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Will Surgeons Lose Proficiency for Open Procedures?

Will Surgeons Lose Proficiency for Open Procedures?
Author Information (click to view)

Skeptical Scalpel

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1200 page views per day, and he has over 7500 followers on Twitter.

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Skeptical Scalpel (click to view)

Skeptical Scalpel

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1200 page views per day, and he has over 7500 followers on Twitter.

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What will happen in 20 years when few surgeons will have sufficient skill to remove a very inflamed open gallbladder?

Media outlets (Wall Street Journal, Gizmodo) are again reporting that automation is degrading pilots’ skills, although this has been known for over 2 years. I blogged about the subject back then as part of a comparison of pilots to surgeons. My point was that surgeons did not have autopilots to rely on in the operating room.

These new reports have prompted some to wonder whether robotic surgery will lead to the deterioration of surgeons’ skills.

In my opinion, that is not likely at this time because the robot is not really doing the surgery by itself. It is simply a tool that helps the surgeon and is under the surgeon’s complete control at all times (except when it runs amok).

However, ever since the advent of laparoscopic surgery over 20 years ago and its popularity for many of the common procedures surgeons do, there has been concern that surgeons may eventually lose proficiency for open procedures. And a number of other open operations have been done less frequently due to alternate ways of treating patients such as non-operative or interventional radiologic techniques.

Here are some examples from the ACGME resident log data for the academic years 1999-2000 and 2011-2012.

We are approaching the critical lower limit for open gallbladder surgery expertise, especially when you consider that only the most difficult cholecystectomies will be done as open cases from now on.

What will happen in 20 years when few surgeons will have sufficient skill to remove a very inflamed open gallbladder?

Does anyone really believe that a surgeon can confidently take out an enlarged spleen having done fewer than two such cases during training?

This is a bigger problem and far more pressing than the possibility that automation will render human surgeons obsolete.

There’s another issue too, which is the predicted shortage of general surgeons in the near future. How are more surgeons going to be trained if there are not enough open cases to train the current number of graduating residents?

Has anyone else asked these questions? Who has the answers?

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1200 page views per day, and he has over 7500 followers on Twitter.

11 Comments

  1. I am not a surgeon.

    However, I have seen an apparent diminution in medical education all around.

    Many of the current new doctors do not seem to have the appropriate training and experience. They don’t seem to be able to think through complex cases. They overly rely on lab and imaging w/o understanding the pit falls. They quote guidelines but don’t seem able to appropriately deviate from them when the pt’s case does not fit.

    I wonder if a lot of this has to do with the hour restrictions? If you train for 40% less hours are you going to do 40% less cases, have 40% less experience? Does that matter?

    At a time when there is a push by many (i.e. NY Times ) to do away with highly trained physicians (on the premise such extensive training is not needed and expensive); it will be very important that physicians, including surgeons, continue to demonstrate the superior benefit of adequate training or we will see physicians replaced by “midlevels” and some patients will suffer because of ut.

    see these links:
    http://www.texaschildrens.org/Learn/Fellowships-and-Residency-Programs/Pediatric-Surgery-PA-Fellowship/
    http://www.newswest9.com/story/24019803/texas-childrens-hospital-announces-first-pediatric-surgery-physician-assistant-fellowship

    Look at this description, taken from the first link, of what shall be accomplished in a 1 year physician assistant fellowship program:
    The PA fellow will be expected to perform daily rounds, present to patients articulately and accurately, describe and implement the plan of care, perform therapeutic procedures, and participate and become proficient in all surgical aspects of the intra-operative care of the surgical patient. The final goal is to foster and instruct the PA so that they develop proficient clinical skills in the pre-, peri-, and post-operative care of the surgical patient.

    Reply
    • Thanks for the excellent comments. I agree that the work hours restrictions may be a big factor in what seems to be a deterioration of residency training. I’m not sure what to make of the PA fellowships. Many PAs learn to specialize during on the job training. Maybe a fellowship would speed up the process.

      Reply
  2. Observing the big name academic center that I train at, it seems that the massive cadre of fellows has lead 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?

    Reply
    • The presence of fellows is a huge problem that academic centers have glossed over for years. The fact that surgeons from academia run both the Residency Review Committee and the American Board of Surgery insulates them from following the rules. Fellows usually do not exist in large numbers at community hospital programs; therefore the residents get to do more surgery.
      ****
      Your 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 fact is also a concern when it comes to these new residency programs that are being established. I think some of them are driven by hospital administrators and not the surgeons themselves. I find it hard to believe that a hospital that has previously not had a residency program and has surgeons who just operate can turn itself into an setting where surgical education is important. Who is going to teach the residents and give didactic lectures? Who is going to write research papers that are required by the RRC? I don’t see how it is possible.

      Reply
  3. 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.

    Reply
    • Wow. That is extremely disturbing. Does he transfer them to another surgeon or does he go to the medical center and do the case with someone helping him? How long can the hospital let this go on?

      Reply
  4. Love your blog and post. I do have senior support and yes you cannot replace experience. However, what is enough experience or more importantly quality experience? Thanks for your response.

    Reply
    • Thanks for reading my blog.
      ***
      You ask a great question for which I don’t have a definitive answer. Enough experience is probably different for most surgeons. Quality experience is hard to define. Is watching someone else do a case adequate? I doubt it.
      ***
      I am pretty sure that doing one open common bile duct exploration and fewer than two open splenectomies as a resident would not be enough experience.

      Reply
  5. As a young surgeon I can perform certain cases laparoscopically that my older collugues would never consider, seconadly knowledge is as important as technique. Basic operative skill suturing, retracting, dissecting are part of any open case. Furthermore residency as we all know is just the beginning of surgical education not the end.

    Reply
    • We all know that you and many others can do some cases laparoscopically that some might not try. The problem may arise when for some reason–equipment failure, adhesions, bleeding, whatever–you have to open. Knowledge will only take you so far. Open case experience cannot be substituted for. I agree with you that residency is just the beginning of surgical education. I hope you have an older mentor or two who you can call if necessary.

      Reply
  6. Very interesting point, and hope more and more discussions will surface on this issue.
    Regards,
    LE

    Reply

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