While the U.S. population has increased 40% in the last 25 years, the ratio of general surgeons per 100,000 population has decreased by 26%. In fact, by the year 2020, the nation will experience a shortage of over 21,400 surgeons (Lowrey). Due to a lapsing supply of young doctors in the field of invasive care, nearly all “open” surgical procedures nowadays are available exclusively amongst soon-to-retire practitioners. This shortage is detrimental to the future health of the population, and the reasons for it are intersectoral – stemming in part from society’s demand for medical perfection. Public health researcher and surgeon Atul Gawande discusses in his essay, “Education of a Knife,” the ethical bounds surrounding novices in the subfield of invasive surgery. Drawing from his past experience as a resident surgeon and later as a full-fledged practitioner, he asserts that “perfection without practice” is an unattainable societal standard that ultimately limits opportunities for surgeons to train and be better (Gawande, 24). Thus, in addressing the plight of young surgeons in the U.S. today, it is crucial to understand that the problem is multifaceted – a forging at the intersection of subpar residency training, the role of mentor-trainee hierarchies, and the systemic failures which hinder so many graduates post-medical school.
When approaching the subject of stabilizing surgical care in America, one must first acknowledge that current trends within the system’s subculture have already heightened the caliber of the challenge – primarily due to shifts in education, subspecialty training, and general notions of what it means to practice invasive care today. According to Cardiac Health, a patient advocacy site created by Dr. Tryzelaar – professor of surgery at the University Hospital in Bosnia-Herzegovina as well as Tufts University of Medicine in the U.S. – “young surgeons are no longer interested in the lifestyle demands of a traditional surgical practice” (Tryzelaar). In other words, increasingly more practitioners are actually subspecializing (ie. orthopedic, perioperative), neglecting emergency calls, and essentially being less competent in general surgery. This is precisely why Gawande emphasizes in his essay the importance of retaining individuals who are “conscientious, industrious, and boneheaded enough” to stick it out in the trade – people who understand and are committed to the expectations of the occupation (Gawande, 19). Present-day, however, due to a variety of mostly institutionalized factors, the prospects of recruiting and building such tenacity amongst future surgeons is uncertain. Resultantly, this puts patient-surgeon relations in a serious grey area, thus forcing society to take a top-down approach in evaluating the agents of this havoc.
The first area of concern is the transition from medical school to residency training. Unfortunately for many medical school graduates, due to a lack of federally and privately funded residency positions, thousands annually struggle to continue their careers. In 2013, some 1,100 U.S. graduates were left without a residency spot in the nation’s programs; in fact, situations have worsened to the point where Congress has been pressured to introduce a bill that would add “15,000 Medicare-financed residency programs over five years” (Olsen). The lack of funding and programming is one of the major factors of surgical incompetence and shortage today. Yet, this reality evokes another concern: top tier training programs – while providing unparalleled excellency in its education – educate so few individuals it barely makes a dent in the field. For instance, the Johns Hopkins Medical School selects a mere six individuals each year to undergo its five-year General Surgery Training (Johns Hopkins). While these schools are investing an abundance of resources into these students – namely the opportunity to attend national conferences, participate in case discussions and lectures, as well as interact with faculty and chief residents – is the cost of such an education truly outweighed by the benefit of their eventual contribution to society? While any straightforward answer to this question risks contradiction, a close examination of these residency programs themselves may help navigate the conversation.
Fundamentally, the mission of post-graduate residency programs is to give aspiring doctors the vital first-hand experience needed to transform their medical school training; however, as a result of various reforms in technique instruction, residency on-call hours, and the dynamic between mentors and trainees, resident surgeons nowadays are lacking the quality first-hand experience necessary for professional practice. In fact, according to a survey published in the U.S. National Library of Medicine in 2013, an assessment of fellows (those having recently completed their residency training) revealed that 66% of them were deemed unable to operate for even thirty unsupervised minutes on a major surgical procedure (Indiana). This sort of statistic suggests that crucial skills in the trade of surgical care are becoming less and less available. Yet, perhaps, this is because we – as citizens and as caretakers of our loved ones – are unwilling to place patients’ health and safety in the hands of a trainee. Perhaps, it is because society is unwilling to admit that there is just no “getting around those first … unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of colon” (Gawande, 24). Simply speaking, residency may be a time for trainees to learn under careful watch, but eventually – they must be able to effectively perform procedures on their own. Currently, only 6-14% of a resident’s total working time during a five-year training program is spent in the Operating Room (OR), and nearly half of all residents have never performed even 60 of the 121 “essential operations” required for general surgery expertise (Treyzelaar). So, from these rates of incompetency emerges the question of causation.
