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LETTER TO THE EDITOR
GENERAL SURGERY NEWS / JANUARY 2022
Allowing Surgical Trainees to Struggle in the OR
[Re: “The Most Harm,” by Miguel Lopez-Viego, MD, November 2021, page 1] To the Editor: Kudos to Dr. Lopez-Viego for speaking up on this pandemic-like issue among the graduating residents and fellows. He has hit the nail on the head, summarizing what is currently going on in U.S. training programs, an issue which is only getting worse with senior residents/fellows being mere observers now in robotic surgery cases. I am currently a second-year attending, and I can’t emphasize how important it is to “struggle” in the OR. There is simply no amount of observing, reading or watching videos that can prepare you for the real world. Dr. Lopez-Viego has rightly pointed out that senior residents/fellows are exploited for administrative tasks while the attending “gets through” the case for myriad reasons. Surgery is all about “see one, do one, teach one.” Unfortunately, this field is moving away from the “do one” aspect rather quickly. It is incumbent upon our leadership to act on this very important issue and ensure the graduating residents/fellows are up to the task that will be handed to them once they are practicing. This article highlights what happens to the unfortunate folks who are not prepared to face the music. As Dr. Lopez-Viego recounts, “All these surgeons eventually had to leave the community discouraged, disgraced, embarrassed and lacking any confidence.” Reiterating the point, the ACS leadership needs to intervene to avoid—despite multiple years of post-residency training—a pandemic of untrained surgeons. Adeel A. Shamim, MD, DABS Minimally Invasive and Bariatric Surgery Mercy Health, Fort Smith, Ark. To the Editor: I am a third-year general surgery resident and would like to share my sincerest compliments regarding the article “The Most Harm,” by Dr. Lopez-Viego. I strongly agree with his message and feel comforted knowing there are surgeon educators who recognize this issue and are speaking out about it with passion. Dylan Johnson, MD, PGY-3 General Surgery Residency Program HCA Brandon Regional Hospital, West Florida Division To the Editor: I thought this was one of the best articles in the history of General Surgery News. Dr. Lopez-Viego calls it like it is. I am not confident, even with the truth, that the problem will be fixed. I think any patient entering an academic institution should have to sign a waiver acknowledging that they may be operated on by a resident under supervision. Only by making this a standard protocol for all academic institutions will the problem be fixed. Patients who want the benefit of these prestigious and well-equipped training institutions will have to make a trade-off, and, if they don’t want that, they can go to a nonacademic center. The legal and administrative departments will be very hesitant, unfortunately, to fix this problem on their own. Matt Pompeo, MD Dallas
To the Editor: I’m a new general/bariatric surgeon, four months out from fellowship, and I just wanted to say how much I appreciated this article. I couldn’t agree more with Dr. Lopez-Viego. I just wish more academic surgeons took their responsibilities as educators as seriously as he does. Thank you, Dr. Lopez-Viego, for taking the time to write this article and for the countless hours you spend in the OR letting your trainees struggle. That really is the most important part of training. Eric Rachlin, MD Houston To the Editor: Dr. Lopez-Viego’s vitriolic editorial, “The Most Harm,” is long on complaints and criticisms of current surgical education but short on solutions. He describes the ongoing devaluation of classic surgical education in general and intraoperative teaching specifically, yet offers no practical recommendations to remedy the situation. The good doctor must realize that surgical education in academic centers is a historical accident. Its perpetuation into modern times is not necessarily the best way to teach residents how to operate. Academic departments of surgery are not fonts of education. These centers are multimillion-dollar businesses focused on financial stability. The dedicated, patient and selfless surgical educator described by Dr. Lopez-Viego does not exist because there is no RVU [relative value unit] for educational effort. That surgeon is an economic nonentity. The literature on the fate of physicians who have won teaching awards reveals just how valuable the premier medical educator is in today’s environment (Medical Education Online. 2000;5:3. www.tandfonline.com/ doi/abs/10.3402/meo.v5i.4313; Perspect Biol Med 1999;42[2]:280-287. doi:10.1353/pbm.1999.0029). The goals of the academic medical center are too diffuse to provide the type of surgical education sought by Dr. Lopez-Viego. The irrefutable fact is that academic surgeons chose their career path not to perfect their craft and pass it on to others, but to do what is required to become a professor. The goal is to write papers, increase a national profile, attend national meetings, obtain research grants, serve the American College of Surgeons and the American Board of Surgery, spend endless hours on committees and at retreats, and, if there is time—perhaps as an aside—instruct residents on the basic mechanics of clinical surgery. To put it bluntly (and to some degree to keep up with Dr. Lopez-Viego), due to a lack of practice and volume of cases, academic surgeons with few exceptions rarely rise above the competency of the fellow. They remain largely unaware of their lack of operative skills. They exist in a world of arrested surgical development. It’s as if you are climbing the White Mountains of New Hampshire all of your life, never realizing that there is a Mont Blanc. A step forward to remedy the problems outlined in Dr.
Lopez-Viego’s caustic essay—did he really equate delaying challenging cases to senior residents as a criminal act?—is to increase the number of rotations outside of the mother ship for surgical residents. I would guess that 95% of graduating residents who have had outside rotations would say that that is where they “learned to operate.” Place a resident into a busy community surgical group performing 10 to 15 cases per week and that resident will learn how to operate safely and efficiently. That was always the appeal and value of a Veterans Administration [hospital] rotation. The community hospital and the VA have only one mission, not four competing missions. The surgical skills of private-practice surgeons greatly exceed those of academic surgeons. The latter never understand this and, in fact, for mysterious reasons, endlessly debase and ridicule community-based surgeons. In addition to spending more time at community hospitals and Veterans Administration facilities, graduating surgical residents should be required to spend six months in a medically underserved part of the world. Many international opportunities are available. I am familiar with a recently graduated chief surgical resident who did this. He returned with a refined set of surgical skills. Those six months put him years ahead of his colleagues in surgical judgment and the ability to recognize and to manage complications. His personal initiative made up for the deficiencies Dr. Lopez-Viego describes. When a graduating resident takes a job, that resident must be certain that a mentor will be part of the employment contract. I am not talking about a half-hour latté schmooze-fest on a Tuesday morning. I am talking about an experienced, broadly trained mentor 10 or 15 years into practice who has a contractually vested interest in the new hire—an interest in the financial viability of that individual and a greater interest in correcting the failures of that individual. I am talking about a colleague who will appear at 0200 hours to help dig out the left ureter! I am talking about someone who recognizes the issues raised in Dr. LopezViego’s editorial and is going to do something about it—a true surgical leader who can correct current educational deficiencies. The academic surgical construct is simply not designed to produce “cutting surgeons.” If the days of the cutting surgeon are gone, there is no reason to fret over this. Laparoscopy, robotics, interventional radiology and advanced endoscopic skills may make up for the demise of the cutting surgeon. But if they are not gone, primary responsibility for surgical education needs to find a way to escape from the historical confines of academic centers. Current graduates are not finished products. If they were, the resident farewell dinner would not be called a “commencement.” Leo A. Gordon, MD Los Angeles Dr. Gordon is a member of the editorial advisory board of General Surgery News.
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khorty@mcmahonmed.com.
