The surgical sky may not be falling

 

Unlike Dr. Elsey (“Surgery can be demanding work: Grit needed,” Letter to the Editor, May 2017, p. 6) and many others in various surgical publications, I have NOT enjoyed recent discussions about my generation’s perceived lack of readiness for independent practice following general surgery residency. Having been subjected to another round this month of “Why The Surgical Sky Is Falling,” I would like to take a moment to offer a different viewpoint.

I graduated from Tufts Medical Center’s general surgery residency in June 2014. After taking the written board exams, I started practice in a hospital-based group in Maine that same summer. My partners, both with 20+ years of experience, instituted a probationary period for observation of skill (ostensibly, and with good-natured teasing, to ensure I would not harm their patients, though I suspect such a thing is fairly universal for a new grad to receive institutional privileges), and, after convincing them I was not a reckless maniac, within a few months I was “on my own” in the operating room. I relied heavily on colleagues those first 18 months in practice, and ,if they ever grew weary of my asking advice about hemorrhoids, biliary colic, and diverticular disease, they never displayed perceptible annoyance. They were, and are, the best mentors I could have had.

I learned quickly that residency cannot teach you everything. In fact, residency doesn’t begin to teach you half of what you learn in the first year of independent practice. What my residency did – and what I humbly believe should be the focus for all surgical education – is provide a repetition of fundamentals that allowed me to make myself ready for independence when the time came. Anyone can do a Whipple as a chief resident when they’re scrubbed with a hepatobiliary surgical oncologist. What isn’t so easy is trying to keep from shaking your way through the first solo laparoscopic cholecystectomy. No amount of training can prepare you fully for the first independent moment in the operating room, and let’s please not pretend otherwise.

Metrics and studies that rely on resident self-evaluation – and conversely, ones that rely on “objective” identification of resident strengths and weaknesses by faculty – are subject to the very bias that has dominated this argument for years. If you tell us we are not good enough or lacking in some capacity, often enough, we inevitably will start to believe it. Then, you will reinforce that same belief in your perception of us, which drives the wedge further into an increasingly irreconcilable situation.

I had a decent self-opinion of my surgical skill as a chief resident, but, on any given day, the number I would have assigned to my own “readiness” for independence would have varied greatly for any number of reasons. I did not contend with much in the way of spirited discouragement or admonishment regarding my skill progression over 5 years, but, in keeping with the “gritty” surgical personality espoused by Dr. Elsey in his letter, I’m not sure I would have let that stop me. Honestly though, it’s impossible to say how it would have affected my confidence to leave residency straight for attendinghood had I been subjected to daily thrashings over 5 years regarding my lack of attending-level skill.

It seems to me, some of the current teaching generation has displayed an inability to connect with their pupils. The majority of surgical residents in 2017 are millennials, and the “good old ways” of effective teaching through guilt, embarrassment, and punitive action will not work. Browbeaters need not apply, for you already have lost this war. For better or worse, educators must find a way to engage these residents on a positive emotional level at the same time as they engage on a higher intellectual plane.

Before the coffee spurts across your OR lounge and the surgical hats start flying fast and furious, let me clarify: In no way do I support the notion that general surgery residents should be coddled, pampered, or emotionally shielded from the gut-wrenching difficulty of practicing surgery. It was imperative in my education that I learned how to be wrong, how to admit it, and how to take ownership of my actions, whether right or wrong. Thankfully, I had a few good examples in Boston, and I’ll never forget the impact they made on my education. But, those lessons were reinforced in a way that made me WANT to weave them into the fabric of my surgical life. Never a heavy-handed dictum; without ego or audience; lacking the morose condescension associated with “those giants” of classical surgical training – what I received in my training was a whole-person engagement that fulfilled my desire to succeed and allowed me the room to grow up as an adult learner without feeling too akin to a 16-year-old, grounded and without car keys, when I had the audacity to make a mistake. Some tried this tack, but my grit won. Somewhere in Lawrenceville, Ga., I hope Dr. Elsey is smiling.

