What is going on in surgery? Why are young surgeons are coming out of residency programs unprepared for clinical practice? A 2013 Annals of Surgery report revealed that 40 percent of surgical residents lacked confidence to practice independently after five years of training, the typical length of a full general-surgery residency. According to the same report, one in five surveyed program directors “felt that new fellows arrived unprepared for the operating room,” and program directors deemed 66 percent of new fellows incapable of operating unsupervised for more than 30 minutes in a major surgery.
While these statistics are frightening, that report is 11 years old. Have things gotten better since? Judging by more recent reports and my conversations with peers, they have not, and in fact, have probably gotten worse. Surgeons I have recently spoken to have observed that too many young surgeons are poorly prepared and need remedial help, such as operating with a more experienced surgeon before they can be trusted to operate on their own. The young surgeons themselves seem to realize their inadequate preparation, as nearly 80 percent of post-general-training surgeons pursue a one or two-year fellowship in a subspecialty, which for some may be a way to get more surgical experience and put off entering general practice.
One possible explanation for young surgeons’ lack of preparation stems from the American Council on Graduate Medical Education’s 2003 decision to limit residents in training to 80-hour work weeks and no more than 24 consecutive work hours. For surgery residents, fewer work hours means less time spent caring for patients and performing surgeries. Only with time and repetition do surgical residents develop the requisite cognitive and technical skills necessary to learn sound surgical judgement—knowing when to operate and what operation to do—and how to operate safely under all circumstances. The hour reductions also have resulted in less continuity, as residents hand off patients to one another, diminishing residents’ sense of responsibility for patient care.
Another reason for young surgeons’ unreadiness is that attending surgeons, aware of young surgeons’ deficiencies, are often unwilling to hand over surgeries to residents, relegating them to assisting or even just observing the surgery. Some programs even allow residents to list in their logbooks surgeries that they have only observed, even if they did not participate. Since logbooks document a resident’s experience and qualify a resident for board certification, padding numbers this way is both unethical and dangerous.
The American College of Surgeons is aware of the failure of surgical education and has even put in place programs to address the problem. But those efforts have hardly improved the situation, based on my discussions with colleagues and residents. While the ACS’s mission is “To Serve All With Skill and Fidelity,” the organization’s leadership is busy pushing the radical and unsubstantiated notion that the College is structurally racist, that its surgeons are racists, and that surgery as a discipline discriminates against minorities. ACS leadership has embraced anti-racism and diversity, equity, and inclusion, even publishing an expansive DEI toolkit for surgeons to implement in both residency programs and their own practices.
ACS fellows who object to this new orientation and seek discussion and debate on how the organization can restore excellence as its primary operating principle have faced censorship and sometimes permanent silencing. I know because it happened to me.
The ACS’s relentless focus on antiracism and DEI further detracts from the time that surgeons in training get to learn the art and science of surgery and that practicing surgeons get to hone their skills treating patients. This will further degrade the quality of surgery in the United States. In the end, it is patients—of all races—who will suffer.
Photo: Morsa Images/DigitalVision via Getty Images