Sunday, June 18, 2017

Surgery Residency: Drop-Out Nation?

In the first decade of the 20th century, William Halsted---using principles he had learned from watching German surgeons---- implemented a new model of training general surgeons in America.  Replacing the old journeyman/apprenticeship paradigm was an intensive, arduous, all-encompassing program that integrated basic science with bedside patient care, emphasized repetition and volume under the tutelage of master surgeons, and introduced responsibilities and skills in a gradual step wise manner.  Resident surgeons basically spent 5 years of their lives living at hospitals, immersing themselves completely in the acquisition of essential skills and knowledge.  The Halstedian paradigm quickly became the standard across the nation as its tenets were adopted by the newly formed American College of Surgeons in 1913.

For most of the next 90 years, he basic training model remained constant.  Of course it was brutal and inhumane.  Young men (almost all men, during these years) literally never saw their families.  Pyramidal structured programs meant that most interns would never make it through the training.  Something had to give. Pyramid programs are no longer acceptable.  Work hour reform has allowed most residents to maintain at least a tenuous grip on sanity.  But there are no panaceas when you are talking about training future general surgeons.  If anything, the demands on a surgical trainee are much greater than even what I faced 15 years ago.  New technology, rapidly changing treatments algorithms, hyper-advances in basic science make it very difficult to acquire a firm knowledge base and technical proficiency in a feld with constantly shifting, expanding foundations.  And despite all the changes with work hour reform, general surgery residents have continued to drop out of training at much higher rates than residents in other specialties, even today.

Heather Yeo and her group at Cornell has a somewhat discouraging paper coming out soon in Annals of Surgery  that attempts to delve into this phenomenon  Theirs is a national longitudinal cohort study designed to identify factors associated with resident attrition.  One important finding, much discussed in a era where women make up slightly more than half of incoming general surgery residency classes, is that the female gender is the most important factor in predicting withdrawal from a residency program.  Further, minority women represent the highest risk cohort for dropping out from surgery training (35% will drop out before graduating).

The thing that jumped out at me was the overall withdrawal numbers, regardless of sex or race.  From an article Christina Frangou of General Surgery News wrote about this paper:
"For the past 25 years, attrition rates have remained steady in general surgery, with about one in four residents not completing training. That is much higher than other specialties, including surgical specialties. Orthopedic surgery has a dropout rate of less than 1%, OB-GYN is about 4.5%, and medicine is about 5%.
“It was thought that changes in work hours and the kinds of things might lower the attrition rate, but they have not. So we need to look at other solutions,” Dr. Yeo said."

Shit man.  You mean 20-25% of highly educated, extremely motivated young adults who have chosen to embark on a career in surgery end up bailing after a couple of years?  That's outrageous.  We're not talking about young buckos who quit McDonald's after a couple weeks because they can't handle the heat of the fryer in the summertime.   These are elite, highly prepared individuals who have busted ass for 15 years, excelled in college and medical school, done internships and sub-internships, sometimes even research in surgical sciences.  And they are quitting left and right.

I don't feel strongly at all that this persistent attrition rate over the decades has anything to do with race or gender or generational dispositions.  It's just that general surgery is fucking hard, man.  And you don't really see it until you start learning it, doing it, seeing older surgeons living the kind of life it requires.  It's a hard ass life.  Emergency and unanticipated cases will always represent 30-35% of a busy general surgeon's practice.  Doesn't matter who you are.  You will always have to take ER call.  You will always have to smile and say "no problem!" when a Primary doc calls you at 4:30 pm on Friday with a "painful hemorrhoid, can you see him in the office right now".

It's a hard, exhausting, brutal life at times.  Rewarding sure.  I can't imagine doing anything different (that's the brainwashing speaking).  But it will chew you up and spit you out.  The years will pass faster than the cards flying by you at a blackjack table in Vegas.

And this essential FACT resonates with residents.  They see what a community general surgeon has to do.  They see these older surgeons working harder than interns.  And I suppose it just gets a little demoralizing after a while.  Who wants to be a grunt for the next 45 years?  As they say in the military, only the nut jobs, eccentrics, cranks and psychopaths actually volunteer for the infantry.  General surgery, man, you're on the front lines.

Even the ones who make it through seem do do so with a jaded eye.  At many top programs, we see reports of 75-80% of 5th year residents going on to do additional training and fellowships.  No one wants to be this thing called a "general surgeon".

I think that's too bad.  We may be on the precipice of another paradigm shift in how surgeons define themselves.  Maybe there's just too much to know, too much to stay up on, too many advanced skills for one surgeon to acquire. Time will tell.  Maybe the pendulum will swing back in the other direction as wider and wider swaths of geographical America finds itself without enough broadly trained, competent surgeons to meet the needs of its population.....

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