Those who taught best in my residency did so by example. They did it by letting me drive the ship, by giving credit when I did well, by educating when I did not. They did it by making me understand a patient is not a statistic, that you can be honest and kind and a giver of hope all at the same time and that a true surgeon does not need to brag and boast about her accomplishments, nor does he imperiously tear down those lower than himself on the “hierarchy.” The best of the best at Tufts Medical Center showed me what it means when a good person sits in an exam room with a hurting human being and starts the healing process with a kind smile, a gentle touch, words of reassurance, and confidence in his ability to change that patient’s life for the better.

Could it be that we need more of that – and less devotion to metrics – in surgical education? What might training become if we focus entirely on the patient and stop worrying about how the statistics make us all look? What would happen if educators traded nostalgia for engagement with their pupils? It may just be me, but all that sounds suspiciously ... old school, no?

So, before I have to choke down another article explaining how my contemporaries and I represent a kind of global warming to the long-established surgical polar ice caps, let me assure you that at least one young whippersnapper made it out of modern (read: postduty hours) surgical training and actually found a little success – and more than a bit of professional satisfaction – in the unforgiving world of independent general surgery by adhering to the same principles that guided Zollinger and DeBakey, Graham and Fisher: Do what is right for the patient, every single time, to the very best of your God-given and man-made ability. Those are some time-tested lessons I am very proud to have learned.

And, if you want the real story about my 3 years in practice, talk to my partners here in Maine. There is no critique quite like daily proximity. For what it’s worth, they have tolerated me splendidly.

Dr. Crosslin is a general surgeon practicing in Rockport, Maine, and an FACS Initiate, October 2017.

 

Unlike Dr. Elsey (“Surgery can be demanding work: Grit needed,” Letter to the Editor, May 2017, p. 6) and many others in various surgical publications, I have NOT enjoyed recent discussions about my generation’s perceived lack of readiness for independent practice following general surgery residency. Having been subjected to another round this month of “Why The Surgical Sky Is Falling,” I would like to take a moment to offer a different viewpoint.

I graduated from Tufts Medical Center’s general surgery residency in June 2014. After taking the written board exams, I started practice in a hospital-based group in Maine that same summer. My partners, both with 20+ years of experience, instituted a probationary period for observation of skill (ostensibly, and with good-natured teasing, to ensure I would not harm their patients, though I suspect such a thing is fairly universal for a new grad to receive institutional privileges), and, after convincing them I was not a reckless maniac, within a few months I was “on my own” in the operating room. I relied heavily on colleagues those first 18 months in practice, and ,if they ever grew weary of my asking advice about hemorrhoids, biliary colic, and diverticular disease, they never displayed perceptible annoyance. They were, and are, the best mentors I could have had.

I learned quickly that residency cannot teach you everything. In fact, residency doesn’t begin to teach you half of what you learn in the first year of independent practice. What my residency did – and what I humbly believe should be the focus for all surgical education – is provide a repetition of fundamentals that allowed me to make myself ready for independence when the time came. Anyone can do a Whipple as a chief resident when they’re scrubbed with a hepatobiliary surgical oncologist. What isn’t so easy is trying to keep from shaking your way through the first solo laparoscopic cholecystectomy. No amount of training can prepare you fully for the first independent moment in the operating room, and let’s please not pretend otherwise.

Metrics and studies that rely on resident self-evaluation – and conversely, ones that rely on “objective” identification of resident strengths and weaknesses by faculty – are subject to the very bias that has dominated this argument for years. If you tell us we are not good enough or lacking in some capacity, often enough, we inevitably will start to believe it. Then, you will reinforce that same belief in your perception of us, which drives the wedge further into an increasingly irreconcilable situation.

I had a decent self-opinion of my surgical skill as a chief resident, but, on any given day, the number I would have assigned to my own “readiness” for independence would have varied greatly for any number of reasons. I did not contend with much in the way of spirited discouragement or admonishment regarding my skill progression over 5 years, but, in keeping with the “gritty” surgical personality espoused by Dr. Elsey in his letter, I’m not sure I would have let that stop me. Honestly though, it’s impossible to say how it would have affected my confidence to leave residency straight for attendinghood had I been subjected to daily thrashings over 5 years regarding my lack of attending-level skill.

