Cognitive Dissonance in Training: A View From the Middle
As a surgical trainee, I am asked this often. It takes a leap of faith for a patient to go under the knife. Asleep, free of pain and memory, patients expect their operation to go smoothly in expert hands, whether they are undergoing an elective laparoscopic cholecystectomy or emergent repair of an acute aortic dissection.
I doubt my patient—we will call her “Ms. Morris”—has read the body of literature demonstrating that there is no substitute for experience. She intuitively understands this. Innumerable studies show the importance of practice and volume for improving technical skill. Surgeons at hospitals who perform an operation more times typically have better outcomes. 1–3 Patients who undergo complex procedures such as pancreatic or esophageal surgery have lower rates of complications and death at medical centers that perform these operations more routinely. 3 K. Anders Ericcson's 10,000-hour rule 4 —simply: expertise requires years and years of deliberate practice and dedication—is universal, but especially true in surgery.
I assure Ms. Morris that Dr. Roses, the attending or senior surgeon, will be in charge. I will assist, and he will allow me to perform technical tasks commensurate with my ability. I am eager to be trained, and he will push me at times, but I am not ready to operate on my own. Still, mastery requires experience, as Ms. Morris’ question implicitly acknowledges.
What she does not know, however, is that surgical training has changed dramatically over the past couple of decades. The days of spending every other night in the hospital—or, as the old adage would contend: “missing out on half of the good cases”—as a resident physician are over. For a number of reasons, the workweek for medical trainees has been capped. Fewer hours have been shown to reduce rates of burnout, depression, suicide and car accidents, and are geared to developing a culture of safety for patients. 5,6 The effects of sleep deprivation are well documented; no patient wants a surgeon operating without his or her full mental faculties.
At the same time, 1 in 5 surgical trainees express concern about their readiness and independence upon graduating from residency, 7 and fellowship program directors believe many are inadequately prepared for independence and operative autonomy, delaying progress or requiring a “catching-up” period. 8 The FIRST trial, which compared 2 different work environments for General Surgery residents, has rekindled the debate over restricting the amount of time residents work in the hospital. The outcome of this study, which involved over a hundred programs across the country, failed to demonstrate differences in patient safety parameters, or resident well being when allowing for longer call shifts within the limits of an 80-hour workweek. 9
Thus, the debate over work hour requirements for residents continues in both the medical community and lay press. Some suggest that training hours should be more flexible; others want the number of hours reduced again. Some argue for additional years of training, compensating for a diminished case volume. 10 Governing bodies and programs push residents to follow the 80-hour workweek as a hard and fast rule, but often a culture of nostalgia for the “good old days” permeates, when residents were truly “residents” of the hospital. Somewhere in the middle of the rules, regulations, culture, and internal pressure is the physician-in-training. The hours may be fewer, but the burdens on trainees are still abundant.