A Physician’s Weekly post I wrote last December was on the subject of surgeons possible losing proficiency for doing open cases because of the ever-increasing popularity of laparoscopic and other minimally invasive techniques. This results in declining numbers of open operations for residents during their training.

Although some suggested that knowing how to do open cases would be unnecessary in the future, to me that is wishful thinking.

One commenter said, “We are seeing the result of this in one of our hospitals with a new surgeon. He frequently aborts cases when he cannot complete them laparoscopically because he does not know how to do the open procedure. Worse, instead of seeking the help of someone who does, he transfers the patient to a medical center.”

A resident said, “Observing the big name academic center that I train at, it seems that the massive cadre of fellows has led to an extremely low and less interesting case load for the rest of the general surgery trainees. Overload of floor management onto the trainees seems to exacerbate the problem. Why not substitute some of the current residency training with more focused experience with mentors—maybe even community mentors outside of academic centers—who perform the cases they’re lacking?”

The presence of fellows is a huge problem that academic centers that both the Residency Review Committee and the American Board of Surgery have glossed over for years. Fellows are usually not present in large numbers at community hospital programs; therefore, the residents get to do more surgery. Two years ago, I wrote about the fact that community hospital residents do more cases and are more satisfied with their training than university-based residents.

The suggestion about mentors from outside of academic centers seems logical. However, it assumes that there are large numbers of community hospital surgeons who are dying to have residents around. In my opinion, that simply is not so. This is also a concern regarding the new surgical residency programs that are being established. I think some of them have been the result of initiatives by hospital administrators (residency programs still bring in government cash) and not the surgeons themselves.

I find it hard to believe that a hospital that has previously not had a residency program and has private practice surgeons who do nothing but operate can turn itself into an setting where surgical education is important.

Who is going to let the residents operate? Who will give didactic lectures? Who will write the research papers that are required by the RRC to prove that the faculty engages in scholarly activity? And so on.

I don’t see it happening. What’s your opinion?

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and critical care and has re-certified in both several times. He blogs at SkepticalScalpel.blogspot.com and tweets as @SkepticScalpel. His blog averages over 1400 page views per day, and he has over 9900 followers on Twitter.