This document summarizes a presentation given by Dr. Jacob Perry at the University of Kentucky College of Medicine discussing why surgical residents may lack adequate operative experience. Dr. Perry reviews research showing that surgical skill is learned, not innate, and that current residents receive significantly less operative experience in essential cases than what is considered the minimum for competence. Factors that limit residents' operative experience include work hour restrictions, pressure for efficiency, and inadequate focus on teaching in the operating room. Improving resident education will require collecting better operative data, evaluating teaching skills, and prioritizing maximum resident benefit in the operating room.

1. Why Johnny Cannot Operate
Jacob Perry, MD
University of Kentucky College of Medicine
Department of Surgery
Grand Rounds
October 28th, 2009

2. Disclaimers

3. Before we get started:
• Not intended to hurt anyone’s feelings
• IS intended to be a discussion about resident education
• Some of this will sound familiar
• No personal agenda
• Discussion of 80 hour work weeks and rest periods
• If you behave, I will continue
Do NOT freak out
(I have no financial disclosures)

4. Why Johnny Cannot Operate
• Richard H. Bell Jr., MD
• Assistant Executive Director, American Board of Surgery (ABS)
• Presidential Address:
– Central Surgical Society Meeting, May 2009
• Article printed:
– Surgery, Sep 2009; 146(533-42)
*
*Now has mustache

5. Why Johnny Cannot Operate
“I CONSIDER THE PERFORMANCE OF SURGICAL
OPERATIONS to be the MOST complex psychomotor activity
that human beings are called upon to perform. In the arts,
athletics, games, and other realms of human activity, I have
found nothing that matches the difficulty of surgery.”

6. Rate of Complication
• 13% morbidity all comers in US surgery
• 2% postoperative mortality
• Spawned “Patient safety movement”
• 2/3 of death & disability due to intraoperative complication
• Intraoperative Mistakes:
– 63.5% = Error in technique
– 29% = Error in judgment
• Both types can be attributed to
LACK OF EXPERIENCE

7. Is he really going to say that we are all
going to be bad doctors?

8. “You were always a good doctor,
just had bad hair”
Source Unknown

9. Where to start?
1. Operative Skill is learned, not innate
2. Current operative experience of general surgery
residents vs. surgical expertise
3. Teaching and learning in the OR
4. Transferable skills?
5. Where do we go from here?

10. Learned Operative Skill
Operative Skill (at least):
1. Technical skills
2. Visio-spatial and tactile skills
3. Determination of pathologic vs. normal
conditions
4. Ability to make good judgments
No traits are possessed A PRIORI:
• Some may be born to BECOME surgeons, but
NO ONE IS BORN A SURGEON

11. Expert
• n. An ordinary fellow from another town - Mark Twain
• n. A man fifty miles from home with a briefcase - Will Rogers

12. Expertise
EXPERTISE: n, the mechanisms underlying the superior
achievement of an expert
i.e. "one who has acquired special skill in or knowledge of a
particular subject through professional training and
practical experience”
- K Anders Ericsson, FSU Cognitive and Expertise Lab

13. Dreyfus Model of Skill Acquisition

14. Competency (based on Dreyfus model)
• Novice
• Advanced Beginner
• Competent *BARE MINIMUM
• Proficient *GOAL @ END OF 5 YRS
• Expert
– 10,000 hours of dedicated practice
– 8 hours per day x 5 years!

