There are 2 truisms about residents in training, compared to their faculty: 1) they are generally slower, and 2) they generally make more mistakes. But a third fact of resident education trumps the first two—it is the responsibility of academic surgery to graduate safe, competent general surgeons who can independently take care of patients.
Thirty years ago, that seemed to be less of an issue. But we must remember that 30 years ago, poorer-quality diagnostic studies and fewer minimally invasive techniques resulted in more surgical intervention for pathologies that today may be managed non-operatively. These cases were frequently done by residents—deservedly and often times with each other—as a result of innumerable hours in the hospital. While faculty were either in their office or at home.
Today, very clearly, residents are trained in a different environment. They cannot be in the hospital for more than 80 hours/week. Faculty is present for most, if not all, of the operative decision-making. Sophisticated technologic and operative advancements (e.g. endovascular or robotic surgery) seem to be taken out of the hands of trainees, and routinely placed in the lap of fellows or junior faculty.
But these problems are only the beginning. Practicing physicians, whether in private practice or in an academic setting, are having their outcomes reported publicly, and with great detail. This transparency will (and already is in medical subspecialties) be matched to reimbursement for surgical procedures, increasing the responsibility of supervising physicians. To compound this pressure on teaching faculty, salaries of academic surgeons are (at best) two-thirds to one-half of surgeons in private practice, as academic centers increasingly rely on departments of surgery to disproportionately account for institution-sustaining revenue. And on top of all this (and sadly mentioned last both here and in the real world), academic surgeons generally have spent more time in training than their private-practice counterparts, with a profound impact on their personal/family life. Having made so many sacrifices to qualify for and achieve a high-quality academic appointment, faculty are asked to repeatedly relinquish personal and family time for another case, another conference, or another meeting.
Obviously, not a single component of these faculty pressures are under resident control. Furthermore, most everyone would agree that residents are under-represented in matters that pertain to their autonomy and education. And as a result, residents continue to feel the brunt of policy decisions that directly impact surgical faculty but indirectly have profound influence on resident education.
Ultimately, the weight of cutting a common bile duct during a cholecystectomy cannot and should not fall on the shoulders of the resident, even if it is his or her fault. Although some may disagree, it is part of our legacy and values that the surgical faculty must carry that burden. But there must be a system by which surgical faculty can be allowed to take more time with residents, allowing them to actually do the case with graduated responsibility, so that a common bile duct doesn’t get cut, either when a resident is in training or subsequently when he or she is on their own.
Public policy is the fulcrum that can help re-balance these opposing forces—and leadership must decide where to place it. At the 2015 Academic Surgical Congress, we will be discussing these challenges facing both faculty and residents. It is our hope that these sessions will spark debate, and perhaps arrive at a consensus, about ways to improve the environment for all parties involved.
The American Board of Surgery