Surgical Competence Today: What Have We Gained? What Have We Lost?

David W. Page, MD, FACS


South Med J. 2010;103(12):1232-1234. 

In This Article

Abstract and Introduction


The complexity of modern surgical practice and the cognitive and technical overload to which trainees are subjected places practitioners and residents alike in jeopardy of developing areas of incompetence. Inadequate exposure to essential operations during residency forces trainees to seek further expertise in fellowships. At the same time, practice burdens increase stress levels on academic and community surgeons, resulting in a 30 to 40% burnout rate. Solutions include modification of restricted duty hours for residents and the institution of a simulation-based national surgical curriculum.


The complexity of modern surgical practice requires long hours of total immersion in difficult decision-making followed by an unfettered assessment of one's results. Competency only arrives when one observes the positive and negative consequences of one's actions. Shift work—the current method of meeting duty hour quotas—risks chopping clinical experience into short, incoherent pieces. In a setting with inconsistent continuity of care, the sum of the experiential parts of surgical training is less than the whole. With approximately ten million general surgery operations performed each year in the United States (US), the recognition and remediation of what is now appreciated as variable surgeon competence is not a trivial challenge.[1]

In a study designed to assess surgeon workload between 1995 and 1997, Ritchie et al determined that the average general surgeon performed about four hundred operations a year from a menu of 293 specific surgical procedures.[2] Only 11% of all general surgery operations were done laparoscopically at that time. A more recent assessment of the general surgery workforce in the US up to 2005 reveals that in the past twenty-five years, there has been a 25.9% decline in the number of general surgeons per 100,000 of the population. In this latter study, 68% of the laparoscopic operations were gallbladder removals, 11% were groin hernia repairs, 7% were appendectomies, and 9% were exploratory laparoscopies and antireflux operations. During this time, the average age of rural surgeons also increased.

Eighty percent of graduating residents enter fellowships rather than pursue a practice career in general surgery.[3] The restricted work hour policies for residents instituted in 2003 substantially increased the academic (urban) teaching faculty's workload, leading to erosion of job satisfaction. Superimposed upon the question of the overall competence of our recent graduating surgical residents is the confounding issue of a shortage of general surgeons.[4]


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