Now I’m really worried about surgical education. Here’s why:
A friend told me that a new attending on his staff was having some problems. Although the young surgeon was a graduate of 5 years of general surgery plus 2 years of fellowship, he was unable to do an inguinal hernia or a laparoscopic cholecystectomy by himself.
This is just an anecdote, but the issue has been identified by others. Remember the paper from Annals of Surgery in September of 2013 that described a survey of fellowship directors? It stated that 66% of graduates of 5-year general surgery training programs could not conduct a major case unsupervised for 30 minutes, and 30% could not independently perform a laparoscopic cholecystectomy.
A study published online in JAMA Surgery in February looked at 20 years of ACGME surgical resident case logs and found that although minimally invasive surgery is being done much more frequently, it is currently performed in more than 50% of cases for only five procedures—cholecystectomy, appendectomy, adult anti-reflex surgery, partial gastric resection, and thoracic wedge resection.
In 2007, the Residency Review Committee for Surgery increased the required number of basic laparoscopic surgery cases from a minimum of 34 to 60 and from 0 to 25 for advanced. The authors expressed concern that there might not be enough minimally invasive cases for all of the residents to do. They also pointed out that since all but five operation procedures are still predominantly performed the open way, there was still a need for residents to learn it. However, as laparoscopic cases increase, the number of open cases will decrease because the total number of cases done by graduating chief residents has not changed significantly in 20 years.
A year ago, I blogged about some potential problems that might occur when surgical residencies are expanded and new programs are begun. Specifically, I wondered if there would be enough teaching cases to go around. It is interesting to see my speculation bolstered by data.
A program director recently told me that there may be a movement afoot to start a Fundamentals of Open Surgery course.
What is going on here? There is already a Fundamentals of Laparoscopic Surgery course. Do we really need to have a separate course to teach residents open surgery? Isn’t that what a “residency” is supposed to do?
How did surgeons of my generation ever learn how to operate without courses in the fundamentals of laparoscopic and open surgery?
The visionary surgeon Leo Gordon saw it coming in 2002. He predicted the need for a “macrolaparotomy” course, and it can be run by the newly created American Board of Open Surgery.
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.