OnSurg founder Dr Chris Porter, posing questions to surgeon educator and creator of podcasts at Clinical Brain Training:
I enjoy your podcasts, particularly when you discuss learning principles and educational models in other industries. What do you see as the biggest flaw in surgery residency training in the US system presently?
I don’t think surgery is unique in having a flawed model; all residencies have been very slow to change. I think the biggest issue is that we have residents with much less clinical experience at almost all levels. But I want to say first that I feel by the end of residency, we mostly turn out competent surgeons. The later years seem to do their job. However, the early years, and especially the interns, are being thrown into complex environments that they are not adequately prepared for. We are also well behind in measuring competency. You would never let a pilot fly a passenger plane because they spent years watching someone else do it. That is essentially the position we put interns in.
Why do you think we persist with our current model?
There is a lot of information out there concerning effective education and simulation, but most of the good work is in domains that MDs don’t look at. Aviation, military, and fire rescue all have teaching processes that are probably far more effective than medicine’s. Also, the residents are placed in an even more dangerous position because the escalation and backup processes in most hospitals are weak, so even if they realize they are getting into trouble, or are just overwhelmed with work and may become prone to serious error, there are few automatic actions put in place to help. The military and fire rescue have ingrained escalation and backup responses that are known to work well and could easily be copied.
If you could design a surgical educational system from scratch, which features would differ most from our current system?
I think the most effective education occurs when you are frustrated and eager for information. Unfortunately, much of the time that feeling emerges when you have made an error. We need to cultivate that eager attitude to absorb and imprint information, without hurting patients. Simulation is the only tool we have to carry that out, but because most places think simulation has to occur in a $10 million sim center with a $500,000 mannequin, they are lucky if they get that experience once a year, which is almost worse than useless.
So I would:
- Create a database of cases, built on real patients using real data and actual outcomes, arrange them into curriculums.
- The residents would need to go through each curriculum of cases, and then be assessed. If they show they don’t possess the necessary cognitive skills, they can’t advance.
- To do that effectively, we can not rely on the residents to be worker bees. We have to create the opportunity for residents who need more time to be competent, to get that time. If they can’t do it after a reasonable period, maybe they need to find another job.
- We can’t provide that opportunity to take extra time until we have enough mid-level practitioners to care for the patients. To have residents be students and independent novice practitioners at the same time is a bad model and needs to change
- We need to do actual technical and cognitive assessments using tabletop simulation (war games), high tech simulation for certain skills, and real assessment with real patients in the OR and ICU/floor.
- We need to get away from calendar page turning as the method of evaluation (you finished the vascular rotation, so you must be competent) and move toward actual skill assessment (like every other high risk domain does).
Care to comment on undergraduate medical education in general? What should change?
If you’ve listened to some of my podcasts, you know I think medical school is extremely flawed. The information is still presented much like it was in 1984 when I was in med school. Your experience the third and fourth years is almost completely random, and dependent on the student’s enthusiasm. You may never see many things that are essential parts of the cognitive skill set you will need to be alone in the hospital with patients on July 1 of your intern year.
Also, the idea that a multiple choice test, and a few standard patients is a modern way to assess competence is nuts. Assessment should be ongoing, and should focus on tactical decision making, and patient safety. Practitioners will fill in the blanks (background knowledge) when they are stimulated to do it. Pushing tons of uncorrelated information into med students brains before they have any way to use it tactically mean it will almost all be forgotten.
How about surgical education for medical students – what needs to change?
I think we need an honest, realistic assessment of what surgical training in med school should provide, and insure the students are competent in those areas before they graduate. For some, that will require four months of surgery, for others one month. The variability in our graduates is just too great.
Once we decide what they need to know, we build illustrative cases around that, teach the cases, then assess with different cases. Since the operative experience is so variable, I don’t see how we can rely on it.
I’m also interested hear from you as a trauma surgeon and intensivist. What has changed most in trauma or intensive care in the last ten years?
Some of the simple things are damage control and non-operative therapy. We used to take patients to the OR and hurt them because we weren’t certain of what was going on. We have much better diagnostic tools, and monitoring capabilities which I believe allows us to avoid surgery in many people who will not benefit from it. I think this has allowed us to save many people who would die in the OR twenty years ago.
Same with damage control. Operating on these patients until their heart stops is out of vogue. Most trauma surgeons have the attitude during big cases “when can I get out and get to the ICU?”. If something doesn’t need to be done right then, it is better to get the patient resuscitated and wait. I think this has saved many patients.
Finally, I think benchmarking and performance improvement has been very important. Everyone thinks they have a great trauma center, but now we can get a good idea of how good. This has allowed us to find best practices and implement them. The trauma community is fairly tightly knit, and we all learn from each other.
In critical care, the progress has been less. We have a better understanding of sepsis, but I think processes between hospitals and even among intensivists are very variable. When there are ten ways to do something that means there is no good way to do it.
Can you site a few important pieces of literature in that time period?
Rotondo’s initial papers on damage control.
The work on occult hypoperfusion done by myself and other investigators.
The ARDS papers looking at low tidal volume.
And I think all residents should begin to familiarize themselves with benchmarking and patient safety. Just go to Wiki and read the entries and then browse through the references.
Are surgeons using the evidence, that is, practicing evidence-based care in trauma surgery and ICU?
I believe they are, but unfortunately there is little definitive evidence in many areas, and much of it is contradictory. As an example, it was really disturbing to see the recent paper that showed that activated protein C might have actually had a significant effect on sepsis survival. Unfortunately it came out after the product was abandoned. The evidence for efficacy for that drug was contradictory, so what should you follow?
I think the greatest opportunity is to decrease variation and actually see what works. While people are not doing many things completely refuted by the literature, there is so much other variability that it is difficult to assess efficacy of many treatment strategies. Residents should speak up when they see attendings treating the same problem ten different ways. “Dr. Smith, you do this like this, and Dr. Jones does it like that, how can they both be optimal?” I think residents can serve a important role in pointing out to attendings that much of our variability is unnecessary.