Thursday, July 07, 2005
Is Five Years Enough??????
From this month's Bulletin of the American College of Surgeons:How long Should Surgical Training Take?
From this month's Bulletin of the American College of Surgeons:How long Should Surgical Training Take?
The implementation of the 80-hour workweek in American residency programs has aroused significant debate within the surgical community regarding the length of surgical training. Currently, surgical residents have to be trained more efficiently in less time and are expected to provide perfect, error-free care once they graduate into the real world of surgical practice.This has gotten the powers that be thinking:
It is in this changing environment that some have questioned how long general surgery training should take. As the clinical experience obtained by residents decreases with the 80-hour workweek, it has been suggested that the traditional five years of residency are too few to create proficient surgeons, and that additional years of training are necessary. But in reality, is five the magic number of years required to learn the art of surgery? Experience garnered through decades of training general surgery residents tells us that it is. Yet, from a purely technical standpoint, how many cases does one really need to perform to be proficient? Defining mandatory basic skills is difficult because a surgeon is more than a technician. The development of a resident into a competent surgeon requires much more than just exposure to a certain number of cases.The number and type of cases is one of a few objective measurements than can be applied to residents. The other big ones are inservice scores and scores for written boards. The "fast track" programs are discussed:
How long this basic general surgery training should take varies according to subspecialty, with some requiring completion of a full five-year program before additional subspecialty training begins. Some people have challenged this approach, and the current standards required to enter certain subspecialties, such as plastic, cardiac, thoracic, vascular surgery, and others, may disappear in the future. Whether it is possible to learn surgical principles and technique regardless of the case is a subjective question. Likewise, how a general skill can be transferred into a specialty-specific skill varies according to the individual surgeon. But, do you need to be a Âsuper-pluri-potential general surgeon before going into a subspecialty? Is reduced training time for specialists a disaster waiting to happen? Are we weakening surgical training and sacrificing quality by letting all these changes happen?These are important questions since about 75% of residency graduates go on to fellowships.
Surgery cannot be compartmentalized; yet, for example, if your area of interest is breast surgery, do you really need to be proficient in trauma and transplantation? Is performing a pancreatectomy relevant to a plastic surgeon? Does a cardiac surgeon need formal training in colorectal surgery?The short answer is "probably not". Given the evidence of volume and outcomes the cardiac surgeon is probably better served concentrating on bypass and valves after a few years. Pancreatectomys are so infrequent that it come close to a crime to allow someone who will never have to perform that procedure to steal it from someone who only might do it. The ABS, IMHO, has been slow to realize this, at least when I took the written boards. Lots of questions on head and neck, and "send the patient to your friendly neighborhood ENT" was not an option.
These questions present surgical educators with an enormous challenge as to how we deliver the necessary skills and knowledge to the next generation. Lowering standards to fit lifestyles is unacceptable, especially in an era of surgical quality improvement programs, possible pay-for-performance, the growing predominance of volume as an indicator of quality, and the persistent liability crisis. Inadequate training will initiate a domino effect that will yield significant consequences for the future of surgery.While studies have so far shown no reduction in cases after the 80 hour week was introduced, it is still early in the game and the number of cases may yet fall. Given the link between volume and outcome the number of cases performed during training becomes even more important. If the numbers fall, the powers that be may find it necessary to increase the residency to six years. Surgical residencies have the potential, based on surveys, to become more popular to the workweek restrictions. If the training is extended, that popularity may evaporate. It is probably inevitable that early specialization tracks will become more prevalent. |