It seems to me, some of the current teaching generation has displayed an inability to connect with their pupils. The majority of surgical residents in 2017 are millennials, and the “good old ways” of effective teaching through guilt, embarrassment, and punitive action will not work. Browbeaters need not apply, for you already have lost this war. For better or worse, educators must find a way to engage these residents on a positive emotional level at the same time as they engage on a higher intellectual plane.

Before the coffee spurts across your OR lounge and the surgical hats start flying fast and furious, let me clarify: In no way do I support the notion that general surgery residents should be coddled, pampered, or emotionally shielded from the gut-wrenching difficulty of practicing surgery. It was imperative in my education that I learned how to be wrong, how to admit it, and how to take ownership of my actions, whether right or wrong. Thankfully, I had a few good examples in Boston, and I’ll never forget the impact they made on my education. But, those lessons were reinforced in a way that made me WANT to weave them into the fabric of my surgical life. Never a heavy-handed dictum; without ego or audience; lacking the morose condescension associated with “those giants” of classical surgical training – what I received in my training was a whole-person engagement that fulfilled my desire to succeed and allowed me the room to grow up as an adult learner without feeling too akin to a 16-year-old, grounded and without car keys, when I had the audacity to make a mistake. Some tried this tack, but my grit won. Somewhere in Lawrenceville, Ga., I hope Dr. Elsey is smiling.

Those who taught best in my residency did so by example. They did it by letting me drive the ship, by giving credit when I did well, by educating when I did not. They did it by making me understand a patient is not a statistic, that you can be honest and kind and a giver of hope all at the same time and that a true surgeon does not need to brag and boast about her accomplishments, nor does he imperiously tear down those lower than himself on the “hierarchy.” The best of the best at Tufts Medical Center showed me what it means when a good person sits in an exam room with a hurting human being and starts the healing process with a kind smile, a gentle touch, words of reassurance, and confidence in his ability to change that patient’s life for the better.

Could it be that we need more of that – and less devotion to metrics – in surgical education? What might training become if we focus entirely on the patient and stop worrying about how the statistics make us all look? What would happen if educators traded nostalgia for engagement with their pupils? It may just be me, but all that sounds suspiciously ... old school, no?

So, before I have to choke down another article explaining how my contemporaries and I represent a kind of global warming to the long-established surgical polar ice caps, let me assure you that at least one young whippersnapper made it out of modern (read: postduty hours) surgical training and actually found a little success – and more than a bit of professional satisfaction – in the unforgiving world of independent general surgery by adhering to the same principles that guided Zollinger and DeBakey, Graham and Fisher: Do what is right for the patient, every single time, to the very best of your God-given and man-made ability. Those are some time-tested lessons I am very proud to have learned.

And, if you want the real story about my 3 years in practice, talk to my partners here in Maine. There is no critique quite like daily proximity. For what it’s worth, they have tolerated me splendidly.

Dr. Crosslin is a general surgeon practicing in Rockport, Maine, and an FACS Initiate, October 2017.

 

Unlike Dr. Elsey (“Surgery can be demanding work: Grit needed,” Letter to the Editor, May 2017, p. 6) and many others in various surgical publications, I have NOT enjoyed recent discussions about my generation’s perceived lack of readiness for independent practice following general surgery residency. Having been subjected to another round this month of “Why The Surgical Sky Is Falling,” I would like to take a moment to offer a different viewpoint.

I graduated from Tufts Medical Center’s general surgery residency in June 2014. After taking the written board exams, I started practice in a hospital-based group in Maine that same summer. My partners, both with 20+ years of experience, instituted a probationary period for observation of skill (ostensibly, and with good-natured teasing, to ensure I would not harm their patients, though I suspect such a thing is fairly universal for a new grad to receive institutional privileges), and, after convincing them I was not a reckless maniac, within a few months I was “on my own” in the operating room. I relied heavily on colleagues those first 18 months in practice, and ,if they ever grew weary of my asking advice about hemorrhoids, biliary colic, and diverticular disease, they never displayed perceptible annoyance. They were, and are, the best mentors I could have had.

I learned quickly that residency cannot teach you everything. In fact, residency doesn’t begin to teach you half of what you learn in the first year of independent practice. What my residency did – and what I humbly believe should be the focus for all surgical education – is provide a repetition of fundamentals that allowed me to make myself ready for independence when the time came. Anyone can do a Whipple as a chief resident when they’re scrubbed with a hepatobiliary surgical oncologist. What isn’t so easy is trying to keep from shaking your way through the first solo laparoscopic cholecystectomy. No amount of training can prepare you fully for the first independent moment in the operating room, and let’s please not pretend otherwise.

