Robert Stone Lecture

RETHINKING RESIDENCY TRAINING

Shaf Keshavjee, Bob Stone and Lee Swanstrom

Lee Swanstrom, Professor of Surgery at Oregon Health Sciences University and Director of the Minimally Invasive Surgery program, presented the Robert Stone lecture “Rethinking Residency Training. Perspectives gained from the Minimally Invasive Surgery Revolution” at Toronto Western Hospital on Friday, May 13th 2011.

“The laparoscopic revolution began in the late 1980s when Erich Muhe in Germany did the first laparoscopic cholecystectomy. He performed 38 operations with one death. He was reviled by his colleagues, lost his privileges, was jailed and his wife left him, illustrating the dangers of being the first. Eddie Joe Reddick brought the technique of laparoscopic cholecystectomy back from France and developed weekend courses for general surgeons in North America. He charged $3,000 for each surgeon to come and watch him perform the operation. He was able to retire after five years, then bought a music publishing company. Eventually, he lost all of his money and went back to work. He was a better surgeon than he was a businessman.”

The standard approach to surgical residency training is the Halsted apprenticeship model. Over a period of 5 to 8 years, surgeons gradually take on increasing responsibility. They are punished for their mistakes by withholding progressive opportunities to operate as part of this training paradigm. Under the old system, training was long and the pace of surgical evolution was slow. For example, it took 25 years of operating to achieve the first survivor of esophagectomy.

Of all the radical revisions introduced by laparoscopic surgery, weekend courses were the dominant new feature. These introduced industry participation and marketing as well as a short duration of training. Laparoscopic cholecystectomy training had to be rapidly introduced, so that all 20,000 general surgeons in the United States could quickly learn the technique. This stimulated innovation, the rapid development of new instruments, and rapid introduction of new techniques into practice. Surgeons who performed laparoscopic surgery could control their own practice. Hospitals advertised the skills of their laparoscopic surgeons to increase their market share. By 2005, not only cholecystectomy, but nearly every operation in the surgical armamentarium had been done using minimally invasive surgical techniques.

Fig. 1 The Triangle of shame

As it turned out, weekend courses were a mixed blessing, because training for a weekend left the participants with no muscle memory and no way for their teachers to measure their competency. Common duct injuries were common in the early learning phase of laparoscopic cholecystectomy, occurring in 0.3% of cases - ten times the rate of injury in open procedures. This period Lee refers to as ‘the triangle of shame’. Laparoscopic surgery proved to be bad for residency training, as teachers were slow to pass their techniques on. It drove up costs and introduced conflicts of interest with industry that verged on the unethical.

It is now unacceptable to subject patients to such learning curves. It stresses the surgeon, the operating room staff, the healthcare system, and the patients. With the publication of the IOM’s “To Err is Human” mandatory improvement in learning new surgical techniques was required. Current negative influences on the development of laparoscopic surgery include its cost and restrictions from the IRB. The reaction to this pushback has been the development of centers of excellence, where high volume is equated with expertise. The catch 22 of this linkage is that it is difficult to get these high volumes unless you practice in a center of excellence.

Bob Stone, Steve Gallinger and Hugh Scully

One possible solution to the problem is the NICE Program (National Institute for Clinical Excellence) introduced in the United Kingdom. The NHS, based on a NICE evidence review, has decided not to pay for open colectomy after 2014. In order to ensure that surgeons become proficient at laparoscopic colectomy, the government funds regional training centers and pays for surgeons to attend courses. The government also hired 15 travelling expert surgeons to certify the competence of those trained at the centres. They visit the surgeons in the operating room, and proctor their performance. The American College of Surgeons has also initiated a program of regional training centers for surgery, but without the mandate, funding or government backing of the British system. We also have few measures of competency. At this time, the American Board of Surgery requires applicants to have FLS Certification (Fundamentals of Laparoscopic Surgery) and there will soon be a similar program for flexible endoscopy (FES). This is timely as the American Gastroenterological Association and other medical societies have taken a position that “surgeons are poor practitioners of gastrointestinal endoscopy and we shouldn’t be responsible for their training”. The burden of adequate training and now guaranteeing to the public that their surgeon is competent clearly rests on the shoulders of the surgical community.

Short courses don’t work well for residents, and the reduction in workweek hours has led to a situation where “training is overreaching and underachieving in general surgery”. The number of advanced laparoscopic surgical cases seen in most residencies is usually low. For this reason, minimally invasive surgery fellowships are needed, plus the use of virtual reality and internet programs.

Will the system tolerate training as we knew it? How will we accomplish the “10,000 hours of deliberate practice?” demonstrated by Ericsson to be necessary for expert performance. Lee proposes that we change our thinking about residency training. “We should start at the other end of the spectrum, introducing residents to laparoscopic surgery at the beginning, rather than open techniques. Over time, they can progress to performing open operations in the 4th and 5th year.” Lee also proposes that we proctor those who attend short courses, design ways to measure their competence and train them toward expertise. During the question period the appropriateness of screening applicants for three dimensional spatial sense was raised. Dimitri Anastakis pointed out that studies completed here and published in the Lancet show that it is not necessary to exclude applicants whose three dimensional sense is less developed. They can eventually be trained to perform at a competent level. Hugh Scully asked if we are training enough general surgeons to manage highway crash victims. Lee felt that the direction that this is going is toward training trauma surgeons and acute care surgeons, and the use of trauma centres. Dimitri Anastakis asked how to pay for the $110,000 simulators needed for training. Lee answered that the US Congress has been asked to address this as it should be the responsibility of society. Shaf Keshavjee suggested that industry should pay for the simulator in order to prepare surgeons to use their $2.3 million devices later on in their careers. Chris Feindel raised the question of the effect of limited work hours. “We no longer train the general surgeon as a universal genius capable of every operation. The answer seems to be in specialization. ”

M.M with notes from Lee Swanstrom