RESIDENTS

Since the death of Libby Zion and the “Case That Shook Medicine”[1] over 30 years ago, the controversial topic of resident work hours has garnered consistent attention from both the public and the media.

Two recent American trials studying work hour restrictions for residents have once again brought this topic back into the limelight.[2,3] As surgical residents, we know of no better way to rile up our staff surgeons than to innocently bring this up as a topic of discussion – as we are about to do in this article.

Current Work Hour Restrictions

In the United States, the Accreditation Council for Graduate Medical Education (ACGME) is the body that accredits American residency programs and sets their duty hour policies. In 2003, the ACGME limited all residents to 80 hour work weeks with the traditional 24 hour (or more) call shifts averaged over four weeks. In 2011, they went further and restricted all first year residents to 16 hour maximum work days. In addition to these work hour restrictions, the ACGME entitles residents to one in seven days completely off from clinical duties and recommends “strategic napping” following 16 hour call shifts.

In Ontario, resident work hours are governed by the collective agreement between the Council of Academic Hospitals of Ontario (CAHO) and the Professional Association of Residents of Ontario (PARO). In contrast to the ACGME restrictions in the United States, residents in Ontario are not limited to a specific number of work hours within a week or call shift. However, we are restricted to 1-in3 home-calls or 1-in4 in-house calls in any given month. Residents who perform in-house call are required to go home post-call and there are specific conditions within the collective agreement governing when a resident on home-call is able to take a post-call day. Furthermore, the PARO-CAHO agreement requires that residents are off clinical duties for two weekends in a month.

The Evidence

The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial has recently been published [2], while the iCOMPARE trial is examining this issue in medical residents and is currently still on-going.[3] These are cluster-randomized trials including over 50 residency training programs. Both trials aimed to compare the newer – and more stringent – 16 hour call shifts with the traditionally more flexible 24+ hour work shifts. Both trials included the 80 hour work week, as well as the nebulous “strategic napping” recommendation from the ACGME. The primary patient outcome is 30 day mortality derived from NSQIP data, while the primary resident outcome is self-reported satisfaction with overall quality of resident education and overall well-being. The studies are not without their own controversy and both have been criticized on an ethical basis secondary to a lack of informed consent.[4]

Results of the FIRST trial suggest that there is no difference in patient morbidity and mortality at 30 days when comparing the more stringent 16 hour work restrictions for residents with the more flexible 24+ work hour restrictions. The authors therefore concluded that 24+ hour call shifts were safe for patient care. The resident outcomes were a mixed bag of unsurprising results where residents in the flexible group were more satisfied with continuity but less satisfied with rest. Ultimately, there was no difference in job satisfaction or morale between the two groups. I prefer John Birkenmeyer’s conclusions where he suggests the results effectively debunks the concerns over patient continuity and handover. In the group with more hand-over (strict policy) patient outcomes were not different. He further suggests we move on and develop an academic system which does not depend solely on overworked resident physicians.[5] Beyond gross negligence, it is the minority of poor outcomes/complications that can be linked to a single individual. Complications are nearly always a systems issue and Libby Zion’s death was a failure of the medical system rather than an individual resident having been tired. This has been elucidated in a number of ways including the impact of hospital procedural volumes[6] and teaching hospital status.[7] High volume academic centers who monitor and aim to improve quality have better outcomes. This does not minimize the impact of individual surgeons and indeed operative technique[8] and surgeon procedural volume[9] are linked with patient outcomes.

Past, Present and Future

While we may lament the good-ol days, no surgeon who trained in the era suggest it was a physically or emotionally healthy model of training. Further compounding work-hour restrictions is the growth of medicine in terms of volume and complexity of knowledge. The amount of information to be learned in a 5-year residency today cannot be compared to 20 years ago. Oncology in particular has changed drastically through the development of new chemotherapies, neoadjuvant therapy and non-operative management. Gone are the days where radical mastectomy was the mainstay of breast cancer treatment. The National Comprehensive Cancer Network (NCCN) guidelines for breast cancer is 188 dense pages of algorithms.

In general, surgical residents are happy Canada has not adopted the 80-hr work week limits. Within our collective agreement in Ontario, there is room for surgical residents to have more control over his or her own education as adult learners. However, we must ensure surgical residents are not taken advantage of and realistically examine how our academic centers function, often on the backs of residents. Surgical residents provide a substantial service to the hospital for comparatively little compensation. The entire budget for Ontario residents is approximately $400 million and the on-call budget is approximately 10% of this. Given that call (at least in our experience) represents a full time job by hours worked, it is an extremely cheap way to service our system.

Working tired and sleep deprived to meet service needs versus meeting personal education goals are two different scenarios. As an example, junior surgical residents often will stay to work a full day after 3-days of “home-call” purely to cover the pager for floor and emergency consults. This is unacceptable, and we should be adequately staffing our academic hospitals to meet personnel obligations or develop more creative solutions. There is no issue with a senior surgical resident staying to operate the night after call. This is why we became surgical residents - to operate. A mentor once said, “you can either be a well-rested surgeon at the end of residency or a competent surgeon.” This is a simple statement to a complex paradigm of training a competent surgeon but encapsulates the pressures on surgical residents and the limited time-frame (5 years) to train us. We cannot envision a day after completing our residency where we look back and regret staying for a case after a busy night of call.

