August 9, 2023
We have all heard our surgical mentors recount their time as residents. They were confined to the hospital for days at a time; sleep was a privilege; they did not see their friends and family for long periods of time. It was a badge of honor.
Thankfully, times are changing. After the landmark report from the Institute of Medicine (now the National Academy of Medicine), “To Err Is Human: Building a Safer Health System,” which investigated medical errors that occurred in the US medical system, detailed the challenging, long work hours in residency training, the concept of duty hours was born.1
Since that time, there has been a substantial amount of research evaluating duty hours—most recently with the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial that demonstrated noninferior outcomes when comparing flexible, less-restrictive duty hours to the standard duty-hour requirements.
The FIRST Trial, as well as many other studies, showed weaknesses in training in regard to resident well-being, with 39% of residents reporting weekly burnout symptoms.2 In response to this growing body of research, in 2017, the Accreditation Council for Graduate Medical Education revised its Common Program Requirements requiring all residency programs to address physician wellness and resiliency.
Similarly, there have been significant evolutions to the manner in which competency is evaluated, dramatically changing residency training. The paradigm of “see one, do one, teach one” is no longer the standard. Instead, there has been a shift to a competency-based training model to assess a resident’s ability to perform procedures versus the sheer number of operations they have performed, as volume alone is not an indication of technical skill.
The American Board of Surgery introduced an Entrustable Professional Activities project to assist in the assessment of residents as the shift to competency-based training is fortified. Even with these changes in the educational priorities and evaluation metric of surgical residencies, there remains significant concern regarding the effects of these changes on physician readiness for practice.3
While uncertainties remain in surgical training, this transcends level of training and persists with early career surgeons who are navigating many changes as they transition to attendings.
As part of the Associate Fellow Committee of the Resident and Associate Society (RAS), our goal is to address the issues often faced by early career surgeons and support everyone in this exciting but, sometimes, turbulent endeavor.
A study from de Montbrun describes the four stages of becoming an attending. The initial phase is called “getting undressed” where attendings can no longer identify with the residents and fellows, but still do not belong to the attending group.4
The transition from residency to becoming a new attending challenges physicians with a multitude of new tasks. New educational responsibilities include working with residents, medical students, and advanced practice providers (APPs) but no longer interacting as just a trainee. The onerous task of being responsible for all decision-making, which now includes the actions of residents and APPs, is a particularly difficult function to come to terms with and can take several years (some may say never) to fully master.
Committing to research projects and maintaining productivity outside of the clinical realm is increasingly used as a measure of success, especially in academic systems. Additionally, there are new responsibilities for these individuals, including practice management, which could entail billing and coding, running a clinic, managing hospital staff expectations, and learning a new system.5
The process of transitioning to practice may include balancing some or all these tasks. Depending on the residents’ training, it may be the first time in their careers as surgeons that they are responsible for these tasks.
One way to set residents up for success is to incorporate a transition to practice curriculum early in residency education.6,7 To address feelings of inadequacy in regard to independence, some programs have instituted specific rotations to enhance autonomy and challenge residents to think as if they were in practice on their own.5
There are some barriers in this type of programming as educating residents as a new faculty can cause conflicting interests. Productivity measures are monitored for promotion and career advancement, but educating learners can impact productivity. Unfortunately, the increased level of involvement by senior residents in patient care often can be misconstrued by the public as a lack of attending involvement or subpar care.8
In a survey of 2,000 respondents, one-third of patients would only allow a PGY-5 to be involved in their care, one-third believed they were more likely to have a complication if a resident was involved, and one-third would not allow a resident to perform the procedure independently without the attending in the room no matter the resident’s experience with the operation. In addition, 80% indicated they should be able to decline resident participation in the surgery.8
Changing public perceptions and spending dedicated time talking to patients regarding residents will enhance surgical training and patient satisfaction.
In addition, many institutions have resident expectations for rotations, but not always for attendings. Senior partners and mentors are helpful in setting goals for new attendings. Continued encouragement and open dialogue are essential and should be integrated in the first year of practice. Understanding the institutional expectations for junior faculty at one’s own residency program also can help develop educational responsibilities and goals.6
Many surgical societies offer formal mentorship programs for early career surgeons.
Similarly, some institutions have developed onboarding programs that include mentoring and leadership development along with training on nonclinical skills such as billing and coding.6 Self-assessment guided by strong mentors allows for challenges to be addressed as they occur versus dissecting how one could have done better retrospectively.
In some cases, early career surgeons who may be doubting themselves in their new roles may have internal and external conflicts when paired with a confident, perhaps, overzealous chief resident. While some surgeons would not be challenged by this level of pairing, others may prefer to work with more junior residents as they become more comfortable in their new role. Changes in rotation structures for the educational benefit of both the early career surgeon and residents can be addressed as necessary with scheduled check-ins between junior and senior attendings.
