Initial Training, and Re-training Senior Doctors
Complications, A Surgeon's Notes on an Imperfect Science, by Atul Gawande, published by Henry Holt, 2002. find library or excerpts or buy
" 'Hello, I'm Dr. Gawande. I'm one of the surgical residents, and I'll be assisting your surgeon'... Yet to say I just assisted remains a kind of subterfuge. Otherwise, why did I hold the knife? Why did I stand on the operator's side of the table? Why was it raised to my six-feet-plus height?...
"When an attending physician brings a sick family member in for surgery... a first-timer is certainly not going to do it. Conversely, the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented...
"You do get good at certain things, my father [a urologist] tells me, but no sooner than you do, you find what you know is outmoded, New technologies and operations emerge to supplant the old, and the learning curve starts all over again. 'Three-quarters of what I do today I never learned in residency,' he says. On his own, fifty miles from his nearest colleague... he has learned to put in penile prostheses, to perform microsurgery, to reverse vasectomies, to do nerve-sparing prostatectomies, to implant artificial urinary sphincters. He's had to learn to use shock-wave lithotripters, electrohydraulic lithotripters, and laser lithotripters (all instruments for breaking up kidney stones); to deploy Double J ureteral stents and Silicone Figure four coil stents and Retro-Inject Multi-Length stents (don't ask); to maneuver fiber-optic ureteroscopes...
When an important new device or procedure comes along, as they do every year, surgeons start out by taking a course about it -- typically a day or two of lectures by some surgical grandees with a few film clips and step-by-step handouts. We take a video home to watch... But there's not much by way of hands-on training. Unlike a resident, a visitor cannot scrub in on cases, and opportunities to practice on animals or cadavers are few and far between. (Britain, being Britain, actually bans surgeons from practicing on animals.) ... Patients do eventually benefit -- often enormously -- but the first few patients may not and may even be harmed... you can't train novices without compromising patient care...
"Do we ever tell patients that because we are still new at something, their risks will inevitably be higher, and that they'd likely do better with others who are more experienced? Do we ever say that we need them to agree anyway? I've never seen it. Given the stakes, who in their right mind would agree to be practiced upon?...
"I noticed on the expert's desk a picture of his child, born just a few months before... 'So did you let the resident deliver?'... 'No,' he admitted. 'We didn't even allow residents in the room.'...
"If you're going to do nothing but fix hernias or perform colonoscopies, do you really need the complete specialists' training (four years of medical school, five or more years of residency) in order to excel?"
Limited Quality of First Training
"Does resident post graduate year influence the outcomes of inguinal hernia repair?" Wilkiemeyer M, Pappas TN, Giobbie-Hurder A, Itani KM, Jonasson O, Neumayer LA. Ann Surg. 2005Jun;241(6):879-82; discussion 882-4. Cited by 7 articles
"Despite the presence of an attending surgeon, open hernia repairs performed by junior residents were associated with higher recurrence rates than those repaired by senior residents."
96% of hernia repair operations in the study had interns or surgical residents doing or helping with the operation. Interns and 2nd year residents had a recurrence rate on open hernia repairs (not laparoscopic) of 6.4%, 3rd year residents had 3.0%, and 4th or later year residents had 1.1%.
All levels averaged 9.8-11.5% recurrence on laparoscopic hernia repairs. "Only when the attending surgeon and the resident are highly experienced in laparoscopic repair techniques, are recurrence rates for laparoscopic repairs reduced."
"Hands-on instruction and graded clinical responsibility are integral components of surgical education in North America... One variable that could have affected the results seen in this study is degree of attending surgeon supervision. Fallon et al (note 11) have reported that, when surgical procedures were performed with low levels of attending surgeon supervision, complication levels and mortality were raised...
"Under these circumstances, the results we describe raise important questions about the effectiveness of supervision of inexperienced surgery residents. While it is understandable that the instruction of an inexperienced resident will take longer and lengthen the operative time, why were recurrences more common when junior residents were involved? Should not the supervising surgeon corrected [sic] any errors in technique and achieved the same outcome as if the attending surgeon had performed the operation?"
The attending surgeons knew they were part of a study where results would be measured. Would they do even worse normally?
"If experience is required of a closely supervised surgery resident to achieve optimal patient outcomes, how is it possible to begin the educational process for a surgeon-in-training and still safeguard each patient’s welfare?... Which points in each procedure are most vulnerable to inexperience? What must the attending surgeon do to confirm accomplishment of maneuvers critical to the outcome of the procedure?... None of these questions has been adequately addressed by surgical educators...
"Hopefully, the future will include better training tools for teaching surgical procedures outside of the operating room...
"Should only senior residents do hernias? I think the answer is clearly no. I think we have to be better at teaching interns and second-year residents how to do these operations."
One question in the discussion published with the paper asked, "do you plan to change anything based on patient informed consent, given the data in this study?" No further discussion of patient information or consent was given.
Weaknesses of Senior Doctors, Benefits of Simulators
"Assessing the Performance of Aging Surgeons" Katlic, Coleman, Russell, free summary in JAMA
"considerable decline with age in virtually every test... lack of self-awareness is common... experience and decision-making of older surgeons contribute to the lower mortality through both improved patient selection and avoidance of high-risk procedures." So patient access can be reduced by older surgeons' selection of patients.
"Expertise in Medicine and Surgery" Norman, Eva, Brooks, Hamstra, chapter in Cambridge Handbook of Expertise and Expert Performance, edited by Ericsson. Charness, Feltovich, Hoffman. Cambridge University Press, 2006. cited by 133 studies.