As always, if there are any resident-related issues you would like to bring before the OAGS or discussed here, please contact me or OAGS at info@oags.org.

REFERENCES

[1] Lerner B. A Case That Shook Medicine. Washingst Post 2006. [2] Bilimoria KY, Chung JW, Hedges L V., et al. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. Obstet Gynecol Surv 2016;71:348–50. [3] iCOMPARE: Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education. Available at: http://www.jhcct.org/icompare. Accessed August 14, 2017. [4] Lowes R. Two Trials Extending Resident Hours Called “Unethical.” Available at: http://www.medscape.com/viewarticle/854845. AccessedMay 29, 2017. [5] Birkmeyer JD. Surgical Resident Duty-Hour Rules — Weighing the New Evidence. N Engl J Med 2016;374:783–4. [6] Birkmeyer JD, Siewers AE, Finlayson EVA, et al. Hospital Volume and Surgical Mortality in the United States. N Engl J Med 2002;346:1128–37. [7] Burke LG, Frakt AB, Khullar D, et al. Association Between Teaching Status and Mortality in US Hospitals. JAMA 2017;317:2105. [8] Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical Skill and Complication Rates after Bariatric Surgery. N Engl J Med 2013;369:1434–42. [9] Morche J, Mathes T, Pieper D. Relationship between surgeon volume and outcomes: a systematic review of systematic reviews. Syst Rev 2016;5:204.

The Cutting Edge newsletter, Issue #39....still pending

---

“The higher education so much needed today is not given in the school, is not to be bought in the market place, but it has to be wrought out in each one of us for himself [herself]; it is the silent influence of character on character.” - William Osler

In the next few years, residency training will undergo the largest transition since its inception by Osler at Johns Hopkins in the early 1900's. Competency-based medical education (CBME) is in development and set to begin as soon as next year for some surgical specialties. CBME is a paradigm shift in education from a time-based approach to an outcomes-based approach, which “focuses education on patient outcomes, emphasizes learner abilities, de-emphasizes time-based learning and increases individualized trainee plans for the learner.”¹

As this transition is underway, it is worthwhile to look in the past and consider residency training over the last 100 years. The original training system devised by Osler required young physicians to reside in the hospital for an undefined number of years in an apprentice-like system. At this time, Osler and Halstead required total immersion in surgery until a “superior level of competency and maturity was reached.”² This was also without pay, although room and board in the hospital was provided. The first residency program was built on the relationship between teacher and student with residents and faculty forming close relationships and developing plans for each patient under their care. The hierarchical environment still exists today, although in a relatively muted form. The propagation of medical knowledge in the early 1900's was immense. Eleven of the 17 chief residents who trained under Dr. William Halsted established surgical residency programs at other institutions. Growth at each institution was limited to maintain a superlative educational and teaching environment. The teacher was exalted, respected and even loved. That being said, this era was also mired by paternalism, elitism, racism and sexism.

Fast-forward to the post-war period; the war brought about significant medical and non-medical technological advances which affected healthcare and the training of physicians. The breadth of medical knowledge expanded dramatically with access to new ideas and technologies. Antiseptic technique, safe anaesthesia, and antibiotics all considerably reduced the morbidity and mortality of surgery. Surgeons had evolved from barbers and butchers to skilled practitioners. Tissue handling, hemostasis, and controlled pace were increasingly valuable as unbridled quickness was no longer required due to advancements in anaesthesia. The system changed as well. Standards for both practice and licensing were devised and set. In Canada, after completing a single year of internship, physicians could write an exam and then practice as a general practitioner. Residency was reserved for those wishing to complete further training in subspecialized fields. This was an era where the Royal College had defined failure rates. These failure rates were acceptable because most Canadian residents had a General Practitioner license from internship and could still work or moonlight as a practising physician if he or she failed.

From the 1970s to the early 2000s, residents across the country formed organizations that focused on advocacy both for residents and medical education. These include the Resident Doctors of Canada (RDoC) founded in 1972 [formerly known as CAIR: Canadian Association of Internes and Residents] and the Professional Association of Residents of Ontario (PARO) founded in 1968. PARO first began in Toronto but has since expanded province wide. Similar organizations now exist in other provinces across Canada. Most residents now refer to themselves by Post Graduate Year (PGY) rather than as an intern vs. resident. The “strike to end all strikes” occurred in 1980 and won residents the right to binding arbitration in Ontario - a right the MOH refuses to grant the Ontario Medical Association (OMA). The strike was a mere ten-years after residents were first recognized as employees and learners who provide significant service in exchange for training and financial reimbursement.