Many academic centers have criteria listed for promotion and the time it will take on average to reach these goals. Guidelines for community-based and private practice surgeons tend to be less clear on how to advance in those settings.
These criteria often are not completely stated upfront or difficult to understand, which can delay advancement for early career surgeons. There is typically no education or discussion regarding these topics in residency so many surgeons may be ill-equipped to ask the right questions. It is essential that departments and institutions share specifics regarding goals for advancement and educational expectations along with any recurring updates as necessary based on their professional level.
Regular proactive mentoring with evaluation of productivity can ensure that professional goals are being met or on track.
Imposter syndrome is defined as the persistent inability to believe that one’s success is deserved or has been legitimately achieved as a result of one’s own efforts or skills.9 One in four physicians experiences imposter syndrome, and the rate of imposter syndrome is likely higher for young surgeons.10
As we begin our careers as surgeon educators, these are feelings we often have, but are they warranted? Residency taught us to operate and take care of patients, so even though we may feel inadequate in our clinical skills at times, we truly are qualified.
How to teach, on the other hand, is not formally integrated into residency curriculum and, in essence, many of us learn to do this by trial and error. Despite the lack of formal education in this area, we are expected and required to teach.
To address this conundrum, many programs have attempted to integrate teaching curricula into residencies with variable results depending on the method employed.11
The ACS has an annual 2-day Residents as Teachers and Leaders course that helps address these essential nonclinical skills. Due to space limitations, resident funding, and time constraints, though, not all trainees are able to take advantage of this type of focused programming.12
With the uncertainty of our own paths, it may feel difficult to teach and mentor others. To address these feelings and help manage any doubts, early career surgeons should be encouraged by their partners and departments to set expectations and goals in regard to teaching and rotation expectations.
In some cases, surgeons may choose to operate with an intern, particularly if the surgeon is not ready to yield control. Alternatively, for complex cases, it may be beneficial to have the more experienced hands of a chief resident as an assistant, which will enhance trust as their skill and judgment can be assessed.
The most important factor in being a successful teacher as a new surgeon is setting clear expectations with trainees. Although an early career surgeon may not be able to give the same level of autonomy to residents as our partners who have been practicing for 20 years, there are other ways to enhance their clinical and nonclinical training. If we are doing a certain portion of the case, explain what we are doing, and more importantly, why. This is an example of show and tell, which is an important step in surgical education.
Another way to provide education as a young surgeon is to offer information on how to successfully transition to an attending. Some small steps could include talking to the family as a team, so the resident has the opportunity to watch how you manage this interaction. Eventually, this can progress to the resident talking to the family with the attending observing. In fact, this could be a step in establishing entrustable professional activities for residents.
Another important lesson is building relationships with other services and providers, which will translate to relationships which are needed to develop one’s own practice.
Currently, there are several programs that can assist surgeons as they move on to their first jobs following residency or fellowship. The ACS holds multiple online coding courses that are available on demand or in person. In addition, the College has produced resources to aid in practice management as trainees may not have been exposed to these responsibilities in residency.
Just as a focus on well-being and mental health has now been integrated within general surgery programs, incorporating billing and coding can be the next step in preparing residents for their first jobs out of training. This can be included in SCORE curriculum or Grand Rounds programming. The ACS also has developed the Mastery in General Surgery Program for residents who decide to take an additional year to focus on fine-tuning their skills and obtain a broad understanding of practice management.
While the ACS also provides information regarding finances through conference programming and webinars, there is no formal programming or incorporation of financial literacy into residency training. Emphasis on educating oneself regarding finances during and after residency should be addressed early on in training. Finance-related tasks are not something many surgeons have the time or ability to comprehend, and there is no shame in seeking the counsel of financial advisors who specialize in working with physicians.
The ACS also has a wide source of Continuing Medical Education credits through conferences and educational tools such as the Surgical Education and Self-Assessment Program that practicing surgeons can use to remain up to date on general surgery topics.
We need to continue evolving our training programs to not only produce the most technically skilled residents but also surgeons who are prepared for their transition into practice. Surgical residency is difficult and already saturated with the essentials on how to be a safe and competent surgeon. However, this should not deter us from constantly striving to improve.
As we continue providing excellent training to residents and surgical care to our patients, our goals should be to support trainees and early career surgeons and provide materials that enhance their ability to practice surgery and reduce the burden and anxiety of practice management. Incorporating curriculum for the “practice of surgery” early on in our training can aid in this endeavor.
Dr. Joana E. Ochoa is an assistant professor of surgery and endocrine and general surgeon at the University of Florida (UF) College of Medicine—Jacksonville. She also serves as an assistant program director for the general surgery program at UF Health Jacksonville.