Surgical education: A problem with resources

Most specialties are either surgical or medical specialties. Surgical specialties include general surgery, neurosurgery, thoracic surgery, etc. Medical specialties are everything else, like internal medicine, psychiatry, dermatology, etc. Some specialties like family medicine and emerg have a mix of both surgery and medicine. Surgical residencies are known as brutal 5-6 year experiences because of the long hours as well as the busy and frequent nights on call. These residencies are intense, in part, because surgery is a challenging skill for residents to develop.

Learning surgery from a book is much more difficult than learning medicine from a book. Both are best learned and remembered in the context of real patients (i.e. I am more likely to remember how to treat sepsis if I learn about it while managing a septic patient rather than only reading about it in a text book), which is the argument for why we need a residency after we complete medical school. However, if context isn't available, it is much easier to learn medicine form a text book. In fact, I think it is almost impossible to truly learn surgery without practicing it on an actual patient under the watchful eye of an attending.

Learning a hands on technical skill is a new challenge for most residents. Excelling in academics from grade school through undergrad and into medical school has made most residents very proficient at learning theory from a book. However, on average, we are much, much slower at picking up practical hands-on work.

Thus, a surgical education is significantly more resource intensive than a medical education. The limiting factor in the training of a future surgeon is most definitely operating room time. There is a surplus of patients that need surgery. There is a surplus of medical students who want to become surgeons. The resource that is scarce is operating time. With limited operating rooms, you can only hire a limited number of surgeons. A surgeon can only really teach one resident how to perform one type of surgery at any given time.

If a hospital has eight surgical residents, but only four operating rooms where surgeries are occurring on a given day. Then only half of the residents will be in the operating room learning how to perform surgery. Since surgery is already difficult to learn, the fact that they are not in the operating room every single day slows their education even more. Thus, they need to work long hours and have frequent overnight call shifts to maximize their opportunities to learn their trade.

Surgical residents would have a much better and more balanced experience if they were able to always be the first assist learning directly from a fully trained surgeon every day. Unfortunately, this is not an economically feasible possibility. This is particularly unfortunate because I think the lifestyle of a surgical resident scares away many talented medical students who may have the potential to become great surgeons.

Of course, in Canada, we currently have a surplus of surgeons graduating every year, so I doubt there is sufficient motivation to address this problem in the near future... Plus, most surgeons wear the challenging lifestyle of their residency as a badge of honour.

Surgery as a Med Student

Our third year surgery rotation is made out to be one of the most intimidating experiences that we will ever face in medical school. Horror stories abound about 6am rounds, standing in the operating room (OR) for hours pulling back a fat flap so the surgeon can have better access to the tissue, crabby surgery nurses that yell at you for breathing, and attendings who yell at you because you can't do anything right even when you do exactly what they tell you to do.

Needless to say, the horror stories are exaggerations...at least mostly. Depending on which surgical subspecialty I was doing, I would have to be at the hospital some time between 6:15-7am. When I was in the operating room, sometimes I had to retract tissue, sometimes I was the first assistant helping the surgeon, sometimes I closed the surgical incision after the operation was completed, and sometimes I stood. The nurses were nice as long as you were friendly with them and showed them that you were at least competent enough to ask them questions if you had any. Experiences with attendings varied from student to student and attending to attending. No attending ever yelled at me, though, some certainly did ignore me. However, most of the attendings I worked with were actually really friendly, wanted to teach, and tried to convince me to become a surgeon.

My major frustration with my surgery rotation is that there wasn't a lot for me to do as a medical student. In some ways, that should draw a collective sigh of relief from the general public. Do you really want a medical student to be heavily involved in your surgery? However, it was frustrating for me because I had completed my internal medicine rotation and I was accustomed to managing patient care from start to finish. As a surgical med student, I was often given odd tasks here and there when the surgeons and their residents were too busy to do the task themselves. Of course, there are also a set of "med student tasks", such as closing the incision, guiding the camera in a laproscopic surgery, and checking patient labs (in order of excitement).

There is also an interesting type of unity that forms amongst the surgical residents. A surgical residency is tough...actually, brutal. They work from 6am-5pm or later for five days a week and their work is always go, go, go. They also have call 1 in 3 or 4 days, which means they are working every other weekend. They also have a huge patient load and they barely have an opportunity to familiarize themselves with the patient charts. When they get home from work, they have to find SOME time to study. And, oh yeah, they need to find some time to have a life and see their friends and families. However, they are all in the same stressful situation for five years, so there tends to be a really strong bond between them. Uniting against a common enemy, even if that enemy is a residency program, makes working with the residents a lot of fun. They were definitely the most stressed, but most entertaining group I have worked with so far.

So my thoughts on surgery as a med student:

Positives
1. Get to be in the OR (and actually do stuff).
2. Learn how to deal with acute, surgical emergencies.
3. Finally do procedures.


Negatives
1. Lots of standing around feeling useless.
2. Long days.
3. Attendings and residents were often too busy to teach, even if they wanted to.
4. Residents never seemed happy...some were neutral, but most were always stressed.

Surgery was a busy rotation, but being in the OR and seeing surgeons cut people open to fix them was definitely one of the coolest experiences I have had in med school