In addition to the innovation and advancement of medicine and surgery, the emergence of Medicare (or Universal Healthcare) coincided with the founding of PARO in 1968. The increased coverage and reduced length of stay of patients resulted in a drastic increase in the number of admissions and number of surgeries performed each year at Canadian hospitals. Despite the changing face of surgery, little about the way surgical residents are trained has changed since Osler’s time. No doubt Osler expected both quality and competence from his trainees, but these terms bear further examination. Quality and competence are reified and although referred to commonly in reference to healthcare and medical education, their meaning are widely variable to various stakeholders. As a result, I still have a hard time defining quality and competency within medicine and medical education. Part of the challenge is attempting to define individual competence and quality when all physicians, in particular surgeons, exist in a system where high quality care relies not only on individuals, but also the healthcare system as a whole.

It is perhaps easy to recognize and focus on those among us who do not provide quality care or who are not competent. The worry is that CBME will be designed with those people in mind and may hold little relevance to the needs of the majority of learners. Unfortunately, with the loss of the intern year and the general practise license, residency has higher stakes and failing a resident has very different ramifications than 20 years ago. The debt obligations and human resource investment are not to be taken lightly. We should not be aiming to push through those who will not thrive in his or her chosen specialty, but rather we should strive for early identification of struggling trainees and invest in solutions. Such solutions will need to be individualized and may include facilitating transfer to other residency programs or remediation within the same program.

I have my own reservations about CBME, and while I will likely not have to experience it as a resident, I will experience it after completing residency as a surgical educator. The Royal College seems to be taking a thoughtful and strategic approach to implementing CBME.³ There needs to be considerable thought towards balancing service and education and defining competencies. There will be a shift towards efficient and high-quality educational opportunities, but someone, particularly academic institutions, will need to provide service to our ever-expanding healthcare and surgical needs. Some surgical programs are already struggling to maintain the balance of education to service.

Surgical programs have an advantage over non-procedural-based residencies, as competency for procedural domains are slightly easier to define. Ontario has already helped define some through Quality Based Procedures (QBPs), for instance colonoscopy. An individual’s ability to reach the terminal ileum is a good measure of competence and a target can be used to judge how well those performing colonoscopy achieve that metric. More challenging issues include defining competence in professionalism, advocacy, communication and many of the CanMEDs domains. Significant buy-in from faculty and educators is required to observe and give feedback on these, and this may represent one of the largest barriers to CBME.

As part of the ongoing discourse around CBME, many challenging questions will need to be asked. One of my own outstanding questions is whether many of the surgical educators who will be evaluating residents are themselves competent in all domains. At a recent meeting on CBME a hypothetical question to the mixed administrative/physician audience was asked: “Is there a resident who recently graduated from your program whom you would be uncomfortable with taking care of a family member?” Most of the audience suggested they knew one or more recent graduates who they would not be comfortable with taking care of a family member. A rebuttal question was posed: “Is there a seasoned faculty member whom you would be uncomfortable with taking care of a family member?” An equal number of hands went up. Again, this represents the minority of trainees and practising physicians but highlights the importance of self-regulation. Improvements can always be found, but before completely revamping our education system, I think we should seriously examine inwardly at where we succeed and where we fail - both as clinicians and educators.

As always, if there are any resident-related issues you would like to bring before the OAGS or discussed here, please contact me or OAGS at info@oags.org.

LINKS/REFERENCES
"The Future of General Surgery: Evolving to meet a changing practice", RCPSC – http://www.royalcollege.ca/rcsite/documents/educational-strategy-accreditation/future-of-general-surgery-report-e.pdf
1) Frank, J.R., Snell, L., ten Cate, O., Holmboe, E.S., Carraccio, C., Swing, S.R., et al. Competency-based medical education: theory to practice. Medical Teacher 2010; 32(8):638-645
2) Royal College of Physicians and Surgeons of Canada. Competence by Design: Reshaping Canadian Medical Education, March 2014.
3) Imber G. Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted, Kaplan Publishing (UK), 2011.

I would like to begin by thanking the Ontario Association of General Surgeons board members for the opportunity to represent General Surgery residents across the province. I appreciate the opportunity and look forward to the experience and advocating for residents and General Surgeons.

After reviewing the previous Resident Rostrum columns on the job crisis and endoscopy by Dr. Kellen Kieffer and the impact of super-specialization and modern limits on resident education by Dr. Julie Ann Van Koughnett, I decided to tackle a different topic for my first column. Namely, I have decided to focus on the topic of mental health during residency. The aforementioned topics continue to remain important issues for residents, and I encourage those interested to review the 2013 National Physician Survey and the 2014 report by the Royal College of Physicians and Surgeons of Canada “The Future of General Surgery: Evolving to meet a changing practice.” The two reports tackle the current status of General Surgery provincially and nationally and discuss the future of General Surgery and residency training, in particular.

Physician and resident mental health is a concern that has received increasing attention in academic literature and lay media. It seems, every year an article is published about new residents committing suicide. In New York last summer, two fresh interns ended their own lives within weeks of each other. This is not a new trend. In looking back and even asking fellow colleagues, it is not a challenge to find someone touched by mental illness, either personally or through peers. Sadly, it can take the death of a fellow colleague to prompt change. Stanford, in 2010, created the “Balance of Life Program,” following the suicide of a newly graduated General Surgery resident turned Vascular Fellow just four months after his fellowship began.

