While you might believe that my title is an ode to Christmas, you would be wrong. In addition, you would be mistaken if you thought I was about to write about the coming of Spring following a cold and miserable Winter in Michigan. As an academic surgeon who trains residents and fellows, this is the best time of the year because we get to see the fruits of our labor.
Being a faculty member in an academic residency training program is a little like the movie “Groundhog Day” except on a lengthier time frame. Each year, we welcome new residents into our training program. They come armed with four years of medical school that has exposed them to the foundations of basic sciences as well as robust clinical exposure across the spectrum of medical care. In many ways, the medical school curriculum has advanced to include concepts of professionalism, system and practice-based learning, and a better understanding of the broader concepts of health care delivery. But all this education prepares people variably for the essential transaction that occurs between patient and doctor. That first day of internship for many young doctors is “shock and awe”. Translating didactic and practical learning into actual patient decision making can seem overwhelming. Sure, an intern has their senior resident and attending to guide them but fundamental to any training program is paving the trainees path to independence so that they are prepared to care for their patients.
Each step of the progression for a resident begins the process anew building upon their previous experience. For example, a surgical intern learns how to care for patients recovering from surgery, readmitted to the hospital, or those with conditions best managed by surgeons. They also learn who to work with and how to progress care in the complex ecosystem of the hospital and health system. While they may have had experience with this during medical school, every health system has its unique culture and workflow that an intern needs to grapple with. The following years are filled with exposure to progressively more complex surgical training, learning how to exercise clinical judgement to help their patients make good decisions, and acquiring additional skills that will help them achieve success in their future careers.
And that is why this is “the most wonderful time of the year” for both faculty, residents, and fellows in a surgical training program. Much of the hard work of acquiring the skills needed to be competent at a particular level of training have been achieved at this point of the year. The massive ship of a clinical service runs smoothly with only minor adjustments required. The rest of the year can be devoted to refining these skills and preparing the resident or fellow for their next step in the process. Because of my clinical practice, I am exposed to residents mainly at two points during their surgical training. The first is early on as residents work with me in the OR learning endoscopic/laparoscopic skills. The second time is during their more senior years where they work with me caring for patients with urologic cancer and learning robotic surgical skills. Along the way, I have the fortune of working with residents in the hospital caring for inpatients and in my clinic where we focus on evaluation and shared decision-making with patients around the treatment of their condition. By the last 1/2 to 1/3 of the year, most of our trainees have the fundamentals mastered and we get to transition from “good to great”.
I obviously don’t work in isolation. Both my faculty colleagues and senior residents have imparted their expertise to residents along the way. As a teacher, I have come to appreciate that we all have our strengths and weaknesses and I am fortunate that I am faculty in a training program that has skilled educators which complement each other’s strengths. As such I get to focus on what I am good at which I like to refer to as finishing school. I expect those who are working with me to be able to cut, tie, and sew. I also expect that our trainees know about the patient and the steps of the surgical procedure before they participate in a case. Once I am confident in their abilities, my focus is really helping my residents accomplish three goals.
The first goal is efficiency, not speed. Every surgery is composed of different steps with different levels of complexity that are connected and feed into the next step. The goal of a surgeon is not to be fast. It is to move efficiently through steps of the procedure where immediate risk is low and there is minimal impact to functional or oncological outcomes. However, a resident or fellow must also recognize when to slow down and take their time when their technique does influence outcomes because of the nature of the tissue or the reason for the step of the procedure. Overall efficiency comes from knowing when to move with purpose and when to slow down. It also comes from constantly analyzing the steps of the procedure and understanding what movements and steps don’t add to the progression or outcomes of the case and eliminating them. Another key component is thinking like a chess player and communicating the next several moves and what is needed to the entire surgical team. We can’t always guarantee we are working with our usual crew and engaging the entire surgical team by clearly outlining next steps and needs helps everyone to work together efficiently.
The second part is exposure. Surgical training has changed a great deal over the last 20 years. Gone are the days where an attending left the room and came in only to perform or assist with the “critical portions of the procedure”. Our patients expect their surgeon to perform the surgery and I deliver on that promise. However, we as teaching faculty have an obligation to prepare our residents to go out in the world as safe, compassionate, and skilled surgeons who can make good decisions about whom to operate on (and who to not to) with reproducible outcomes. This can still be accomplished in our “hands on” training environment and I believe a key component is to have the residents learn to use their retraction and assistants to optimize their surgical view. For robotic surgeries, the way I have seen many surgeons teach is to hand off particular steps of the surgery under close observation. Many times, they have already set up the retraction and instructed the bedside assistant so that the resident only has to do the dissection in an already optimized field. This is not what a resident needs to learn at this time of the year- they already know how to do that. What they need is to first emulate good exposure and second, be expected to set up their exposure when progressing the case forward. Learning how to optimize exposure is the fundamental base for safe and efficient surgery that many people do not figure out until several years into practice.
A third component is staying out of trouble. Of course good exposure keeps you out of trouble to some extent. But more important is having a strong understanding of the anatomy related to the surgery that is being performed. If a resident knows the anatomy then they can anticipate where problems may occur and avoid them. Similarly, knowing the anatomy informs how a surgeon exposes to visualize all the critical elements in a field. At this time of the year, I expect a resident to articulate how these elements of anatomy are informing their surgical decision making.
My greatest satisfaction is to help my residents/fellows achieve these finishing touches that will allow them to safely and effectively care for their patients as they take their first job or enter fellowship. But it is not all fun and games because there is one final piece that I try to teach that is somewhat in direct contradiction to how we think of surgical training in this day and age.
The current dogma is that people learn best by reducing the tension in the environment. I don’t disagree. It is hard to process information when you are constantly being scolded or yelled at. But it is hard to argue that surgery is not a high stakes environment and we need to prepare people to perform under pressure. Our Department was recently given a presentation by the head of security for the health system and his words summarized the critical nature of being able to respond during a crisis. He of course was talking about a security threat but these words ring true in the operating room as well. “We don’t rise to the level of our expectations, we fall to the level of our training.” (Archilochus, a Greek lyrical poet) If we never test how someone performs under pressure, then they will not be prepared when the time arises. At this time of the year, I try to shift my expectations from teaching skills to teaching performance. Reading through my previous resident evaluations, I feel that some of my former trainees appreciated this. I also have received feedback that former trainees have heard my voice in their head that has helped them deal with challenging circumstances. While I am not a sadist, I take great pleasure is seeing trainees rise to expectations because I know their patients will be well cared for and they will have the confidence to be successful.
This experience is not unique to medicine. Other professions have the great privilege of seeing their student, apprentice, or trainee transform over the course of their education. The rest of the year is not so bad but being able to transmit hard earned lessons from my experience to a resident who can now understand is a true joy. It means they will be better equipped than I was to tackle that next step. I continue to work hard and learn every day but my hope is that I will help those around me be better. It truly is the “most wonderful time of the year”.