Volume 14, Issue 1, Spring, 2007
Training Environment Changes,
Residents Still the Same
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by Karen D. Horvath, M.D.
Associate Professor
Director, Residency Program
When I sat down to write this Synopsis article, my concern was not what I should write about, but what I should leave out! The residency program at UW, along with surgical education in general, is going through a period of unprecedented change. The 21st century has heralded the 80 hour work week, ACGME competency project, a trend towards national educational standards and ever-increasing compliance requirements. In fact, most of us would scarcely recognize the training program where we were residents even a decade ago. Needless to say, for surgical educators it is a very exciting time of constant challenges with endless opportunities to make a difference.
The 80 hour work week commenced in July 2003 and has brought big changes to the program. In the month prior to the new guidelines our residents were working about 110 to 120 hours per week. After three and a half years, I can say with confidence that the 80 hour work week is a good thing and was long overdue.
At UW, we have tried to view the 80 hour week as an opportunity to do a better job of training residents in less time. One example of this was to create an EVATS rotation. This was a UW invention and is now being used by other programs in the U.S. It has clearly enhanced resident education and the program. During the EVATS rotation, done in each year of training, residents are available to cover for emergencies and take a block vacation. In addition, they have time to complete an academic project (now required for graduation), time to work on ACGME competency learning projects, and have dedicated time to work on an open and laparoscopic technical skills curriculum in our new ISIS lab.
Another way we’ve enhanced training is with an improved and very popular Surgical Science Series. Based on feedback from the residents, we now have SSS every Wednesday from 7:30-11:30 a.m., separating the junior and senior residents. During this four hour block we start the morning with the standard general surgery curriculum review then add in open and laparoscopic technical skills courses and education in other areas such as “How To Give Bad News,” “The New Professionalism,” “Ethics in Surgery” and a Practice Management Series.
Another big change to the residency was a long-overdue increase in our categorical resident numbers from six to seven in 2003. Before this, our last increase was in 1970 despite a more than 250% increase in patient volume (surgical admits and OR cases) at HMC and at UWMC between 1988 and 2003 alone. Coincident with this increase, the subspecialties have grown their programs as well, so the total number of UW surgery residents we train each year is now up to 80 residents.
I think the biggest challenge we face is how to teach our residents how to provide excellent patient care in a system we never experienced ourselves. So much of surgical education is in ”passing the baton” and in this new era, there is no baton. One area we struggle with is in finding mechanisms to provide better patient transfer of care. With the increased frequency of patient hand-offs in the 80 hour work week and the complexity of our patients, finding watertight communication mechanisms continues to be a challenge.
We are also trying to confront the reality of ”team medicine.” Team medicine is a rather new name, but in actuality slowly began many years ago. Our patients are cared for by intra- and interdisciplinary teams. But much of our system still functions as if we practice medicine in silos with U-shaped communication systems: attending to senior resident to junior resident to a consult junior resident to the consult senior resident to the consulting attending. How can we do a better job of working within our team structure – not only the surgical team, but the greater team of subspecialty consultants, nurses, therapists and others? Can we create better systems for communication and coordination of care at UW as well as when our patients go home to a near or far location? These are the issues we’re trying to tackle for ourselves and teach our residents.
What’s coming in the near future for surgical education? A national standardized technical skills curriculum is coming through a joint effort of the APDS and ACS, probably as soon as July 2007. The ACS has already developed a first year didactic and technical skills curriculum that is now being piloted. A national didactic curriculum is also being developed at the ABS, with help from the ACS and APDS.
Competency-based advancement through the residency program is probably not far off, following the introduction of national skills and knowledge curricula. Some time in the near future, the training time will probably be adjusted to reflect more of a modular system with basic training in general surgery for three years followed by two to three year blocks of additional certificate training in various subspecialty areas.
We are already seeing the beginning of this movement in Vascular, Plastic and CT Surgery. UW continues to play a national role in surgical education. We strive to be on the cutting edge of developing new models and systems for training residents through our research work and involvement. The residency program is fortunate to still attract the top applicants from around the country and competes favorably with the other most highly respected training programs in the U.S. each year in the match. Each group of new residents is hard working, compassionate and committed to our patients and our residency program and their own education. They are also incredibly bright and talented, with unique gifts that continue to amaze and humble us.
Most of all, I can assure you that our residents today are like our readers who trained in past years: we continue to train residents who will be future leaders in American surgery – whether in the universities or the communities of our country.