In the USA, approximately 400 physicians will take his or her own life this year, which amounts to two medical school classes a year. Canadian statistics are more limited, but data out of British Columbia suggests approximately 20 per 100,000 physicians will commit suicide each year, which, while lower than Americans, at 30-40 per 100,000 is nearly double that of the general population.1,2 Perhaps an even more concerning trend is that women physicians are more likely than men to be depressed and to commit suicide. Fortunately, women surgical residents are also more likely to seek help than their male counterparts.3,4

Before considering why surgeons are so poor at seeking help, I believe it is important to examine potential reasons which place surgeons, and particularly surgical residents, at risk of mental health issues. Perhaps, choosing surgery as a career self-selects a subset of individuals more likely to have “Type-A” personalities and to be perfectionists. These are seemingly desirable qualities for surgeons, but may lay the ground-work for mental illness when strained. I believe environmental considerations play a larger role, ranging from a lack of sleep and stress for innumerable reasons including patient care, education, debt, hospital politics, program expectations, and lack of mental health support, among others. A recent report commissioned from the Austalasian College of Surgeons points to a more worrisome finding of emotional, physical and sexual abuse – although I would like to believe this is not a problem in Canada, perhaps naively so.5

Stoicism is a quality surgeons have historically taken pride in, dating back to Dr. William Osler. However, while this quality may allow us to be steady in the operating room and calm in chaotic situations, it likely limits our ability to seek help. Surgeons are less likely than other physician to seek mental health services. A multitude of reasons can offer explanation, including individual denial, perceived stigma from peers, monetary concerns, or licensing implications. The last two reasons I believe have a great impact on residents. Many residents have seemingly insurmountable debt, which can reach upwards of $300,000,. This may contribute to mental health issues, as well as act as a barrier to seeking help. To put it frankly, no disability insurance could cover living expenses and loan repayments, much less address the time away from residency and the potential effect on future employment and licensing. This leaves those struggling with mental health issues in a vicious cycle. Even if a resident or staff physician would like to get help while continuing to work, there is too little time to schedule visits with a therapist or psychiatrist. Residents who take time away during training may face difficulties when it comes time to obtain a license, as time away and declaration is required on the licensing application. Additional documentation from the CPSO is usually required, and there can be delay in obtaining an independent practice license.

There are no easy answers to mental health challenges in either the general population or the physician population. The recent announcement of the planned reduction to 50 residency spots in Ontario has the potential to overwhelm remaining residents with increasing service over education as well as additional time stresses. The continued OHIP cuts provide a source of financial frustrations for practising physicians. I can only hope that my colleagues and I can offer support for our peers, akin to the support we offer our patients. Our friends and partners in medicine should not have to suffer alone, or in silence.

As always, if there are any other resident-related issues you would like to bring before the OAGS, please contact me or the OAGS at info@oags.org or contact your local OAGS Resident Liaison: McMaster University: Jennifer Li, PGY4 NOSM: Justin Poling, PGY3 Ottawa University: Nikoo Rajaee, PGY5 Queen’s University: Mike Rizkalla, PGY5 University of Toronto: Debbie Li, PGY5 Western University: Mostafa El-Beheiry, PGY3

- Dr. Patrick Murphy, OAGS Resident Representative PGY 3, General Surgery, Western University

LINKS/REFERENCES

• National Physician Health Survey – http://nationalphysiciansurvey.ca/surveys/2013-survey/
• The Future of General Surgery: Evolving to meet a changing practice – http://www.royalcollege.ca/common/documents/educational_initiatives/future_of_general_surgery_report_e.pdf
• Professionals Help Program offered by the OMA – http://php.oma.org/
1)Goldman LS, Myers MM, Dickstein LJ. The Handbook of Physician Health, American Medical Association, 2000.
2)Canadian Medical Association. Physician Health Matters: a mental health strategy for physicians in Canada, February 2010.
3)Gerada C, Jones, R. Surgeons and mental illness: a hidden problem? BMJ Careers. 2014.
4) Aminazadeh N1, Farrokhyar F, Naeeni A, Naeeni M, Reid S, Kashfi A, Kahnamoui K. Is Canadian surgical residency stressful? Can J Surg. 55(4):S145-51; 2012.
5) Royal Australasian College of Surgeons. Expert Advisory Group on discrimination, bullying and sexual harassment. Sept 8, 2015.

I will admit that when I joined the OAGS as the Resident Rep, I had a bit of an agenda in mind. But for my colleagues who have worked so hard for the past 5 years, sacrificed time with their families, and who have then been blind-sided by a total lack of job opportunities, this issue dwarfs all others in comparison regarding its importance to residents today.

DIAGNOSIS
A review of the facts about our job crisis:
1. We are in this job crisis because of massive over-training of residents and the only way to solve this problem is significant cuts in residency positions. The government is not paying for any new OR time. Over the past few years, we have squeezed as many extra bodies into the surgeon pool as we could – the “locum circuit”, scope shacks, fly-by-night on-call warriors. The generosity of certain groups has not gone unnoticed, as they have given up some of their own OR time to fit in a new grad, usually on a part-time basis. But as we flood the Canadian market with over 50 surplus surgeons every year, the avenues for “squeezing in” are quickly becoming exhausted, and we will truly see surgeon unemployment.

