I’ll admit that I was a bit concerned I was stepping in it yesterday morning.

Frank Lewis, the Executive Director of the American Board of Surgery, recently proposed that general surgery residency should be followed by a mandatory fellowship.  To explain this a bit more succinctly for those who don’t understand the precise implications, this plan would mandate a 1 (or more) year fellowship follow a 5 (or more with research time) year general surgery residency.  Never one to be shy with my opinions, I promptly went on Twitter with the link and said “I disagree- #fixthefive. ”  What has impressed me is the number of academic surgeons, including E. Chris Ellison, who have weighed in supporting the idea of fixing the 5, rather than turning it into mandatory 6+.  I’ll also admit that I didn’t originate the phrase “fix the five”- credit for that goes to Julie Freischlag or Barbara Bass (I’m sorry that I don’t remember which of these esteemed women used it first).


Dr. Lewis provided five key reasons why more data keeps accumulating that indicates that general surgery residents aren’t ready for independent practice at the conclusion of their training.  As reported, these were the following:

  • Reduced surgical exposure and experience in medical school
  • Highly variable teaching effectiveness at different institutions
  • Reduced breadth and complexity of surgical resident experience
  • The 80-hour workweek
  • Reduced opportunity for autonomy and independent decision making in the senior years of training

My response to each of these is a variant on a theme- we’ve created our own monsters, and we haven’t dealt with them properly.

If our students aren’t getting adequate exposure and preparation, that’s our fault as educators for not determining what their needs are and meeting those needs.

If surgical teachers aren’t effective at a given institution, the RRC does have the power to address this by mandating training for the teachers (aside:  How many surgeons do you know who actually DO have formal training in teaching?  Maybe that’s the core issue!).  If no improvement is seen with a formalized training program, maybe that institution doesn’t need to be a training site.

If the residents aren’t getting adequate breadth and complexity of experience, isn’t it our responsibility as educators to find a way to make that happen?  I believe it can happen within the confines of the 80-hour week.  If we are training based on competence, not time on service, 80 hours is plenty.

Then there’s the ubiquitous attribution of our woes to the 80-hour week.  The 80-hour workweek isn’t the devil.  It’s the fact that we continue to try to shove 10 pounds of flour into a 5 pound sack, so to speak.  We simply must find ways to be more nimble, more efficient in how we expect our trainees to acquire their skills and knowledge.  Or, as was astutely stated by Chief Resident Stefan Leichtle during a panel at this year’s Academic Surgical Congress, “If you can’t teach residents what we need to know in 80 hours a week over 5 years, something is wrong with what you’re doing.”  He’s right.

In terms of the reduced autonomy question, this likely relates to the quality of teaching issue that was raised.  If we are effective teachers, we can provide appropriate autonomy without jeopardizing patient safety.  We can also redesign our programs to make the 5th year look more like the existing Transition To Practice programs, with 5th year residents being credentialed to perform those operations in which they have demonstrated competency.  This is not an insurmountable problem if we are willing to shift our paradigm.

Our residents don’t need an extra year.  We need to #fixthefive, and we need to do it soon.