In My Day

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When I was in training, attending surgeons regularly complained about the low quality of the residents they were teaching. Most didn’t recognize the changing landscape of medicine which, to be brutally honest, had been far from an abrupt shift and much more of a gradual evolution that they didn’t feel the need to accept or even acknowledge. Those attendings dedicated to medical education frequently tried to explain the changes and encourage open-mindedness about alterations to the status quo, but this has never been a strong point among the stereotypical surgeon, who would commonly instead complain about how things were different when they were in training.

During my residency, there was a requirement laid out by the Accreditation Council for Graduate Medical Education (ACGME) that trainees’ work hours be limited. This wasn’t done with the consent of trainees or residency programs, wasn’t established based on experimental evidence of improved patient outcomes or improved resident education, and wasn’t optional for residency programs that wished to continue their “accredited” status—a requirement for their graduates to become board certified, in turn a requirement for them to get a job. The residents were not given a choice in this change, but senior physicians blamed them for it, blamed their generation for choosing to implement rules that the residents neither chose nor implemented. When I trained, it was the new resident’s fault that the ACGME was attempting to correct problems that had been laid bare during the training of the very attending surgeons who were ridiculing the new rules.

My training was accompanied by these rules limiting monthly work hours and mandating time-off periods, but also by the dichotomous teaching that told us the rules were inviolable and that we were weak and useless if we didn’t violate them. Residents were chastised for failing to log their work hours and for accurately logging their work hours. Lying on the timesheet was a fireable offense, while following the work hour rules was enough to form a poor academic evaluation or recommendation. Residents were told they should value time away from the hospital to maintain “work-life balance” but that if they didn’t want to be in the operating room after they were told they had to leave, they would never be “good surgeons”.

When I trained, residents didn’t commune with one another; there was too much work to be done within a mandated fraction of each week to spend time in a lounge, to read and study together, to establish camaraderie, reliance, and trust. The number of admissions and discharges managed by each resident increased dramatically, the average level of patient illness increased dramatically, and the ability to longitudinally follow each patient’s hospital course nearly vanished, all related to the work hour rules, all of which were again blamed on the residents. Residents’ inability to provide the in-depth coverage and understanding of their patients’ needs expected by the attending surgeons was considered a failure of the resident, or, at best, of the resident’s “time management” skills rather than any systematic malfunction of a system the residents neither created nor had the power to change.

When I was in residency, the number of attending surgeons had expanded so dramatically without an increase in the number of residents that residents were unable to even assist on (or “cover”) all the surgeries that were performed. This initially led to attendings scrubbing with more junior residents than they previously had—and thus, attendings had the impression that the residents’ surgical techniques were markedly worse. Next, senior residents were no longer given the opportunity to teach more junior residents, so attendings were forced to teach skills (like, say, skin closures) which they hadn’t needed to before—again, the impression that the residents are unprepared. The attendings themselves became busier, so they spent less time teaching tasks they felt were less important, then complained about having to perform the tasks themselves. (Notably, while too busy to teach, they had enough time to blog about their frustrations and, again, blame the residents.) When there were finally too many cases to be adequately covered by the residents assigned to a service, the residents took the initiative to find residents from other services to assist, or to lurk in the OR for uncovered cases on other services despite needing to complete their other assigned work—and the attendings complained that they didn’t have a resident who “knew the patient”.

When I was in training, attendings no longer left residents to operate on patients alone, either out of fear of litigation, fear of a new hospital policy that suggested it was inappropriate to “learn on human beings”, or (though presumably subconsciously) fear that they hadn’t taught the resident well enough to do so. They didn’t let residents learn things themselves, then complained that residents always wanted to be “spoon fed”. They trained residents to consider hospital administration, insurance companies, and government agencies incompetent and meddlesome while avoiding teaching the skills they used to work with these ever-present groups. They complained about the time residents had to spend wording progress notes to the exacting specifications of a utilization reviewer but simultaneously complained that it’s the residents’ time management failures that kept them “over hours”.

When I was in training, the trainers chose to denigrate the generation they had themselves created. The Generation X attendings who identified with films from Dazed and Confused to Slacker had decided the Millenials were the terror that would end the world. The Boomers and Gen-Xers who had pushed so hard to obtain affordable advanced technology maligned Generation Y for using it. The attendings who had raised their children by giving them participation awards, nurturing environments, and political correctness complained vociferously about residents who’d been raised with participation awards, nurturing environments, and political correctness.

The way it was when I was in training isn’t so different from how it is now. And, as it turns out, it’s not now so different from when most attendings were in training. Surgical students and residents want to learn and to operate and to take care of patients. There are obstacles. And the obstacles are far more often erected by the trainers than torn down by them, but far more often blamed on the trainee. The few amazing surgical educators who recognize and celebrate differences, who see the ways that medicine both has and hasn’t changed over the last hundred years, who find the methods and make the time to reach their students, who think about the many, many times they “catch” a millenial doing something right—these surgeons seem to very seldom talk about how it was when they were in training.

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