2. This problem will not go away on its own, and it gets worse every year.
It has been remarked to me that (much like the stock market), the pendulum for the job market will naturally swing from side to side every few years. We have only to be patient and ride out this “trough”, and the good times will roll again in the near future. On the contrary, if we continue on our current course, in 10 years there will be two surgeons for every job.

3. We are training too many doctors overall
Many other specialties are suffering from new grad unemployment. We are all aware of the job crises in surgical specialties such as Orthopedics and Neurosurgery, and medical specialties such as GI and Nephrology. What we may not yet recognize is that specialties recently thought of as underserviced, such as family medicine, are quickly heading the same way. I have recently heard of several centres in Northern Ontario turning down family doctors who sought to practice there – Sault Ste. Marie, Dryden, and Kenora to name a few – claiming that they had enough family docs already. It won’t be long at all until family doctors are competing for patients. The Ontario Physician Human Resources Data Centre reports that we are training about 1,000 medical students per year in our province, compared to ~870 physicians retiring. If we add IMG’s (international medical grads), we are dealing with 1,200 new doctors per year – 33% more than retirements. Training in excess of retirements to increase physician numbers is a strategy that is useful if you have a shortage, but now that we have physician sufficiency, this type of strategy will quickly lead to an over-supply and must be stopped.

TREATMENT
Though we knew we were headed for a job crisis, during my five years of residency there has been little progress (if any) towards a solution. Cutting residency positions is a feat not easily accomplished. It would be more straightforward if there was a body that could make decisions at a national level. Instead, there are many stakeholders, each with their individual interests, that must be coordinated in order to produce long-term stability.

1. Provincial ministries of health: These provide funding for residency positions, which includes not only the resident’s salary, but also the greater sum paid to the medical school to fund the training. The Ontario MOH has claimed they have a model to project the need for surgeons, and residency positions are allocated accordingly. I see no evidence of this, as there have been no training cuts initiated by the government. I fear that the necessary changes will not come from the government side. The political impact of the physician shortage of 10 years ago was so significant that many people today still believe we have a shortage. I do not see any political will to cut residency spots, even though money is being wasted training doctors we don’t need.

2. Surgical residency programs: They have every incentive to take on more residents rather than cutting positions – more funding, more manpower to fill the call schedule, and more manpower for research. The academic surgeons with whom I have spoken, however, seem to place more value on the future of their trainees than their own gains. They are willing to make cuts but don’t know (a) how many positions to cut, and (b) what overall effect these cuts will have on the job crisis. If one program acts independently to reduce their numbers and none of the other programs follow suit, the overall national effect will be negligible. Our hopes should not rest in appealing to program directors individually, but rather effectuating a nationally-coordinated strategy in which all programs make cuts and are assured that the sacrifices they make will produce the desired outcome.

3. The Royal College: Manpower planning has not traditionally been a mandate of the Royal College. However, in early 2013, they produced a report on “specialist unemployment” and organized a conference on the same subject in February 2014. Theoretically, the Royal College does have the power to impose cuts – they could revoke accreditation for programs which do not comply. They don’t seem to have the appetite for this; rather, they seem to want to act as facilitator for others to take the necessary action.

4. Specialty societies: The only success stories in physician manpower planning have come when national specialty societies take the bull by the horns and solve the problem for their specialty. A good example is Radiation Oncology. Realizing they were in crisis, last year they cut their training numbers by 25%. Comparatively, CAGS is in the best position to provide direction for our specialty.

5. Advocacy groups: It’s time that the OMA acknowledge and treat the job crisis as a priority. We commend the OMA’s negotiating team for their dedication and hard work negotiating on our behalf. But in a few years with a massive surplus of physicians, their negotiation power with the Ministry will be absolutely crippled. Furthermore, who is going to pay for all these extra doctors? The Ministry’s position seems to be that we (the doctors) will pay. This is illustrated by the most recent report from our OMA President outlining the Ministry’s intent to cap the “physician services” budget at a finite level. From our perspective and the taxpayers’, it is in everyone’s best interest if we control our numbers.

PROGNOSIS
Is there any hope for getting out of this mess? I believe there is, and it’s easier than we think. Consider these 3 steps to achieve manpower stabilization for our specialty:
1. Decide how many general surgeons we want: In an ideal world with unlimited resources, this would be based on population and disease rates. However, we must work in the confines of our current system, which is limited by available resources. We need to look at current OR time across the country and tally the full-time surgeon equivalents. This is best suited to be organized by a national body, ideally CAGS.

2. Figure out how many surgeons we need to train, per year, to maintain the total surgeon population from #1. For every general surgery resident admitted in PGY-1, how many practicing General Surgeons do you get at the end? This number is certainly much higher than it used to be, as attrition rates are way down and losses to other countries are down as well.

3. Allocate residency spots in line with #2: This will certainly involve massive cuts from our current levels. Consider the following figure as an example of the magnitude of cuts that are required to train based on need. The blue bars illustrate PGY-1 general surgery residents admitted in 2014, while the red bars suggest what it ought to be to solve the job crisis.