15. So where are we?

16. Operative Experience of “New”
General Surgery Residents
• Hot topic at ACS/AAST
meetings this year
• Generally perceived as poor
nowadays by the “old
guard”*
• Begs the question:
Can Johnny Operate?
*Anecdotal, but just ask any of ‘em. They will tell you all about it

17. Are residents competent?
• Surgical residency program directors
• Rank 300 ACGME index cases according to
necessity for competency
 A = “essential”
 B = “should be”
 C = “not necessary”
• 121 operations were “essential” components of
GS resident training by majority of PD’s
(n=114/254)

18. Results…
• Review of ACGME op log for 2005 graduating
chief residents
• Of 121 “essential” cases:
– #1: lap ccy; median (M) cases reported= 84/resident
– #38: M<5 cases
– #74: M< 2 cases

19. …were shocking
• 52% (63/121) “essential” cases: mode number
of cases/resident = ZERO
• Cases such as:
– CBDE
– Transanal excision
– Whipple
– Anal Fistulotomy

20. Could the data be skewed?
• Most cases reported were bottom heavy
• e.g. Parathyroidectomy mean <10, Mode 4
YIKES!!!

21. Operative Experience
• 70% agree/strongly agree they are happy with their operative
experience
• Per Dr. Bell (anecdotally)
– Chiefs & Attendings concerned about skill set and independent operative skill
of graduating residents
– Fellowship directors are “unimpressed” by the quality of applicant’s surgical
skill…
• Will residents be the source of agitation for change in the operative
experience?
– According to Bell, No. Instead increased number to pursue fellowships
– I ask, “Why not?”

22. So… we need to do more
parathyroidectomies?
Sure, why not?

23. 10,000 hours to becoming an expert
• 80hrs x 49wks x 5yrs = 19600hrs/residency
• Dr. Bell’s method:
1. 121 essential cases x hour value per case
2. Mean number of cases x hour value per case
• The global data:
– # hrs OR on “essential” cases/resident = 1,148
– 6% of 80-hour work week = ½ day in OR/wk
– Chung, et al., reported 2793 hours (14%)
in OR when ALL cases included

24. The UK data
• Caseload per M&M data
• Hours per case (my best guess)
• 80-hour work week
• Double scrub cases count for both residents
• Limitations:
– 4 residents on vacation
– 4 services not represented (SGR/TXP/STJ/MHD)
– Poor M&M recording

25. The UK Results
OR time per resident (n=16):
Overall 9.1 h/wk/res = 11.4%
PGY5 11.5 h/wk/res = 14.4%
PGY4 16.5 h/wk/res = 20.1%
PGY3 5.5h/wk/res = 6.5%
PGY2 1.16h/wk/res = 1.5%
PGY1 0.3h/wk/res = 0.4%

26. 1st annual Gabriel Bietz busiest resident award
21.5 hrs/wk = 26.9%
The Enterprise thanks Gabe for single handedly doubling
the workload at UK Good Samaritan

27. UK Data by service
• SGB 44.75 hr = 11.2%
• Caveats:
Endo 2.5 = 3.1%
- No breast “fellow”
• PDS 17.75 = 22.2% - No vascular junior
• SGG 11.5 = 4.8% - Only one Categorical on PDS
(intern vacation)
• SGO 12.5 = 15.7%
- VAGS PGY3 on vacation
• CT 4.5 = 5.6%
• VAGS 11 = 13%
• VAVASC 11.5 = 14.3%

28. Conclusions about UK
• We Own Johnny
• Overall, above average amount of time in OR
• Juniors underrepresented in data because of
Morehead, but still lacking OR time
• Does not tell us much about what is actually
going on in the OR

29. Teaching Hospital?

30. Learning Hospital?

31. Dearth of information
• Relative lack of papers written on teaching
of residents in operating room
• Recent trend of evaluating skill acquisition
in simulation labs (minimally invasive labs,
technical skills) in the literature
• Surgical education vs. Surgical teaching

32. Ideal world
According to Bell:
– Resident comes prepared
– Practiced on simulator
– Resident briefed by attending day prior
– “Read a book”
– Post-Op debriefing
– Standardized grading tool & National
database
– Feedback analysis on attending teaching and
resident learning
– Video review and note taking post-op to
review difficult areas & improve in future

33. Current world
According to Bell:
– Unprepared resident
– Uninformed about patient
– Uneducated about steps of
operation
– Goes through motions
– Feedback: “good job” & “make
the incision look nice”
– Resident moves on to lunch,
flirting with nurses, whatever…
– Lather, rinse, repeat.

