Wednesday, November 11, 2009

How long to train a surgeon?

Concern has been raised about the training of doctors. Gretchen Purcell Jackson and John L Tapley, pediatric surgeons from Nashville, have just published an article in the BMJ which suggests that our surgeons are in danger of being seriously undertrained. Typically, a surgical training takes 5 years to obtain the necessary skills to be come a general surgeon with extra years for research and subspecialty training. Educational psychologists have shown that acquiring an elite level of expertise or performance requires 10 years of intense involvement and 10,000 hours of practice. This would be true for musicians, chess players or Olympic divers. The authors suggest that surgery, which requires both manual dexterity and cognitive understanding, needs twice that amount of training.

In the States surgeons are rejecting the idea that an 80 hour working week is sufficient to train a surgeon while in Europe the working-time directive is insisting on a 48 hour week. Sleep researchers have demonstrated that heavy night call, defined as every fourth or fifth night, compromises attention and vigilance as much as alcohol intoxication. One institution that introduced the 80 hour week found it produced happier trainees with a better quality of life but it also may well have compromised the surgeons' educational experience.

5 years at 80 hours a week does give the necessary 20,000 hours, but only if no more than 2 weeks holiday is taken. How can Denmark train its surgeons with a 37 hour week?

Although, the prime purpose in reducing surgeons' hours has been to enhance patient safety, it seems to have had the opposite effect where it has been tried. at one center preventable and non-preventable complication rates increased significantly after the introduction of an 80 hour week. In New York, where Teaching Hospitals adopted the 80-hour week but non-teaching hospitals did not, there were increases in unintentional punctures and thromboembolic events in those with the hours restrictions. The extra duties have to be done by someone - the answer is often moonlighting or else lying about hours.

When I think back to my own training, in the early days I worked alternate nights and then on a 1 in 4 rota. Hematologists in the UK have to obtain both the MRCP like internal medicine specialists and then the MRCPath like pathologists. They are also expected to publish. I completed my training 6 years after qualifying, but I did take work home. It may well be that surgeons need a longer period of training because of the 'piano practice' required. Musicians don't expect their instruments to start hemorrhaging uncontrollably.

When I was younger there were trainee surgeons in their early forties. Such were the rewards in private practice that they were prepared to put up with this extended training. Nowadays we see consultant surgeons appointed in their early thirties. They do far fewer operations than their forbears, both in range and number. I know one surgeon who never opens an abdomen, but is an expert in taking out lymph nodes and removes spleens through a laparoscope. Perhaps they are all a lot more talented than they used to be.

1 comment:

Anonymous said...

This entire subject has been incorrectly addressed in the US.

During my 5 years of post graduate medical training the amount of "call" and the in hospital workload steadily decreased in an incremental fashion but overwhelmingly exceeded that required of today's residents and fellows.

As an intern I was, no doubt, overworked at times and likely made some decisions with less than my full intellectual capacity, BUT as one of my attending physicians told me...the purpose of this was so that when I was called in the middle of the night about a sick patient I would be able to 'pull the correct bottle off of the shelf'.

I do believe that that was true and has served me very well throughout the years of my private practice.

The dirty little secret that all of the apologists won't share is that when one is in private practice one may be "on call' 24/7 for days on end and the need to make important, life dependent decisions is needed at all times, not just from 8 AM to 5 PM.

One of the most amusing (and ridiculous) things to come out of this are the guidelines adopted by various organizations which supervise post graduate medical training. Among them is a policy that precludes a resident who spent the prior night on call from seeing any new patient the following day. These residents, by the way, are excused from work at 12;30 PM on the day following a night of call.

Many a time I have advised a resident assigned to my service for training that I was asked to see a very interesting patient or that one of my own patients with an acute and likely instructive medical problem was in the emergency room, only to be advised that he or she could not see the patient! The morning after being on call is often a morning wasted insofar as learning is concerned.

This is a terrible waste of time and of learning opportunities.

So often the unintended consequences of new rules are absurd!