It has been a privilege to have had the opportunity to sit in with the OAGS board as the Resident Rep. When the OMA economics department warned of the looming job crisis 4-5 years ago, the OAGS was the first to take it seriously. Their dedication to the surgeons in this province in all domains of advocacy has certainly earned my respect for years to come.

Although my time as the Resident Rep has come to an end, I hope to continue advocating for better manpower planning. I am more than willing to discuss this issue with anyone who wants to. Please email me: kkieffer@nosm.ca.

As always, if there are any resident-related issues you would like to bring before the OAGS or discussed here, please contact me or the OAGS at info@oags.org or contact your local OAGS Resident Liaison:
McMaster University: Jennifer Li, PGY3
NOSM: Kellen Kieffer, PGY5
Ottawa University: Nikoo Rajaee, PGY4
Queen’s University: Mike Rizkalla, PGY4
University of Toronto: Debbie Li, PGY4
University of Western Ontario: Mostafa El-Beheiry, PGY2

Kellen Kieffer, OAGS Resident Representative
PGY 5, General Surgery, Northern Ontario School of Medicine (NOSM).

There has been a lot of talk lately about the role of endoscopy in the future of General Surgery. There is no question that it has become a highly politicized subject, and we are at risk of being edged out by the gastroenterologists.

In my training so far, I have witnessed collegial and productive relationships between our two specialties. There are problems of a medical nature, such as chronic diarrhea and IBD, which require endoscopy for diagnosis and management – well suited to gastroenterology. There are also surgical problems, such as colon cancer, best handled by General Surgeons…. We’ve all been there - hours into a laparoscopic sigmoid colectomy converting to a low anterior because the cancer that was measured at 25cm is actually in the mid-rectum. In practice, however, there is no distinct line between the diseases managed by GI and by General Surgery. The “scope” of practice (pun intended) between the two specialties has considerable overlap, and that leaves room for some jockeying for work.

There are two factors pushing us toward a turf war. The first and most important is that colonoscopy is paid very well. We wouldn’t even be having this discussion if not for the seemingly arbitrary way that colonoscopy is one of the most lucrative parts of medicine. Secondly, both General Surgery and GI are training way too many residents, and we’re all going to want an income after graduation.

Back in the 70’s, colonoscopy was pioneered by surgeons and then fell quickly out of favour because, as is the case with most new technology, it was felt to be cumbersome and dangerous. The specialty of gastroenterology originated and prospered because as endoscopic technology improved, General Surgeons were slow to become interested again.

I would argue that endoscopy is an essential part of General Surgery, and much of endoscopy, especially interventional endoscopy, belongs in the surgical realm.
1. Endoscopic interventions are used for surgical diseases. These are diseases that have traditionally been treated by major surgery (e.g. GI bleeds, bile duct stones, large colon polyps) and are now treated using endoscopy, because it is better for patients. General Surgeons understand the full course of the disease: we admit the patients to hospital, follow them, perform the endoscopic intervention and then perform the surgery - should endoscopy fail. I would argue that our judgment for each individual part of the patient’s care is better, because we have a better understanding of the whole picture.
2. Often, endoscopic interventions are surgery. An ERCP is endoscopy up until the sphincterotomy. That is surgery. You are cutting human tissue and you are assuming the inherent risks such as perforation and massive bleeding. Management of surgical complications is a cornerstone of surgical training and practice, something to which medical specialists are not exposed. The same can be said for mucosal resection of colonic polyps and dilatation of strictures.

I have just mentioned two reasons why General Surgeons are important in endoscopy, but we also have to consider why endoscopy is important for Surgeons:
1. Endoscopy makes up about 30-40% of the work of your average community General Surgeon. It contributes to 50% of our income. If we were to lose endoscopy, there would be room for far fewer General Surgeons.
2. Endoscopic surgical techniques could very well become much more important in the future. Interest in NOTES has declined because in its current form, it is too expensive and too complicated to provide any advantage over laparoscopic or open surgery. However, the potential advantages of endoluminal surgery are significant, and we would be remiss not to be involved as the technology improves. PCI was a “disruptive” technology that revolutionized the treatment of cardiac disease, and cardiac surgeons have largely been replaced as a result. If an endoluminal technique revolutionizes GI surgery, then those who already possess advanced endoscopic skills will be in the best position to move forward. Those individuals should be us.

