What goes around comes around. I did my general surgery residency at Northwestern University in Chicago, IL. Looking back I can see how hard they worked to systematically try to educate us inside and outside of the operating room; especially outside. I remember feeling that the mandatory lectures and skill sessions were detracting from my potential education with patients on the floor or in the operating room. Now, on the other side of that relationship, trying to educate trainees, I have a new appreciation of what it takes to prepare a surgeon and I want to find where all the barriers are located.
After graduating [not during training] from residency and leaving Northwestern, I realized how lucky I was to have received such great training and really wanted to make medical education an important component to my practice. Upon clinical appointment, I pursued a master’s degree in medical education at the University of Pittsburgh and in my “Innovative Teaching Strategies” class, this paper “Why Johnny Cannot Operate” was among our assigned reading. This article was written by the former Northwestern Chair of Surgery, Dr. Richard Bell, after he retired from clinical practice and joined the American Board of Surgery to develop further education pursuits for surgical residents via Score.
When I read this, I was amazed by how timely it is, how much I agreed with it, and could not believe it was written 6 years ago from the person who recruited me as a medical student. I think it was a little ahead of its time because we are not yet at a point where these suggestions are a reality. In this paper Bell discusses Dr. Ericsson’s “10,000” hours to develop expertise and asserts the following, based on analysis of ACGME case logs. The average resident spends 1,148 hours during a 5 year residency doing essential operations (a list of 121 determined by program directors) and possibly 2,753 hours if you include all operative time beyond the essentials. Most notably mentioned is that the mode on 63 of the 121 essential operations is “0” and that across the country there is concern about the operative skill set of residents at the time of graduation.
Compounding these challenges have been the increased work hour restrictions, increased fellowship positions, technology advancement, oversight, quality assurance and quality initiatives (QAQI), cost and efficiency concerns, increased malpractice lawsuits, and also, generational changes in the demographics of trainees. We are no longer training Baby Boomers, not that I was ever one myself, but Millennials are different. Many of us pursue surgery because of the immediate gratification of fixing a problem: instantly opening a blocked artery, instantly repairing a perforation, or instantly removing a tumor. However, surgical training does not lend itself to instant gratification. We all know we cannot obtain the necessary skill sets to perform these operations “instantly”. For me, “instantly” is 11 years and counting since graduating medical school because, unfortunately, surgery and medicine is humbling in that it constantly shows us we do not know everything. While we all learned the dogma “see one, do one, teach one” it is pretty clear that this is not a viable strategy for training surgeons in the modern era.
Dr. Bell in his article makes 8 recommendations for how to move past this paradigm and train Johnny to operate:
- Insist on accurate national data on operative experience of residents
- Do interim evaluations of resident operative experience
- Change the required standards for case experience
- Make operative skill a required competency for board certification of surgeons and develop tools to assess it
- Study and improve teaching in the operating room
- Develop a pedagogic scheme for teaching operations
- Develop validated, standardized assessment tools for resident performance in the operating room
- Move the simulation agenda forward with a national consortium
I know. It sounds like a lot of time and expense. However, I portend there are individuals out there working on each of these recommendations in some form completely independent of ever having read this article. Personally, I am working toward trying to establish predictive validity for robotic hepatobiliary training using proficiency based virtual reality simulation, deliberate practice high fidelity inanimate models, video teaching, and operative scoring real time and via video. It is a tremendous amount of work for what may seem like a narrow application. However, it is a paradigmatic shift in the way we are training HPB/SSO fellows in complex foregut surgery. Already we have seen tangible return with an immediate increase in the number of trainees able to complete the very complex task of robotic pancreaticoduodenectomy. I would propose by joining forces as a society where each educator brings their niche, the Association of Academic Surgeons could become a forum to showcase and disseminate an innovative pathway to high quality, high fidelity surgical education.
Bell says, “In an ideal, future world, I would suggest that a resident would come to the operating room having undergone both cognitive training and skills training in the procedure to be performed.” This seems like a simple request and absolutely necessary, but do we feel this is currently being achieved? If not, it should be, and as academic surgeons it is our calling to work towards this for our patients and our pupils.