Discussant Dr. Frank R. Lewis, executive director of the American Board of Surgery, said that even though the 80-hour work limit has effectively subtracted 6-12 months from the general surgery residency, he doesn’t believe this emotional and contentious issue is the main problem. He noted that at present the average number of operations done by a first-year resident is less than two per week, while second-year residents average only two to three per week.
"Our residents are spending 80 hours a week while doing two or three operations per week, which arguably could be done in half a day. It would be hard to imagine a less efficient educational process," Dr. Lewis complained.
He added that nobody should be surprised by the Fellowship Council survey results. During the past decade the failure rate on the American Board of Surgery’s oral exam has climbed steadily from 16% to 28%. At present the percentage of examinees who fail either the oral or written ABS exam the first time around is in the mid-30s.
"That’s arguably an absurd failure rate for a 5-year training program in a group of people who should have mastered the subject," the surgeon added.
Dr. Mark A. Malangoni
He asserted that most of the factors responsible for the decline in the competence of graduating general surgery residents are beyond the control of academic surgeons. These factors include the gutting of surgical clerkship opportunities in the fourth year of medical school, along with changes in the surgical landscape that have caused once-popular operations to essentially go away due to technical advances or improved drug therapy.
Discussant Dr. Mark A. Malangoni, associate executive director of the ABS, noted that the more complex open surgery operations previously done by general surgery residents have in many cases been converted to complex laparoscopic procedures that have become the purview of the subspecialty fellowships. Why not abolish the fellowships and drive all those interesting cases and that dedicated training effort back into the residency years? he asked.
That’s not going to happen, Dr. Mattar replied, citing the huge market demand and need for these fellowships.
"They’re very rewarding to all stakeholders," he added.
But constructive changes are afoot, according to Dr. Mattar. Plans are well underway to change the fourth year of medical school so that students interested in a career in surgery can begin to prepare for it then. And there are also efforts to custom-tailor the final year of general surgery residency so that residents can prepare for their fellowship year. Toward that end the Fellowship Council has moved the fellowship match date up to June so residents who know they are fellowship bound can put their fifth year to the best use.
The survey was conducted by the Fellowship Council, an umbrella organization with oversight over surgical subspecialty fellowships. Dr. Mattar reported having no financial conflicts.