Realistically, we should be the ones developing the advancements in the first place, because if we don’t, then someone else will. We need to take a page from the vascular surgeons rather than cardiac surgeons, to secure the future of the specialty. So, if you will agree with me that endoscopy is important, how, as residents, do we put ourselves in the best position to make endoscopy a big part of our future careers? I have been given some advice in this regard that I agree we all need to hear:
1. Log as many scopes as you can. It has been recommended that we perform 300 colonoscopies during our training to be considered “competent” to perform this procedure after graduation. This number seems ridiculous to many, considering how many active surgeons do very well with colonoscopy, having only completed a handful in their training. And why should we spend so much time on one procedure when we are responsible for learning so many more, of much greater complexity? The answer is that we need to do this for political reasons. A number like 300 clearly favours GI trainees, who will easily be able to achieve it, and it likely originates from GI academics whose careers have been made by endoscopy “quality assurance.” And although this is probably at odds with what’s best for the health care system, it’s the way it is, and if we don’t keep up, then we will be edged out. So, pick up community rotations or do extra scope days - whatever it takes to get to 300 (or as close as you can realistically get.)
2. Try to develop a breadth of endoscopic skills. Good examples include variceal banding and esophageal dilatation. Banding is a potentially life-saving skill that many surgeons are happy to defer to gastroenterology. That being said, how many places outside of major academic centres have a full complement of on-call gastroenterologists providing 24/7 coverage? Often the buck stops with the General Surgeon.
3. When you are out in practice, do endoscopy! This includes procedures like the ones mentioned above, with which many General Surgeons don’t feel comfortable and don’t perform in their practices. The more endoscopic procedures we stop doing because of “comfort levels,” the more endoscopy we will lose to GI.
4. We need new graduates with skills in ERCP and perhaps also endoscopic ultrasound. There are many surgeons across the province who do ERCP, and their training for this procedure varies from some extra time after residency to something they learned in residency to something they learned on the job. Now, it is expected that we learn this as residents or fellows, and it seems that only GI fellows are learning it. All HPB fellows should be training in ERCP (which is not currently the case) and some General Surgery residents should learn it as well, to provide coverage across the province.
5. We need General Surgery graduates to subspecialize in advanced endoscopy and take on this role in academic centres. This will allow us to be active participants at the cutting edge of technology, and it will ensure that we have an equal share in resources at the hospital level (a problem in Ottawa, for example). I feel that an advanced endoscopy fellowship would be an excellent way to market yourself to an academic centre, either by itself or in addition to colorectal or HPB.

Endoscopy may not be the most glamorous part of General Surgery nor the most exciting, but it is likely to be a big part of the future of GI surgery, and it will certainly pay off your mortgage and put your kids through college. If we hope to keep endoscopy within our scope of practice, we will need to be well trained and proficient right off the bat…which means a few extra days in the endoscopy suite!

As always, if there are any resident-related issues you would like to bring before the OAGS or discussed here, please contact me or the OAGS at info@oags.org or contact your local OAGS Resident Liaison:
McMaster University: Jennifer Li, PGY3
Ottawa University: Nikoo Rajaee, PGY4
Queen’s University: Mike Rizkalla, PGY4
University of Toronto: Debbie Li, PGY4
University of Western Ontario: Dave Paskar, PGY5

Kellen Kieffer, OAGS Resident Representative
PGY 5, General Surgery, Northern Ontario School of Medicine (NOSM).

Our specialty is in the midst of a job crisis. Unemployment issues, which started as new grads not being able to secure the job they wanted, have turned into new grads not being able to secure a job at all. A recent Royal College survey quotes our unemployment rate at 16% and going up fast. This is the most important issue facing surgical residents today and an issue of utmost importance for the future of our specialty.

General Surgeons rely on hospital resources and operating room time to serve the community. As these resources remain fixed, there is only room for a finite number of General Surgeons in our province. Training more will not have any impact on wait times or patient care; it will just produce more underemployment and unemployment. We are highly trained and highly specialized, so we cannot easily be made to serve the public in other areas of medicine. There are a limited number of openings for new full-time surgeons every year - openings created when older surgeons transition out of full-time practice (to retirement or something else productive). In Ontario, this number is about 15.

Our current job crisis was completely predictable. About 20 years ago was when we started training more residents than the magic number of 15, as stated above. Initially, this was not a problem. In fact, it was a big help, as we actually had a shortage of surgeons in the mid 90’s. But it didn’t take long to fill the deficit, and all the while, training programs continued to grow. There is every incentive for a medical school to take on additional residents. Every resident carries with him/her government funding that goes to the training program (in addition to the resident’s salary paid to the resident). Extra bodies means more hands to share the workload and cover the call schedule. More residents means more research output, bringing more prestige to the program. A larger resident contingent “buffers” against drop-outs. When union-mandated resident work-hour restrictions came into effect, however, the size of residency programs shot up even further.

Right now, there are over 50 General Surgery residents completing their 5th year in Ontario medical schools. Compare that to 15 annual retirements, and we are training over three times the number we need! As you can see with such a surplus of surgeons flooding the job market every year, our training system has quickly become unsustainable. We need to get back to a situation where we are training the number we need. That means significant cuts to residency programs. Accomplishing these cuts, however, has proven quite difficult. Though we have known about this problem for over 3 years now, relatively little has changed.

One of the major obstacles to necessary change is the misinformation that is circulating regarding manpower in our province. A popular myth is the idea that there is a large group of “baby boomer” surgeons delaying retirement because of the recent economic recession. On the contrary, the practising General Surgeons in Ontario comprise a very young group compared to the average physician with the largest proportion between the ages of 40-49 (data from OMA economics department). Another myth is that surgeons of the “new generation” are willing to work far fewer hours than their predecessors. Billing data demonstrates that this is false. After their first two years, new grad surgeons bill just as much (and therefore work as hard) as their older colleagues. Some advocate that the answer lies in the creation of new jobs and opening of new ORs. Unfortunately, just the opposite is occurring. As health care budgets tighten, physicians’ salaries are cut (eliminating the potential to job-share) and hospitals reduce OR time.

