Are U.S. Training Programs Producing Incompetent General Surgeons?

 From the annual meeting of the Central Surgical Association, Sarasota, Fla., March 6:

In his presidential address at the meeting today, CSA president Dr. Richard H. Bell painted a worrisome picture about the training of general surgeons in the United States. Citing concerns that he had heard from fellowship program directors about the lack of competency in graduating general surgery residents, he decided to see if there was evidence to support their stories.

Dr. Bell, assistant executive director at the American Board of Surgery, noted that research into activities that require long-term psychomotor learning to master, such as sports, chess, and performing surgery, suggests surgeons gain competency after about 10,000 hours of practice. But the average general surgery resident in the era of the 80-hour week has operated for about 1,150 hours by the end of their 5-year residency, he said.

In one survey that Dr. Bell cited, general surgery program directors were asked to pick which of about 230 general surgery procedures that they regarded as essential to learn in a training program. A total of 121 procedures were selected by at least half of the directors. Of these 121 procedures, the one most often performed by residents in 2005 (the last year for which data are available) was laparoscopic cholecystectomy, with a mean of 84 performed by graduation. There is a steep drop off in mean cases performed per resident as one goes down the list of the directors’ selected procedures, such that the mean number of cases performed for the last 60 or so procedures is less than 10 per resident.

Dr. Bell highlighted parathyroidectomy as an example in which residents with large numbers of cases skewed the results. In 2005, residents performed a mean of nearly 10 parathyroidectomies. However, the median number of cases was eight, while the mode, the most frequently occurring number of cases, was only four. Dr. Bell said that it would be hard to argue that a graduating general surgeon with only four parathyroidectomy cases under his or her belt would be considered competent to perform the procedure.

He also noted that the citation that is issued to training programs by the Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education when a program’s total case logs for an operative procedure fall below the 10th percentile does not relate very much to how well particular programs are training residents. For many procedures, the difference between the 10th percentile and the 30th or 50th percentiles may be as little as one or two cases.

Some people claim that surgical skills gained for performing one procedure can be transferred to another, Dr. Bell said. While this may be true of technical skills, research shows that when surgeons operate, they think in discrete modules for each specific operation and check each step of a procedure against their previous experiences with that procedure. They do not think in terms of a group of operative skills that can be transferred from one specific procedure to another.

Dr. Bell’s recommendations for remedying the situation included more careful documentation of residents’ operative cases, the formation of a national operative simulation program in general surgery residency programs across the United States to help in the training of residents, and the development of standardized and validated means to evaluate surgical faculty members on their teaching and training of residents.

–Jeff Evans

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