34. Reality?
Somewhere in between

35. Obstacles to learning
• Bad timing/change in practices
• Ideas of teaching/learning at odds
• Minimal scientific studies
• Poor/useless assessment tools
• Outside influences
– Pressure to produce
• Supervision of teaching
– Who is watching those who watch the residents?
• 80 hour work week

36. Does anyone recognize this?

37. Now we have this…

38. Pugh et al.
• Asked Attendings @ ACS:
– Which areas do residents need to study to be better
prepared to perform an operation?
• Asked Residents @ ACS:
– What do you need to understand better to be
prepared to perform an operation?

39. The Rankings
Area of study Residents (n = 125) Attendings (n = 92)
Instrument use/selection 1 11
Selection of suture
material 2 12
Operative field exposure 3 7
Patient positioning 4 9
Sequence of procedure 5 5
Procedure choices 6 4
Postoperative care 7 8
Follow up procedures 8 10
Patient selection 9 6
Anatomy 10 2
Patient outcomes 11 3
Natural history of disease 12 1

40. So what does that mean?
a) Are we all just too incompatible?
b) Do we have to break up?
c) Are residents untrainable?
d) Are attendings bad at teaching?
e) NONE OF THE ABOVE

41. Transferable skills
• Idea that skills can be transferred between
procedures
• e.g. Ileocolic 2 layer anastamosis 
esophagogastric 2 layer anastomosis
• Parathyroidectomy  thyroidectomy
• Maybe it is the same…
• But what about mobilizing right vs left colon?

42. Read a book!
• Not good enough
• Research shows we need multiple
exposures to procedures to develop
rich, detailed mental models
• Even “master surgeons” can do it all
because, for the most part, they have
done it all!

43. Where do we go from here?
• National, accurate electronic data collection on resident
case loads
– Can be built into computerized case records
• Interim evaluations of resident operative experience
– UK already does this (good job, Dr. Endean)
• National standard change for case requirements
– Current index requirement >10 % of previous
– No repercussions for individuals, just programs

44. Where do we go from here?
• Make operative skill a required, testable
competency
– They actually used to do this
– Too expensive, subjective for PPPHs/administrators
– Should be the job of the residency right?
• Study and improve teaching in the operating
room
– This is a fascinating idea
– Video evidence is abundant
– Resident opinions are abundant too…

45. Where do we go from here?
• Scheme for teaching
– Briefing, intraoperative teaching, debriefing
– S.C.O.R.E. modules
• Standardized, validated resident evaluation tools
– Pay attention to them
• Simulation
– Seems to work pretty well for laparoscopy
– Don’t confuse learning with teaching
– Pie in the sky?

46. MRB

47. Maximum Resident Benefit

48. Maximum Resident Benefit
Those days are long gone…
• Hospital regulations on supervision
• Malpractice
– Has been identified as a potential factor in decreased resident
volumes
• Pressure to be efficient
– Long operative times are bad
• More infections (thanks Levi)
• More money
– Decreased operative times/staffing issues

49. MRB
• Can’t just operate on everyone who rolls in…
• Other things to do
– Lots of clinic
Do not fall asleep near this man
– 80 hours
– Call coverage
– ESS/trauma workups
– Research

50. MRB
• Resident case logs show decreasing number of 1st assist &
teaching cases
• Bell suggests, (and I personally agree) allowing modest increase
in operative times & resident autonomy in training facilities
• Supervision determined by resident operative ability
• The short term benefits of faster/”safer” surgery may be
detrimental to development of proficient surgical residents

51. MRB
• Necessary to identify and maximize good
teaching behaviors.
• Evaluations of teachings need to fulfill 4 criteria
– New Knowledge
– Value
– How to change
– Motivation

52. Characteristics of good teaching
• Answers questions clearly
• Confident in role as surgeon and teacher
• Provides feedback without belittling
• Remains calm and courteous
• Exhibits fairness toward House officers, no favorites
• Role models good interaction w/ OR staff
• Explains reasons for actions/decisions
• Allows learners to feel pathology
• Demonstrates respect for patient
• Teaches with enthusiasm

53. 80 hours
YES!!!

