COMMENTARY

No, Smartphones Aren't Making Med Students Less Dexterous

Arghavan Salles, MD, PhD

Disclosures

July 09, 2019

Work Hour Concerns

The article does get one thing right in discussing the association between volume and outcomes. Data suggest that surgeons who perform a procedure more often have better outcomes. This is intuitive: Like any other skill, the more a surgeon practices, the better they become. However, the author suggests that working 80 hours a week limits today's residents from acquiring adequate surgical skills.

This is a controversial point, and this is not the first time anyone has expressed this concern. However, data are mixed, with several studies finding that trainees are now doing more cases, whereas other studies have found they are doing fewer cases. Although working 120 hours a week may have had some advantages, such as continuity of care, rational educators are not arguing for returning to that bygone era. It is our job to train residents in the allotted amount of time per week.

A full discussion of duty hours is beyond the scope here, but let's face it, even 80 hours a week borders on inhumane.

Jumping to Conclusions

In the closing of the article, the author cites a study that suggests a large proportion of complications from procedures may be avoidable. Although this may be true, the writer assumes that the source of complications is always technical. Surgeons that know a host of factors contribute to outcomes, including comorbid conditions and decision-making regarding antibiotics, deep vein thrombosis prophylaxis, and fluid resuscitation, among others. Technical errors certainly contribute, but so does the rest of the medical care provided. The assertion in the New York Times that intellectual capacity has "nothing to do with" being a good surgeon reduces surgeons to technicians, which is a huge disservice and, frankly, insulting.

One person responded to my Twitter thread and suggested that my irritated response meant the article hit too close to home. When smartphones first arrived, I was already a surgical resident. I am not personally in the generation of which the article speaks. My visceral reaction was not in my own defense; it was at the insults being thrown at today's medical and premedical trainees. We do no service to anyone by writing off an entire generation, saying that because they grew up in the current era they can't be surgeons. That is just nonsense.

Actual Issues Facing Medical Education

There are very real challenges in surgical education today. One is our limited ability to measure surgical skill. Dr John Birkmeyer and others have done some excellent work on this using videos of laparoscopic surgery to assess surgeon skill. Unfortunately, many operating rooms are not configured to record open surgery, and finding time for trainees to review these videos is challenging. The technology of simulators is not at the point where we would like it to be. In particular, they tend to fall short on tissue handling and tactile feedback, both of which are hugely important.

As medical knowledge expands exponentially, another challenge is teaching trainees how to keep up with that knowledge. Although knowledge of anatomy, physiology, and other topics is always relevant and important, our understanding of other topics—such as the microbiome or cancer immunology—is rapidly evolving. How best to synthesize the ever-expanding medical data and incorporate them into practice is a priority for modern education.

As surgical educators, our job is to foster the growth of young people into excellent surgeons. That should not require them to work 120 hours a week. It should not require that they take on unrelated hobbies, in which they may have no interest. We need to meet learners where they are and provide support for them to learn and grow.

Soviet psychologist Lev Vygotsky called the skills and knowledge that are just beyond a learner's abilities the "zone of proximal development." This is precisely where we need to be working. By providing guidance and encouragement, we help learners make the leap from where they are to where they would like to be. If we can't do that, the failing is ours, not theirs.

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