One apparent factor is that residency programs in the recent years have implemented new simulator devices, inanimate skills stations, and animate models to their training. The danger of these simulators is that they have replaced many of the hours residents would otherwise be spending assisting on cases in the OR (Treyzelaar). On top of this, most programs’ current method of meeting duty hour quotas allows residents to divide their clinical time into short intervals – ultimately resulting in discontinuity of care and an incoherent experience for both the patient and the surgeon in training (Treyzelaar). Together, looking at both the impact of simulators and shifts in on-call hours, it seems there is a lack of both adequate quality and quantity of practice. In fact, in addressing the curiosity of practice itself, Gawande remarks: after days and days of trying to make sense of fragments of, in this case, a procedure … suddenly, “conscious learning becomes unconscious knowledge, and [one] cannot say precisely how” (Gawande, 21). Due to the nature of practice, there is simply no formula to the madness of mastery; for this exact reason, steering residents away from repeated practice on real patients is unacceptable. If left unaddressed, these issues will ultimately leave society with only a handful of schooled amateurs – rather than legitimately skilled practitioners.
Knowing this, it is reasonable to feel that the state of training programs is the main factor in determining the deftness of a practitioner; still, it is far too easy to assume poor residency programs are the immediate cause of incompetent surgeons. Regarding this, Gawande makes a conscious effort to recognize that most of the knowledge one employs as a surgeon is not available in even the most highly praised residency programs (Gawande, 25). And, this is a result of many factors – namely that of the introduction of advanced technologies: new tools, medication, models, equipment, etc. Therefore, practitioners must undergo the learning curve every time an item of novelty is incorporated into their routines. In fact, this learning curve is a source of conflict amongst attending surgeons and residents. Many new graduates have reported bad experiences during their residency due to older surgeons “protecting their turf” – the “turf” being anything from patient cases to expertise on new equipment (ACS). Perhaps, teaching hospitals more so than non-teaching hospitals, have the challenge of providing honest mentorships; at the end of the day, an experienced practitioner does not want to be devalued, or have their authority undermined. According to the Albert Einstein College of Medicine in Bronx, NY, “it is similar to the military when it comes to respecting your place in the chain of command;” oftentimes, attending surgeons just want to show off their power and smarts (Campbell). Thus, the current trend of surgical incompetence seems to be a result not only of inadequate programming and problematic societal expectations, but also of ill-dynamics between various health care personnel.
Hence, to permanently reverse the manpower shortage and incompetence in surgery today, it will require a multi-decade effort of evaluating residency education, billions of dollars in funding, a revised process of admitting medical school graduates, and above all – a redefinition of the field of general surgery. Society perceives doctors – including surgeons – as flawless, heroes who emerge from years of education, masterful. However, in the face of new technology, the rising power of the patient, and new avenues for subspecialty training, society must now revisit the fundamentals of treating pain and suffering in hospitals and beyond.
“American College of Surgeons (ACS) Establishes “Transition to Practice” Fellowships.” Skeptical Scalpel. N.p., 18 Apr. 2003. Web. 19 Sept. 2015.
Campbell, Kendra, M.D. “Top 10 Mistakes Made in Clinical Rotations.” Albert Einstien College of Medicine. Albert Einstein College of Medicine, n.d. Web. 19 Sept. 2015.
“General Surgery Training Program.” Johns Hopkins Medicine. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System, n.d. Web. 18 Sept. 2015.
Indiana University School of Medicine, Indianapolis, IN, Virginia Mason Medical Center, Seattle, WA, and University of Michigan, Ann Arbour, MI. “General Surgery Residency Inadequately Prepares Trainees for Fellowship.” National Center for Biotechnology Information. U.S. National Library of Medicine, Sept. 2013. Web. 19 Sept. 2015.
Lowrey, Annie, and Robert Pear. “Doctor Shortage Likely to Worsen With Health Law.” The New York Times. The New York Times, 28 July 2012. Web. 10 Sept. 2015.
Olsen, Elizabeth. “Medical Students Confront a Residency Black Hole.” Fortune. N.p., 01 Apr. 2013. Web. 19 Sept. 2015.
Treyzelaar, Dr. “Surgical Competence, a Crisis in US Health Care?” Cardiac Health. N.p., 19 Sept. 2015. Web. 19 Sept. 2015.