‘We must advocate that if there is only one physician left on earth, he/she had best be a general surgeon …’—Stanley Dudrick, MD
The restructuring of university hospitals as a result of COVID-19 forced residency programs across the United States to quickly adapt, in terms of both manpower and academics. The Accreditation Council for Graduate Medical Education responded by permitting continued resident involvement in the care of COVID-19–positive patients, but left the task of figuring out where the new fulcrum point was between clinical and academic requirements. For programs near heavily affected cities, personnel were in high demand and surgical teams quickly became critical care teams to keep up with the growing ICU census. But for the majority of programs, the clinical load quickly dropped. Operative volume dramatically decreased after the American College of Surgeons recommended suspension of elective surgery, citing hospital and resource utilization.
For programs that usually run a robust acute care surgery service, these changes were less severe compared with programs that generate most of their volume from elective cases. We found ourselves with more residents than work. To be in accordance with guidelines, we scaled back the teams in order to limit exposure at the hospital, rotating teams in and out to allow time at home for symptom monitoring. The challenge with this arrangement was that we needed a way to keep accountability of residents during off weeks that also facilitated continued learning. I would like to share a few things that worked for us.
After the restructuring, we initially put out a reading curriculum with weekly question banks and a moderated discussion forum, but realized we needed more interaction. This bought us a little time until we were able to broadcast our morning conferences via a virtual meeting platform. There was definitely a learning curve and it took some time to work out the kinks and have everyone comfortable interacting through their phone or computer. The next step was to have a plan for each day of the week, something consistent that could be repeated week after week. The virtual meeting format was ideal. It allowed for maximal participation of staff and residents, both on and off site. The platform let us easily and efficiently disseminate information, since there seemed to be a new policy or memorandum every day. There was still high visibility of resident learning, and we purposefully chose daily activities that required preparation and participation. The daily meetings were always intended to augment personal reading. Lastly, the format let us reach out to graduated chiefs—now junior faculty at other hospitals—so they could stay engaged as well.
We start the week with a surgical debate between two residents of the same year group (similar to “The Great Debates” in General Surgery News). We have each resident present an opposing side of a controversial topic, followed by a series of short rebuttals before the floor is opened up for discussion. The goal is to assign topics that are appropriate for that year group. Some examples are operative versus nonoperative treatment of appendicitis and prophylactic mesh placement for midline laparotomy. I think this format has been hugely successful and something people look forward to now. Every Tuesday, there is a faculty lecture that follows the usual didactic format. Wednesday is standard morbidity and mortality conference. Thursday is our “preoperative conference.” Here we had to get creative since there were fewer and fewer cases on the board. As it stands now, if there is nothing scheduled, the chiefs will assign cases that are again appropriate for that year group. For example, an intern may be assigned laparoscopic cholecystectomy and a more senior resident, distal pancreatectomy. Each resident is assigned a faculty mentor. Again, since these are not actual patients, the resident creates a realistic scenario, reviews the workup and imaging (usually borrowed from another patient), and works through the operative steps. More senior residents and faculty will pose questions about tricks, pitfalls and bail-out maneuvers. Of course, we would like for this conference to be reserved for actual patients, but this has been a valuable substitute. It keeps the interns looking at anatomy, the residents reviewing operative steps and the faculty engaged in education. Lastly, we alternate journal club and trauma/critical care lecture every Friday, led and moderated by a resident.
All of this to say that the past few months have forced residency programs to come up with creative solutions. Here we have leveraged remote learning with in-house staffing to still provide care to patients with urgent surgical needs. Despite the growing pains, this period was an opportunity to see the heart behind general surgery education. Coronaviruses are not in the surgical textbooks. So why are surgery residents reading JAMA guidelines and reviewing vent management? Because it is hammered into us that when there is a problem and the consultant is out of town or unavailable (every oral exam), we find a solution. That mindset becomes part of who we are.
I began with a quote from Dr. Stanley Dudrick, who sadly passed away this past January. He was most recently chair emeritus at the Department of Surgery at Yale University, but will forever be known for his pioneering work in parenteral nutrition. It is a reminder that when called upon, we are all global surgeons and global physicians, even if on a small scale.
-Dr. Halgas is a general surgery resident in El Paso, Texas. His articles on surgical residency appear every other month.
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