Now Im really worried about surgical education

Heres why.

A friend told me that a new attending on his staff was having some problems. Although the young surgeon was a graduate of five years of general surgery training plus two years of fellowship, he was unable to do an inguinal hernia or a laparoscopic cholecystectomy by himself.

This is just an anecdote, but the issue has been identified by others. Remember the paper from Annals of Surgery in September of 2013 that described a survey of fellowship directors? It stated that 66% of graduates of five-year general surgery training programs could not conduct a major case unsupervised for 30 minutes, and 30% could not independently perform a laparoscopic cholecystectomy

A study published online in JAMA Surgery last month looked at 20 years of ACGME surgical resident case logs and found that although minimally invasive surgery is being done much more frequently, it is currently performed in more than 50% of cases for only five procedures—cholecystectomy, appendectomy, adult anti-reflex surgery, partial gastric resection, and thoracic wedge resection.

In 2007, the Residency Review Committee for Surgery increased the required number of basic laparoscopic surgery cases from a minimum of 34 to 60 and from 0 to 25 for advanced . The authors expressed concern that there might not be enough minimally invasive cases for all of the residents to do. They also pointed out that there was still in need for residents to learn open surgery since all but five operation procedures are still predominantly performed that way. However, as laparoscopic cases increase, the number of open cases will decrease because the total number of cases done by graduating chief residents has not changed significantly in 20 years.

A year ago, I blogged about some potential problems that might occur when surgical residencies are expanded and new programs are begun. Specifically, I wondered if there would be enough teaching cases to go around. It is interesting to see my speculation bolstered by data.

A program director recently told me that there may be a movement afoot to start a Fundamentals of Open Surgery course.

What is going on here? There is already a Fundamentals of Laparoscopic Surgery course. Do we really need to have a separate course to teach residents open surgery? Isnt that what a "residency" is supposed to do?

How did surgeons of my generation ever learn how to operate without courses in the fundamentals of laparoscopic and open surgery?

The visionary surgeon Leo Gordon saw it coming in 2002. He predicted the need for a "macrolaparotomy" course, and it can be run by the newly created American Board of Open Surgery.

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Patients vs doctors

A JAMA Viewpoint article suggests that doctors should be aware that patients may be surreptitiously recording their conversations. The author, a neurosurgeon, takes a very benign view of this issue and recommends that if a doctor suspects that patient is recording a conversation, "the physician can express assent, note constructive uses of such recordings, and educate the patient about the privacy rights of other patients so as to avoid any violations."

He also says this would show that the physician was open and strengthen the relationship between the doctor and the patient. Im not so sure.

Heres a different perspective. If a patient is secretly recording a conversation, the relationship between him and the doctor is already in serious trouble. What I would do is to tell that patient to find another doctor.

If a patient asked me if it was OK to record our conversation, I would agree, but I would also want to record it to preserve a complete copy.

This comes on the heels of another privacy and trust question—should doctors google their patients? There is no consensus on this, but having read several discussions on the topic, most writers feel that googling patients should only be done for certain narrow reasons which you can read here.

Most medical societies have not weighed in on the subject, but I would guess when guidelines are published, they will discourage the practice. But of course, patients may google physicians at will.

Taking it to another level, Dr. Jeremy Brown, Director of the Office of Emergency Care Research at the National Institutes of Health, recently proposed that emergency physicians should be equipped with body cameras to record audio and video of patient encounters.

Leaving aside such questions as who owns the videos, how to store the vast amount of data, and what impact this would have on the performance of the individual physicians, body cameras would establish an adversarial relationship that is unnecessary for the overwhelming majority of doctors and patients.

A physician interaction with a patient begins on terms quite different from those of a police officer interacting with a suspect in which the adversarial relationship is already established. The increasing number of controversial and highly publicized cases involving police and suspects has resulted in a need to protect both parties. This need seems much less pressing in medicine.

Where does this end? Should all patients be equipped with body cameras too in case the physician copy "gets lost"?

It is sad to realize how far we have sunk as a profession.

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