Halstead is Dead: The Resident Perspective

William Halstead, the creator of the residency model and one of the great fathers of surgery, died more than a hundred years ago. In fact, he died before the Bovie electrocautery, CT scans, and penicillin were invented. Yet, we hold tightly to the system he created, despite the fact that it no longer serves us. 

This was the theme of my interview with Dr. Liz Malphrus, an attending plastic surgeon in Philadelphia. As we discussed the changing face of medical training, our conversation continued to come back to the same points, time and again. Residents are insufficiently trained, undervalued, and burnt out. All of this led to the same terrifying conclusion; residency as we know it just doesn’t work anymore.

1. Surgical residents are graduating without the skills they need to practice independently. 

Residents themselves feel less competent and less confident in their skills than ever before, with 80% of graduating chiefs pursuing fellowships, many of them citing lack of confidence as a key reason they pursued further training. 

This holds true on assessments from their faculty, as well. A recent survey of fellowship program directors found that 40% of first year fellows lacked the clinical preparedness they were expected to have. Similarly, 43% of fellowship directors suggested that their incoming fellows could not safely and independently complete 30 minutes of a basic operation, such as a laparoscopic cholecystectomy. 

This is unacceptable, unthinkable incompetence among our graduating chiefs. 

2. Surgical residents are already working more than 80 hours a week, and we want to work. 

While many argue that the solution to the competency crisis described above is increasing work duty hours, this discussion often lacks an accurate picture of surgical residency. While official logs often report compliance with 80-hour work weeks, anyone who has trained as a surgeon can tell you that those logs are inaccurate. As Dr. Malphrus put it, “All the 80-hour limitation did is encourage residents not to document their actual hours.” Residents often face pressure, either from their peers or from programs, to under-report their hours. Studies show that, when accurately self-reported, surgical residents are still working more than 80 hours a week for about half of each academic year. Residents are deeply passionate about their work and are clearly willing to spend the time it takes to train. 

So, if this time isn’t spent on meaningful education, where is it going? It is going a number of places, such as into the electronic medical record. 30% of a resident’s time, averaged across all five years, is spent on documentation and EMR-related tasks. That is 6,000 hours, per resident, spent looking at a computer screen rather than at a patient. 

Their time is also going into cases spent holding the camera. Be it for a fellow who has yet to build the same skills the residents are learning, or for an attending who faces so much pressure to produce RVUs that they can't afford the time it takes to let their residents try.

Their time is going into hours spent on the phone with insurance companies and case managers, fighting to discharge patients from gridlocked units. 

If these hours aren’t serving our residents, and often not our patients, who are they serving? The answer is easy- residents serve the hospital systems that employ them. 

3. Surgical residents are revenue generating machines, and they are woefully underpaid. 

Surgical residents are responsible for keeping hospitals and services running. Surgical services generate as much as 70% of the revenue for any given hospital, and much of that work is done by trainees. Residents see consults, round on patients, place orders, request studies, and complete surgeries at a rate that is unmatched by other staff. 

We get in early, stay late, and go the extra mile because we care about our patients. We are willing to cover nights, weekends, and holidays, and we currently do so with no incentive pay, something no other comparable employee would do. 

As was seen when the neurosurgery program closed at University of New Mexico in June of 2020, it took three APPS to replace a single surgical resident. With the average starting salary of $125,000 a year for a newly graduated physician assistant, this shows that the work completed by a single resident is worth at least $375,000 to a hospital. In contrast, residents average $55,000 in salary. 

That $325,000 difference is revealing and when it is combined with the $115,000 that the federal government gives each hospital to train every resident the result is shocking. It means that hospital systems are raking in $440,000 per resident. With a program of 6 residents per year for each of five years in a program, that is a thirteen-million-dollar benefit to the hospital for a surgical residency every year that it is functioning. 

This is a windfall, and it comes at the price of resident education. The more work that can be extracted at such a low cost, the more profit the hospital will reap. It doesn’t benefit the system to spend any more time than the minimum requirement on resident education, when the residents could be working and generating more profit. 

This isn't the first time you’ve heard about these issues. You’ve talked to your co-residents, your friends, your family about it. We all have, we’ve complained and ranted but, as Malphrus so insightfully pointed out, “This is the only area in existence where surgeons see themselves as helpless, the only one where we will put our heads down and say there is nothing we can do.” 

Surgical residents are driven, gritty, and determined. We have never met a problem we can’t solve, except when it comes to the conditions under which we train. It is time to change that. To do so, we need the attending surgeons on our side. Join me next time as I talk with our faculty and figure out how we can make changes that benefit us all.