Practice makes perfect ... or something like that

“The surest way to corrupt a youth is to instruct him to hold in higher esteem those who think alike than those who think differently”

~Friedrich Nietzsche

Over the past 10 years, I have had the opportunity to work with residents from different backgrounds, undergraduate majors, and orthopaedic programs. I have worked in 5 different academic settings. I state these facts because my upcoming view is not based on a view of one way of educating (i.e. the Harvard or Duke Way), but based on an understanding of the differences in both teaching and learning styles, academic and clinical settings, and generational changes. In my anecdotal point of view, residents in today's residency setting are technically delayed. The technical skills that I observed in residents 5 years ago don't seem to appear in the residents until about 6 months or so later. Some people reading this may feel that it is a slam. It is not; it is just my observation. When I ask myself why has there been such a change across the board, the only significant change has been the institution of the 80 hour work week.

One of the main reasons I like teaching is because I like to watch the intellectual growth of young surgeons. I enjoy seeing their development from novice surgeon afraid of cutting too deep, to a confident graduating chief. It is almost like raising your kids. "Oh, look he is using the cob like a big boy, now. He makes me so proud." Recently I have begun to notice that some of the skills that I had, I guess, taken for granted are not being developed. Basic skills that many learned in their internship in the past are being learned as second year residents. I wonder if we are failing our residents by not providing them with the tools they need to practice on their own. Are we setting them up for failure?

When the 80 hour work week was initially proposed, many surgical programs and grey-haired, "old school" surgeons said this will never work. I believed and still believe that the change was necessary. I also believe that once all of the data comes out that there will be changes in the duration of residencies (increase in time), the operative logs will be used for hospital credentials (no enough cases in residency = no privileges), and increases in the requirements for initial hospital monitoring of new surgeons and board certification. This is what I see in my crystal ball; although, it is sometimes cloudy.

There has been a recent study that have noted a decrease in cases logged.

Weatherby and fellow researchers used ACGME case logs to study PGY2 and PGY3 students' operative experience gained in a two-person orthopedic residency program in 2002-2003 (before the 80-hour week) and in 2003-2004, after the longer week took effect. Researchers also gave junior residents logs in which to record subjective caseload information, Weatherby said.

In 2003-2004, PGY2 and PGY3 residents performed 759 operations, or 195 (21%) fewer than in the previous year, Weatherby reported. Cases per rotation averaged 79.5 in 2002-2003, compared to 63.3 the next year, showing a 20.44% decrease (P=.009).

"The trend is obvious," he said. "It is obvious that it is national, too."

Residents missed 9% to 13% of total surgical case volume between November 2003 and January 2004, with each resident missing an average 10.8% of cases, totaling 254 cases over 64 post-call days, Weatherby said.

"Our study shows that residents who have begun training after the 80-hour work week will do significantly fewer procedures, particularly at the PGY 2 and 3 level," Weatherby said. "This may result in a decreased level of skill acquired during training or it may shift the majority of operative experience to the PGY4 and 5 years, prolonging the learning curve."

Weatherby called for more research and more assessment of how the new hour regulations affect surgical training. He also voiced concern about residents having fewer opportunities to learn surgical procedures in a reasonable amount of time.

"We must ask ourselves if we will at some point, in fact, build up the skill of orthopedic surgery," he said. "This also supports the theory that operative experience is deferred ... throughout the year, thus prolonging the learning curve."

Weatherby B, Rudd R, Ervin TB, et al. The effect of resident work hour regulations on orthopaedic surgical education. #121. Presented at the American Academy of Orthopaedic Surgeons 73rd Annual Meeting. March 22-26, 2006. Chicago.

I ask myself, how do we accommodate for the decreased numbers? Years ago, many surgeons would practice at home. They would learn how to drill and sew outside of work. They always worked on their technical skills. In the current generation, I have not seen the desire to work outside of “work” to learn how to perform their craft. Technical skill can not be read, it must be practiced. My residents and medical students are well read. They can quote literature, know how to gather information, and put on a heck of a power point show; but operative skill "not so much." The chiefs feel the need to operate because they what to gather the skills before graduating (and they are avoiding clinic) and the juniors operate less because of floor, clinic, and ER responsibilities. Then the cycle continues the next year because the rising junior becomes a chief and needs the operative experience.

I can hear people now saying, "Well just let them operate and get PA's and NP's to manage the floors and clinic." That is not the answer either. One of the most important skills for a surgeon is making good clinical decisions. Decisions like when to operate and when not to operate; which patients are good candidates and which ones are bad candidates; and what your outcomes are realistic expectations from procedures. That experience comes from follow-up. As they say, there is nothing like follow-up to ruin your good outcomes. We haven't even addressed billing, coding, and the other business aspects of a practice that are barely taught in residency.

As I look forward, I wonder if we are failing them by not providing them with ways to develop technical skills without actually operating on a patient. I know that there are simulators that are being used to help address these deficits (arthroscopy simulators), but are they being utilized appropriately? How can we accommodate for a decrease in case volume without increasing residency time? Maybe some of you have ideas. For now, I am still trying to keep from getting frustrated.

“Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.”
~Albert Einstein