From the Editor

From the Editors: A crisis of confidence?


As today’s surgical residents complete their residencies and enter practice, we are compelled to ask, Is their level of confidence and independence different from that of, say, the class of 1978? Have circumstances of training changed to such a degree that graduating residents’ beliefs in their own judgment have been undermined?

The answer is yes: The conditions and circumstances of training have changed substantially. Our attendings were strong role models, but they were not as omnipresent as are today’s faculty, particularly in the operating room. We, therefore, felt a greater sense of autonomy than do today’s trainees.

Dr. Karen E. Deveney, professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland
Dr. Karen E. Deveney
Today’s surgical literature abounds with laments that today’s residents lack confidence in their own technical and decision-making skills. The narrative seems to be that uncertainty is a major factor influencing 80% of residents to extend their training beyond their general surgery years and add years of fellowship. That extended training is said to narrow their practice very sharply and allow them to master the subject matter and thus gain confidence. An excellent review notes that confidence or readiness to practice are issues that have only surfaced since 2008, five years since the implementation of the Accreditation Council for Graduate Medical Education 80-hour work week rule (JAMA Surg. 2016;151[12]:1166-75).

It is unquestionably true that our medical and surgical world has become so much more complex that mastery of the broad range of knowledge and skills encompassing general surgery has become daunting. It is indeed too much to ask that a graduating surgeon be a master at biliary surgery, foregut surgery, head and neck surgery, trauma, critical care, and all the rest.

If we are honest with ourselves, Was our confidence really that much greater in 1978? I think that most of us were scared to death that we would make wrong decisions or encounter a problem that we would be unable to handle in those first few years of practice. That is why most of us chose to enter a practice with a senior partner or partners whose brains we could pick if need be. Of course, it wasn’t fashionable to admit it because surgeons were supposed to behave as though they always had everything under control and had the utmost confidence. Mostly we did, but it was most helpful to run a sticky, complicated patient problem by our all-wise senior partner. Even then, with all our clinical experience and independence, we weren’t as polished or confident as surgeons on graduation day from residency than we would become after 8 or 10 years of practice.

So, what’s different now? From the time that they are pups, today’s residents somehow get the impression that they can’t become good surgeons in the 80-hour work week, that they lack stamina and resolve of past generations, and that they need to do a fellowship to get respect or know enough to do a good job. Although the cause of these problems is placed at the feet of the ACGME, hospital administration, American Board of Surgery, or the residents themselves, surgical faculty should shoulder some of the responsibility. Faculty can and should make changes to their teaching and assessment techniques to better address the realities of today’s generation and today’s surgical realities.

I would maintain that it is possible to produce competent surgeons in five years of training but only if training is revised to reflect the changed circumstances of surgical practice. It must be intentional and evidence-based, much like the surgical practice we wish to promote. It should include simulation supervised by expert surgeons who can immediately correct errors, mandated practice at skills until the resident has passed a competency exam in that skill before taking it into the human operating skill, specific and honest but respectful assessment of the resident’s operative skills, and graduated responsibility with eventual autonomy as the goal. This kind of training can’t happen if the faculty feel bound more by demands of the clock and the pressure to generate more relative value units than by their responsibility to their trainees to coach them in clinical decision-making and technical skills. It is possible as an intending to be present but not make all the decisions. Instead of “Do this!” one need only ask, “What do you want to do?” and then pause for the trainee to respond.

Whenever it isn’t a dire and pressing emergency, what can follow is an honest interchange of ideas. For that to happen, the relationship requires mutual trust and respect. On the faculty’s part, there should be an understanding that there is often more than one acceptable way to proceed and that the resident is not only smart and diligent but usually just as motivated to do the best for his or her patient as is the faculty member. On the resident’s part, there should be the expectation that the faculty member will engage the resident in thoughtful discussion in response to his or her question, even if the answer was not the faculty’s favored way of handling the problem.

Having been a surgical faculty member for almost 40 years and a general surgery program director for 20, I would argue that today’s surgical residents are every bit as dedicated and conscientious as we were. Since there is more to learn and less time to learn it, we faculty need to be more efficient in our teaching and assessment, which means using every opportunity we have to help them become as competent and confident as possible by June 30 of their chief residency year.

Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

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