendous amount of work done by this group already: Curriculum goals and objectives have been developed, and they’re in the process of identifying the content for the objectives,” Dr. Brunt said. “This is going to be a tremendous resource for institutions and departments looking to develop these types of programs for their fourth-year students going into surgery, and will hopefully serve as a template for how these programs should be structured.”

It is clear from the outcomes of Dr. Brunt’s program, and others like it, that accelerated skills training programs result in improved performance, but such programs won’t address all the issues surrounding the fourth year of medical school.

“There are a lot of deficiencies in the fourth-year curricula at most medical schools in the United States, and I feel strongly that they need to be restructured to address some of these issues, particularly the on-call and night float systems, so that students have this experience before they start internship,” Dr. Brunt said. “Ultimately, I think we need to structure the whole fourth year around specific, measurable milestones and curriculum requirements. We can do that and still allow students the flexibility to do elective rotations to round out their educational needs.”