Surgical Resident Unreadiness: Confronting the Issue

As a surgeon of more than 60 years, I have been increasingly encouraged by the many advances in the surgical field. However, in past editions of General Surgery News (November 2021 and January 2022), there were extremely distressing discussions that addressed the alleged inadequacy perceived in operating experiences by present-day surgical residents. The idea that residents are completing their training without adequate operative experience is unacceptable. How can a surgical resident be prepared to practice surgery, especially if it’s in a small hospital, when faced to perform complicated surgery without a feeling of surgical competency? There is no justification for a newly trained surgeon to begin the practice of surgery without surgical competency.

The problem as outlined in General Surgery News must be resolved. It can be achieved if there is a strong input by surgical residents themselves and by a strong support of chairmen and chairwomen of surgical departments throughout the United States. A possible but simple solution could be a note after each surgical operation that is separate from the operating report written by an unnamed surgical resident present at the operation. It is important that the resident not be identified. The short note written by the resident should simply name the senior surgeon who assisted the resident at the operation. The senior surgeons’ teaching assistants at the operation would be based on a scale from 1 to 5, with 5 being excellent and 1 being perceived as a deficient operative experience for the resident. All operations in the department would require this information, and after each month, the unnamed residents’ evaluations of the senior surgeons in the department would be submitted to the chief of surgery. The chief of surgery would now be in a position to evaluate the degree of the residents’ operative teaching by the attending staff. In this manner, chiefs of surgery would be informed of residents’ experiences.

There may be multiple and far better solutions to the problem. The simple solution just suggested in this article brought to mind several personal experiences. While a surgical resident in the early 1950s, I received superb training and surgical experience while training in Boston. One day while I was operating with the assistance of a highly respected surgeon, he became more surgically active during the procedure. I eventually said, “Sir, you’re stealing my case.” This comment drew a lot of attention in the department, but my department chief, who was always very supportive of the residents, spoke to me and said what I had said was permissible since I was entirely respectful. He said if my comment had been disrespectful, I would have been in serious trouble. This episode demonstrates that if residents feel that their operative training is being compromised, they have an obligation to themselves and to future patients to gain as much surgical experience as possible.

The importance of residents taking the initiative in ensuring their operative experience is being achieved must be in accordance with the chief of surgery being sensitive to the operative training of the residents. This reminded me of a personal experience I had as the head of a surgical department about the importance of a resident’s operative experiences. After completing my surgical training, I was assigned as chief of surgery to the Seoul Military Hospital, in South Korea. Upon my return to the United States, I had a strong desire to learn as much as possible in the surgical treatment of very complicated cancer problems. I applied, and was accepted, to the senior resident program at the Memorial Sloan Kettering Hospital, in New York City. At that time, the hospital had two residency programs: a junior program, in which residents came for one year and rotated through the various departments, and a senior resident program of three years, during which time residents rotated through each department for three to four months. This senior program involved six surgeons, including myself. All six of us had already been certified by the American Board of Surgery.

After completing this three-year program, I was invited to remain on the staff at the hospital. Two years later, I was appointed chief of the gastric and mixed tumor service, which was the general surgical department. Members of this department commonly allowed the senior residents, who were already well trained, to be the operating surgeons on the private patients of the attending surgeons. As the new chief of the department, I learned that one of the members of the department never allowed senior residents to assume this role of operating on his patients. I reminded this surgeon that the residents were young, but experienced surgeons, and that they had come to Memorial Hospital to learn the difficult surgical procedures that were routinely performed at the hospital. In spite of this, the senior surgeon persisted in refusing to allow residents to be the operating surgeons. The problem was solved by limiting this senior surgeon to only two beds for his postoperative patients. Shortly thereafter, the surgeon began to allow the residents to be the operating surgeons on his private patients, with him as the first assistant. In doing so, I incurred his everlasting displeasure, but I felt it had to be done. I believe that what I have read about resident unreadiness in this paper is an extremely serious problem, and it must be solved quickly. Whatever the solution, it is crucial that members of surgical departments confront this critical situation.

Dr. Goldsmith is a general surgeon from Glenbrook, Nev.