How do surgical trainees achieve autonomy while preserving patient safety? Issues with the current general surgery residency paradigm

We are in an era of conflicts in medicine. The goal of early discharges is in conflict with readmission rates. Resident quality of life is in conflict with academic productivity and clinical exposure. Perhaps the root conflict arising in surgical training is that between trainee autonomy and patient safety. The goal of surgical residency is to train high-quality general surgeons prepared to independently practice. Are the Halstedian principles practical in the current training environment with the emphasis on patient safety, duty hour restrictions, and increased emphasis on fellowship training? Ultra-subspecialization is replacing the ideal of general surgery that attracted many of us to the field, being able to perform a broad-range of procedures. Nearly a quarter of general surgery residents feel that their residency does not fully prepare them for practice; operative case numbers are down and cases are being spread out over more diverse procedures [1]. Being insecure in starting practice from residency and pressure to go into specialties leads to a large, competitive field of residents seeking fellowship training. Many academicians have completed significant professional development, performing research, earning advanced degrees, and training more than a decade prior to entering practice. This is occurring while we have shortages of general surgeons in medically underserved areas. The current system is not working. To help with decreased autonomy and experience, new “transition to practice” fellowships have been created for residents interested in pursuing general surgery.  Given that preparedness for practice is lacking following surgery residency, more of these fellowships or qualified mentorships could play a significant role, and new residency positions should be created to attract people to the practice of general surgery. Formal graduated autonomy is also needed so that patient safety can be maintained while allowing independent decision making by trainees. A separate academic pathway with shortened general surgery training and emphasis on early specialization and a general surgery pathway with graduated autonomy makes sense for trainees and the healthcare system.

References

1. Hashimoto DA, Bynum WE, Lillemoe KD, et al. See more, do more, teach more: surgical resident autonomy and the transition to independent practice. Acad Med. 2016;91:757-60.