"Systematic consideration of the causes of poor performance in older physicians suggests that premature closure (i.e., excessive reliance on one’s early impressions of a case) may be the primary source of difficulty for those with more experience (Caulford et al., 1994). In other words, more-experienced physicians appear more likely to accurately diagnose using pattern recognition, but as a result of increased reliance on this strategy, they also run the risk of being less flexible, failing to give due consideration to competing diagnoses (Eva, 2002). Historical work into the cost of experience confirms that the more one relies on automatic processing, the harder it is to exert cognitive control when problem solving (Sternberg & Frensch, 1992). More recently, Hashem, Chi, and Friedman (2003) have presented data supporting this idea, showing that medical specialists have a tendency to pull cases towards the domains in which they have the most experience."
"Several studies (Anastakis et al., 1999; Matsumoto et al., 2002; Grober et al., 2004) have now shown that technical skills acquired on low-fidelity bench models transfer to improved performance on higher-fidelity models (such as human cadavers), as well as live patients in the operating room, both in laparoscopic surgery (Scott et al., 2000) and anaesthesia (Naik et al., 2001)." This finding suggests that volume can be obtained in training, without putting humans at risk.
Studies published since 2006 show the continuing need for bench training, such as a 2014 plan for $100 laparoscopic simulators for constant home practice, not just $2,000 simulators for occasional practice at a hospital: "the laparoscopic approach is quite different and different skills are needed. The first is the ability to perform actions in three dimensions when only two can be observed on the monitor. The second is that the difference of depth perception, spatial relationship and long surgical instruments requires perfect eye-hand coordination. Moreover, the arms of the tools act as levers with a fulcrum at the site of the skin incision, and hence the real action with the tool handles is a mirror of the movement of the tool tips seen on the monitor."
Simulation can include live animals, cadavers, artificial materials and virtual reality with tactile feedback. Some authors are concerned there is not enough time to train since residents are limited to 80 working hours/week in the US and 48 in the UK.
A 2013 synthesis commented that with the rise in laparoscopic training, "the open operative experience of current surgical residents has decreased significantly. This deficit poses a potentially adverse impact on both surgical training and surgical care. Simulation technology, with the potential to foster the development of technical skills in a safe, nonclinical environment, could be used to remedy this problem...
"This is particularly true with regard to skills required to competently perform technically challenging open maneuvers under urgent, life-threatening circumstances. In an era marked by a decline in open operative experience, there is a need for simulation-based studies."
Another 2013 overview says simulation should be required in surgical training and asks why it is not, "simulation is still not a mandatory component of all surgical training...
"The role of simulation is not to replace conventional training in the operating room but rather to augment it. By training in a simulation laboratory, a surgeon can acquire the necessary cognitive, technical, and nontechnical skills to shorten his or her learning curve in the operating room."
They even recommend simulated operating rooms to teach group work. Current training fails "to address such nontechnical skills as communication, teamwork, situational awareness, decision making, and leadership. This failure to address nontechnical skills is not acceptable, given the evidence that communication breakdown and failures in leadership and teamwork might be the root cause in up to 60% of major perioperative complications."
The Medical Director and Chief Academic Officer at Carolinas HealthCare System: "Bullard and Hall say the $1 million [simulation] program has paid off by helping doctors and nurses respond to sepsis in the simulation center, rather than relying on real-time cases to learn the procedure. 'It used to be that you saw one, did one, and then taught one. But those days are gone,' Bullard says. 'It's no longer safe to practice that way. Residents learn better in experiential learning environments.' "
Benefits of High Volume per Year, Weaknesses of Older and Senior Doctors
"Prestige of training programs and experience of bypass surgeons as factors in adjusted patient mortality rates." Hartz AJ, Kuhn EM, Pulido J, Med Care. 1999 Jan;37(1):93-103. Cited by 10 articles.
Findings on Annual Volume and Lower Deaths:
"As with previous studies, we found that the more operations a surgeon performed [per year], the lower the mortality rate. notes 8-11 This association may result because a greater number of surgeries may improve physician performance. It is also possible that the best surgeons may be referred the most cases."
The study covered deaths among 83,500 patients in 1990-92 in Pennsylvania (46,000), New York (38,000), Wisconsin (3,000). Each NY surgeon had treated 200+ patients in 3 years. Each Pennsylvania surgeon had treated 30+ patients per year. The Wisconsin patients were only from Medicare, and only from 1 year, mostly 1990, and included surgeons who treated any number of patients.
Findings on Years of Experience, Academic Rank and Higher Deaths:
"Mortality ratios... increased with years of experience, age and academic rank." See graph below left.
"A higher mortality ratio was significantly associated with more years in practice." as shown in the graph above right. The fewest deaths were for the 66 surgeons 5-10 years after training.
The ratio of actual deaths to deaths expected based on patient traits increased with higher academic rank:
0.79 for the lowest academic rank, instructors (death rate 21% less than average)
0.95 for assistant professors
0.99 for associate professors
1.19 for full professors (death rate 19% more than average)
"There was no evidence that surgeons with higher academic ranks had higher risk patients. An explanation for this finding is that the mortality ratio of senior academic surgeons may be increased because more of their operations are performed by residents or fellows."
"Neither the observed mortality, predicted mortality, nor mortality ratio differed significantly between physicians who trained in the most prestigious medical school, residency, or fellowship programs, and physicians who trained in the other programs."
However, "Physicians were more likely to be identified as best doctors [in lists of 'best doctors'] if they trained in prestigious residencies (P<0.01) or fellowships (P<0.05), or if they had an academic appointment (P<0.05) or 15 or more years of experience (P<0.001)."
"Conclusions. Training at a prestigious institution was associated with identification as a "best" doctor but not with lower mortality ratios.
RETURN TO ARTICLE ON FINDING HIGH-VOLUME SPECIALISTS