Editor’s note: The following comments were received regarding a recent article published in the Bulletin.
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Have we drifted too far from the fundamentals of surgical training?
The August 2019 issue of the Bulletin focused on wellness and resilience in surgical trainees and introduced the topic of the Resident and Associate Society Symposium at Clinical Congress 2019—the pros and cons of shift work. Because I am one of those older surgeons the authors disparage when they belittle those who talk about “the good old days” of surgical education, you know what I am about to say regarding the August issue. I have been a surgeon for more than 30 years both as an academic surgeon and in clinical practice at two community hospitals with wonderful, talented colleagues.
Without question, surgical training is different than when I trained. As the authors mention, with laparoscopy, robotics, and the requirement of constant supervision, the resident of today, in many programs, is ill-prepared for the real world of active practice. It is not the fault of the residents we are training, but the fault of those of us who are training them. Academia, surgical organizations such as the American College of Surgeons, and others have succumbed to our present-day politically correct environment where criticism, toughness, and total dedication are seen as evil. Instead of experienced and well-trained staff telling the residents what is expected and what it takes to be the best, the residents tell the staff how they want to be taught.
With laparoscopy, robotics, and the requirement of constant supervision, the resident of today, in many programs, is ill-prepared for the real world of active practice. It is not the fault of the residents we are training, but the fault of those of us who are training them.
As the authors mention, the Halstedian idea of a residency was just that. You lived at the hospital, waited to get married, and dedicated your life to your patients. The authors correctly note that “burnout,” today’s buzzword, should have been an issue then, but there is no evidence to support this perspective. This is because as surgeons we were talking about life and death issues daily. Morbidity and mortality (M&M) conferences were terrifying experiences because our mentors realized that it was vitally important to try to make us understand that we should remember the mistakes we saw at M&M so another patient might avoid death or a complication. It was meant to make an impression, and it succeeded.
The authors also talk about shift work and loss of continuity or sensible balance of responsibility. They thankfully point out that the shift work mentality can be seen as a threat to the professional tenets that define the core values of surgery. I only wish that were the case. Shift work is now the norm and what we tell our trainees they should desire for a good “quality of life.”
Most of the liability lawsuits I read as an expert witness revolve around lack of continuity of care or lack of ownership. What used to separate surgeons from all other health care providers was the dedication to the patient no matter what. I compare surgeons with Navy Seals and other special forces soldiers. We need to make it clear that being a surgeon is special and requires a special person with a special drive and dedication. Stop trying to make surgery appeal to everyone and start going after the best. Make it clear it is not for everyone and that your quality of life is not the issue, but the quality of the patient’s life is the only issue. If you don’t see yourself as being able to make this commitment, then don’t sign up for the tour of duty.
Surgery is not easy, and we have tried to recruit young people by telling them it is easy, and they can have it all. We have become a victim of the lowest common denominator in the recruiting and training of surgeons.
I know I would much rather look up from my stretcher in the hospital at a well-trained, sleepy, dedicated surgeon than one who is well rested, poorly trained, and needs a lavender room to deal with the stress of the occupation. It is time for leaders to lead instead of following the trends and politically correct path. I know it won’t happen, but I can dream.
Guy Voeller, MD, FACS