Metrics and studies that rely on resident self-evaluation – and conversely, ones that rely on “objective” identification of resident strengths and weaknesses by faculty – are subject to the very bias that has dominated this argument for years. If you tell us we are not good enough or lacking in some capacity, often enough, we inevitably will start to believe it. Then, you will reinforce that same belief in your perception of us, which drives the wedge further into an increasingly irreconcilable situation.

I had a decent self-opinion of my surgical skill as a chief resident, but, on any given day, the number I would have assigned to my own “readiness” for independence would have varied greatly for any number of reasons. I did not contend with much in the way of spirited discouragement or admonishment regarding my skill progression over 5 years, but, in keeping with the “gritty” surgical personality espoused by Dr. Elsey in his letter, I’m not sure I would have let that stop me. Honestly though, it’s impossible to say how it would have affected my confidence to leave residency straight for attendinghood had I been subjected to daily thrashings over 5 years regarding my lack of attending-level skill.

It seems to me, some of the current teaching generation has displayed an inability to connect with their pupils. The majority of surgical residents in 2017 are millennials, and the “good old ways” of effective teaching through guilt, embarrassment, and punitive action will not work. Browbeaters need not apply, for you already have lost this war. For better or worse, educators must find a way to engage these residents on a positive emotional level at the same time as they engage on a higher intellectual plane.

Before the coffee spurts across your OR lounge and the surgical hats start flying fast and furious, let me clarify: In no way do I support the notion that general surgery residents should be coddled, pampered, or emotionally shielded from the gut-wrenching difficulty of practicing surgery. It was imperative in my education that I learned how to be wrong, how to admit it, and how to take ownership of my actions, whether right or wrong. Thankfully, I had a few good examples in Boston, and I’ll never forget the impact they made on my education. But, those lessons were reinforced in a way that made me WANT to weave them into the fabric of my surgical life. Never a heavy-handed dictum; without ego or audience; lacking the morose condescension associated with “those giants” of classical surgical training – what I received in my training was a whole-person engagement that fulfilled my desire to succeed and allowed me the room to grow up as an adult learner without feeling too akin to a 16-year-old, grounded and without car keys, when I had the audacity to make a mistake. Some tried this tack, but my grit won. Somewhere in Lawrenceville, Ga., I hope Dr. Elsey is smiling.

Those who taught best in my residency did so by example. They did it by letting me drive the ship, by giving credit when I did well, by educating when I did not. They did it by making me understand a patient is not a statistic, that you can be honest and kind and a giver of hope all at the same time and that a true surgeon does not need to brag and boast about her accomplishments, nor does he imperiously tear down those lower than himself on the “hierarchy.” The best of the best at Tufts Medical Center showed me what it means when a good person sits in an exam room with a hurting human being and starts the healing process with a kind smile, a gentle touch, words of reassurance, and confidence in his ability to change that patient’s life for the better.

Could it be that we need more of that – and less devotion to metrics – in surgical education? What might training become if we focus entirely on the patient and stop worrying about how the statistics make us all look? What would happen if educators traded nostalgia for engagement with their pupils? It may just be me, but all that sounds suspiciously ... old school, no?

So, before I have to choke down another article explaining how my contemporaries and I represent a kind of global warming to the long-established surgical polar ice caps, let me assure you that at least one young whippersnapper made it out of modern (read: postduty hours) surgical training and actually found a little success – and more than a bit of professional satisfaction – in the unforgiving world of independent general surgery by adhering to the same principles that guided Zollinger and DeBakey, Graham and Fisher: Do what is right for the patient, every single time, to the very best of your God-given and man-made ability. Those are some time-tested lessons I am very proud to have learned.

And, if you want the real story about my 3 years in practice, talk to my partners here in Maine. There is no critique quite like daily proximity. For what it’s worth, they have tolerated me splendidly.

Dr. Crosslin is a general surgeon practicing in Rockport, Maine, and an FACS Initiate, October 2017.