Sarah B. Bryczkowski, MD¹; Amalia Cochran, MD² ¹ Rutgers, New Jersey Medical School ² University of Utah, Associate Professor, Department of Surgery The FIRST Trial: The FIRST Trial, or as it is officially known, the National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training, was published online in the New England Journal of Medicine on […]
Disclaimer: I have previously blogged on the topic of millennials and expressed my support for generational evolution.
After reading a column in General Surgery News in which the work ethic of the “youngsters” was again denigrated, my friend Justin Dimick commented on Twitter:
“Why does no one blog when they “catch” a millennial doing something right?”
His point is a valid one- while all of us seem to make plenty of comments about “these kids today…”, we seldom talk about the great things we see them doing. Rather than being moved by curiosity about people who were raised in a very different time and place than those of us born before 1970, we ascribe laziness and bad intent to them. Never mind that laziness and bad intent can be found anywhere if that’s what you are seeking.
So, what have I seen millennials doing right in the last couple of weeks?
- I’ve seen them doing many, many things (some of which appear to be small things, relatively speaking) with great love.
- I’ve seen them challenging themselves in ways that make them a bit uncomfortable, be that trying something new in the professional arena or declaring, “I am a runner!” when that’s an identity they’ve never considered before.
- I’ve seen them being incredibly curious and creative. Y’all know this is how progress is made at a societal level, right?
- I’ve seen them giving generously of time and/ or money to causes they are passionate about.
- I’ve seen them teach and learn in ways that are regarding and collaborative.
Yes, I know that none of those are a terribly specific example of things I’ve seen Millennials doing right recently, but the general themes help to highlight the point that I want to make…the 20 and early 30 somethings are the future of our planet, the future of our profession, and in many ways our own future. They are, just like those of us for whom 40 is well in the rearview mirror, people. They- and we- are all basically good, and we all have the occasional “off”day because we are human. We- and they- want to help make the world around us better.
I suppose some want to take a single incident and use it to generalize about a group in a negative way, and that is certainly their prerogative. As for me, I’ll keep looking for the light, looking for the good things that our millennial colleagues, and the rest of us, are out there doing. That’s my prerogative- that, and closing the 2015 blog posts with music from my senior year of college. Ah, the 80s…good times.
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.