I Want The Residency My Attendings Had

“When I was a resident…” is the single phrase most likely to garner eye rolls and deep sighs from a room full of trainees. Yet, this year as I became a senior surgical resident my ears began to perk up when I heard this lead-in. Sure, I heard the familiar tales of grueling schedules and countless missed life events. They detailed 120 hour work weeks and being berated on rounds. But I also heard something that surprised me, something that has been missing from the conversation around residency culture and work hours: our predecessors were also given far more independence. 

Once I started listening more closely I heard my faculty say things like, “As a third year resident I ran every trauma on my own without an attending in the building,” “As a second year, I did most cases while the attending watched without scrubbing in,” and “I did my first appendectomy alone with a textbook on the mayo stand.” 

These are vignettes that are unimaginable in today’s day in age, where at the beginning of my third year of training I could not complete any single laparoscopic surgery independently. In this modern landscape I know second year residents across multiple institutions who could not confidently place a central line, much less open an abdomen and get down to fascia. 

It is equally difficult to picture for my attendings, who face a litigation threat that is so pervasive that allowing residents the same independence they were given seems unconscionable. They face a demand to generate RVUs at a rate that makes the time it takes to allow trainees to struggle not just difficult, but sometimes impossible to give. They combat ever-increasing pressure to produce more for a system that gives them little incentive to take time and teach well. For the faculty who truly care to invest in residents, doing so comes at a considerable personal cost and with insufficient compensation. As a result, many simply stop trying. Still others attempt to teach while also completing cases at the same pace they would alone, a balancing act that leaves everyone in the room, including them, frustrated. 

At a time when the ACGME and physicians around the nation are struggling to figure out how to deal with the so-called “competency crisis” among graduating trainees, surgery has been at the center of the debate as the system pours out seemingly ever less competent chiefs. The entirety of this conversation has centered around quantity of hours rather than quality of time spent at the hospital. Both aspects of training have seen momentous changes in recent years. 

With fewer hours and increasing restrictions, residents are spending less time in the hospital and the hours that are spent in-house are often spent on tasks that do not benefit the learner, but rather generate revenue for the system. Documentation, responding to patient and nursing chats, and billing tasks take up ever-more hours in the day. This time often comes at the cost of both patient care and resident education, with fewer minutes spent at the bedside or in the operating room. The combination of both changes, poorer quality and lower quantity, has certainly generated less confident and, yes, less competent trainees. There is no arguing that. 

I believe that a major issue with the national conversation is that it has revolved solely around quantity rather than quality, a delineation that could cost us this generation of brilliant physicians. Because while the two variables are certainly linked, they are not inextricable. I am not sure if this is a true misunderstanding of the problem, or intentional focus on quantity for the sake of demanding ever-more underpaid labor from trainees, but it begs the questions I am seeking to answer: 

Do we truly care about generating competent graduating chiefs? If so, are we willing to take the necessary steps to foster them, not just at the end of their chief year, but during their first? 

What would it look like to compensate faculty adequately for teaching, enough so that they are not just able but incentivised to take the time to train well? 

How can we leverage the considerable resources in our system to not just train competent surgeons, but truly great ones? 

If there is a conversation to be had around increasing or changing work duty hours, what would it take to get buy-in from trainees? 

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Join me over the coming weeks as I speak with attending physicians across different specialties and institutions to answer these questions, and seek to find a way forward that is functional for us all.