Surgical Training: Reform or Revolution

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I recent read with growing dismay a series of essays in the Bulletin of the American College of Surgeons. (Bulletin ACS, V99, No. 11) These were the first and second place essays from the 2014 RAS-ACS Symposium on the topic “The five year general surgery residency: revolution or reform?”
My dismay stems from the ideas put forth for changing the future of surgical training in this era of work hour restrictions, cost containment and advancing technology. The claim was often repeated through several of the submissions that surgical residents of today are asked to learn a broader range of surgical procedures due to the advent of laparoscopy, robotics and endovascular repairs. They also claim that the body of knowledge learned in training will become obsolete at an ever-increasing pace. This makes it incumbent that we train surgeons who cannot only do, bit also think. This last statement is one of the few in the series of essays with which I can whole-heartedly agree. I don’t subscribe to the view that the body of knowledge is too broad to be mastered. It has changed in nature, but is no broader that it was when I trained. What has changed is the ability to search and review specialized knowledge as needed. We need smarter surgeons, not surgeons who have memorized a body of facts.
The first place essay makes the statement: “Future endocrine, breast, or vascular surgeons should no longer need to acquire competency in hernia repairs or cholecystectomies. . . . (residents) should not have to demonstrate proficiency in managing conditions for which they will not bear responsibility in their careers.”
The other essays continue in the same vein – training should be more focused; career selection should be made earlier; the concept of the ‘General Surgeon” is obsolete.
I must ask: when did we, as a profession, lose our soul? I do not advocate a long rigorous, training program with no work hour restrictions just because I did it. This is not a case of “They did it to me, so I will do it to you.” We do not spend hours learning specific procedures to be duplicated step-by-step the way that our mentors taught us. What we spend hours learning is a set of manual skills, developing an intimate knowledge of anatomy in all it’s variations, and an intuitive understanding of tissue, its strength and weakness, its tolerances for traction and manipulation. You do hernias and cholecystectomies and colectomies even if your goal is to be a plastic surgeon so that you have an inbred understanding of how to handle and manipulate tissue, not so that you can master a particular procedure. A good surgeon who has a well-developed skill set can do most open operations, EVEN IF HE/SHE HAS NEVER DONE THAT PARTICULAR PROCEDURE BEFORE. There are some differences when it comes to the use of specialized equipment (e.g. Robots or laparoscopic instruments), but a good basic skill set will allow most surgeons to do any procedure. One may not be as fast or smooth the first time through a new operation, but the skill set is the same.
I don’t buy the assertion that the body of knowledge is too large to be mastered, not when the access to detailed information has kept pace with the amount of knowledge available. One may not have all the details on the tip of one’s tongue, but the ability to find the information is as close as the smart phone in your pocket. What is needed is a discipline that recognizes what information is critical and what can be looked up when needed. What is needed is a discipline that recognizes the value of broad understanding of surgical principles. What is needed is a discipline that advocates total responsibility for patient care and does not abdicates the diabetes care to the internist and the cardiac care to the cardiologist and rely on the hospitalist to handle the day to day inpatient care of the post-op patient.
I don’t advocate detailed training in all of those areas. Only enough basic knowledge to understand how they affect the care of the surgical patient.
In my day, (yes, I know that marks me as an old man), the surgeon was expected to be a passable Internist with superioir technical skills. That ideal has not changed. You don’t have to have the level of expertise that a specialist has acquired. You do need to know enough to know what they are talking about and decide if their care is good or bad for your patient.

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