Are modern Surgical Residencies adequately preparing General Surgeons?

Despite a steady supply of medical students entering surgical residencies, the number of general surgery residency graduates entering into general surgical practice is dwindling.  A recent study reported that 80% of new surgery graduates now pursue further fellowship training in surgical subspecialties, leaving a minority that heads directly into general practice.  A lack of readiness to practice may be to blame: a poll of fellowship program directors revealed that almost a quarter of surgical chief residents lack the skill and experience to operate independently.

A recent study in the Journal of Surgical Education explores one possible explanation for this supposed gap.  In 2008, investigators at the University of Virginia noted an institutional “upward shift” from junior to senior resident involvement in common general surgery operations – those that were classically performed by junior residents, like cholecystectomies and appendectomies.  Their observation coincided with a nationwide rise in the popularity of laparoscopic surgery, and they figured that the effect would be transient, diminishing over time as laparoscopy became “mainstream” in surgical training and practice.

Their recently-published results, however, indicate that, at least for some surgeries, this upward shift from junior to senior level involvement has become even more pronounced over time.  The study found – not surprisingly – that laparoscopic surgery became increasingly prevalent over the last several years.  What was unexpected was that junior level involvement in traditionally junior-level surgeries, which are now typically performed laparoscopically, actually went down. In another perplexing twist, this was not compensated for by an increase in junior resident involvement in open surgeries.  In fact, junior residents were less likely to to be involved in those procedures as well.

In identifying the causes leading to decreased junior level involvement in the operating room, a likely culprit is an ever controversial regulation on resident duty hours.  It’s easy to see how restricting intern work hours to 16 hours per day translates to junior residents spending more time rounding on patients on the floor and less time operating.  Interestingly, however, several studies indicate that operative case volume was only transiently impacted by the implementation of duty hour regulations, and now is roughly on par with pre-regulation numbers.

Another possible explanation is that operations that have historically been technically straightforward and thus appropriate “junior-level” cases (appendectomies, cholecystectomies) now require advanced laparoscopic skills that trainees are neither taught in medical school nor in the early years of residency.  The decrease in junior level involvement in open surgeries is somewhat harder to explain.  It could be that in the era of laparoscopy, cases that require open surgery are inherently more complex, or that senior-level residents feel the need to take part in these cases for their own training purposes, now that laparoscopy has become the most prevalent method.

Regardless of the drivers behind the “upward shift” phenomenon, what’s clear is that the modern surgical residency may not adequately prepare general surgeons who wish to practice without pursuing a subspecialty fellowship.  An emerging “work-around” to this problem has been the development of “Transition to Practice Fellowships,” which provide new surgeons with further training in general surgery procedures required for a private practice that, presumably, should have been mastered during residency training.

But perhaps there are ways to increase mastery of general surgical procedures within the confines of the traditional residency.  For instance, earlier training in laparoscopic skills, possibly even during medical school, could enhance resident performance.  The authors also note that an unprecedented opportunity exists for supplemental training methods outside of the operating room, including surgical simulation experiences.  Indeed, the recent literature supports the efficacy of simulation training.  A study among medical undergraduates, for instance, found that practice with a simulator improved performance in intramedullary femoral nailing across multiple domains.  Most likely, a combination of interventions will be required, but as graduating surgical residents continue to report unease with their own operating skills, the need for timely intervention is obvious.