54. 80 hours
• Enacted in 2003
• Will not be reduced in near future
• Alterations in duty hours to be studied and
implemented by 2011
• Have destroyed attendings’ will to live.
• Make residents look soft

55. Does 80-hrs hurt residents?
• According to Most:
– Decreased sense of responsibility
– Decreased ownership
– Less motivation
– Weaker work ethic when entering residency
– Decreased learning due to outside lives
• According to Bell:
– Further limits time available to be in the OR

56. According to me
• Agree with some of the previous
• Changes the way we are perceived by older surgeons
• Does limit patient care time
Limits OR time, and thus experience
• Does NOT make me less motivated.
• No change in sense of patient ownership
• Duty hours not residents’ choice
– Average age of US congressman= 56.7y, senators=61.7
– Average age of ACGME task force on resident duty hours?
• Actually I don’t know, but not < 35, guaranteed!

57. Future directions
• Increasing operative exposure (esp for juniors)
• Attend to teaching in the OR
• Will everyone have to specialize?
• SCORE/Simulation
• Longer residencies?
• Maybe they should study what we do here…

58. So, Why Can’t Johnny Operate?
He is inexperienced
He didn’t come to UK

59. References
• Bell, RH, Why Johnny Cannot Operate, Surgery Sep 2009; 146(533-42)
• A.A. Gawande, M.J. Zinner, D.M. Studdert and T.A. Brennan, Analysis of
errors reported by surgeons at three teaching hospitals, Surgery 133 (2003), pp.
614–621.
• P.J. Fabri and J.L. Zayas-Castro, Human error, not communication and
systems, underlies surgical complications, Surgery 144 (2008), pp. 557–563.
• K.A. Ericsson, Deliberate practice and acquisition of expert performance: a
general overview, Acad Emerg Med 151 (2008), pp. 988–994.
• R.H. Bell Jr., T.W. Biester, A.W. Tabuenca, R.S. Rhodes, J.B. Cofer and L.D.
Britt et al., Operative experience of residents in US general surgery programs:
a gap between expectation and experience, Ann Surg 249 (2009), pp. 719–724.
• R.S. Chung, How much time do surgical residents need to learn operative
surgery?, Am J Surg 190 (2005), pp. 351–353

60. More References
• C.M. Pugh, D.A. DaRosa, D. Glenn and R.H. Bell Jr., A comparison of faculty and
resident perception of resident learning needs in the operating room, J Surg Educ 64
(2007), pp. 250–255.
• J.C. Kairys, K. McGuire, A. Crawford and C.J. Yeo, Cumulative operative experience
is decreasing during general surgery residency: a worrisome trend for surgical trainees?,
J Am Coll Surg 206 (2008), pp. 804–813.
• R.H. Bell, Surgical council on resident education: a new organization devoted to
graduate surgical education, J Am Coll Surg 204 (2007), pp. 341–346.
• .L. Larson, R.G. Williams, J. Ketchum, M.L. Boehler and G.L. Dunnington,
Feasibility, reliability and validity of an operative performance rating system for
evaluating surgical residents, Surgery 138 (2005), pp. 640–649.
• Iwaszkiewicz M, Darosa DA, Risucci DA. Efforts to enhance operating room teaching
J Surg Educ. 2008 Nov-Dec;65(6):436-40.
• S.S. Cox and M.S. Swanson, Identification of teaching excellence in operating room
and clinic settings, Am J Surg 183 (2002), pp. 251–255.
• Procter LD, Davenport DL, Bernard AC et al. General Surgical Operative Duration is
Associated with Increased-Risk Adjusted Infectious Complication Rates and Length of
Hospital Stay. JACS. In Press, January 2009.

61. Questions, Comments?