A second major obstacle is the fact that there is no national body to provide oversight and manpower planning. There are multiple stakeholders involved in the allocation of residency spots. We have the medical schools that actually train the residents, the provincial Ministries of Health that fund the training, and the Royal College which provides academic oversight (accreditation, academic standards) and licensing for new graduates.

To me, there is no question that major cuts to residency programs are going to be the ultimate solution to the job crisis. Some have taken the approach of trying to “make room” for the superfluous trainees such as job sharing, on-call coverage, assisting, working exclusively in “scope shacks” or walk-in clinics, etc. To me, this is a roundabout, backwards way of approaching the problem. Why should all surgeons suffer to accommodate a surplus? Why don’t we just train the correct number in the first place? When the job market is overwhelmed, there will be negative consequences even for those with gainful employment. Our negotiating power with the government will quickly erode and our income will be cut. Our perceived value in hospitals will decrease as General Surgeons become “a dime a dozen”. We will be competing within our specialty for patient referrals and operating time. Eventually, we will need to start advertising.

The unemployment crisis is not something that is limited to General Surgery. Orthopedics, Ob/Gyn, Urology, Plastics... all the surgical specialties are in trouble. This has all come about through poor manpower planning. We are also admitting too many medical students in the first place. The pendulum has swung wide in the opposite direction from the physician shortage of ten years ago.

What are the next steps? We need cooperation and, more importantly, action from all stakeholders - even though this may be difficult in the short term. There is no question that cutting enrolment to medical schools is the first step. General Surgery residency programs across the country will then need to reduce their numbers by 2/3. In Ontario, we should have between 15 and 20 residents per year. For example, the University of Toronto currently admits 14 on their own. This will need to be reduced to about 5 or 6, with similar proportional reductions in other programs. The workload previously shouldered by these residents will need to pass to other healthcare professionals. This could include new staff positions (possibly acute care surgeons), surgical hospitalists, nurse practitioners or physician assistants. On a national scale, we will need to continually reassess the manpower situation and develop projections for future manpower needs. I feel that the Royal College is in the best position, as a national body, to take on a leadership role in this regard and in fact they have already made specialist unemployment a priority going forward.

The Royal College will be organizing a national summit on physician unemployment, tentatively slated for February, 2014. I hope that this will be a launching point for some real action in this matter, because it is a major issue for physicians across the board. The OAGS would welcome any discussion from its members about the job crisis going forward. But most importantly, I hope this issue stays in the forefront of everyone’s mind so that it can be dealt with and the future of our specialty can be secured. As always, if there are any resident-related issues you would like to be brought to the OAGS or discussed here, please contact me or the OAGS at info@oags.org or contact your local OAGS Resident Liaison:

• McMaster University: Jennifer Li
• Ottawa University: Amber Menezes
• Queen’s University: Mike Rizkalla
• University of Toronto: Debbie Li
• University of Western Ontario: Dave Paskar

Kellen Kieffer, OAGS Resident Representative
PGY 4, General Surgery, Northern Ontario School of Medicine (NOSM).

There was a time when a general surgeon would be the go-to person for all your surgical needs. Needed a hip pinned? Get the general surgeon. Aortic aneurysm? The general surgeon will handle it. Caesarean section? You guessed it. There are some places in the world where this is still the model of care – and, in fact, some places in our country and our province. However, in the vast majority of cases over the past six decades, we have seen a continuous trend towards specialization and narrowing of focus in surgery and in medicine as a whole.

The common opinion seems to be that this is driven by public demand. As the depth of our knowledge expands, individuals need to narrow their focus in order to retain the standard of “expert”. And these days, the public demands the best and so we must subspecialize in order to deliver it. Interestingly though, there is no evidence that the public or its demands played any part in the changing structure of the medical field. Alternately, it seems to be something coming directly out of the academic centres. Specialists with deep expertise have ruled the roost in the last 60 years – not only in medicine and surgery, but in most professional domains such as academia, law, finance, and economics. In order to advance one’s career, it was most efficient to specialize. In other professions and in the business world especially, we have more recently seen a backlash against “domain expertise” in favour of generalists who are better able to deal with a complex global economy and are proving to be more effective. We have not seen the same thing in surgery, but would it be the better way to go?

There is evidence to support specialization in medicine. But there is also fairly robust data to support the generalist, both within medicine and more abstractly. Several studies have shown that generalists are better at navigating uncertainty, which is still important in modern medical care, despite advancements in knowledge and technology. The largest of these studies was performed by Philip Tetlock over a 20+ year period. He tested the ability of professional forecasters in many domains to predict occurrences within and outside their area of expertise. He found that generalists vastly out-performed specialists, even within their area of specialization. He concluded that specialists tend to get very focused and efficient with the usual presentation but don’t perform as well when things deviate from the norm. From the medical literature, generalists tend to be better diagnosticians. They tend to be more resourceful problem solvers and produce more innovation, and they are more cost-effective in both single-payer and private health care systems.

More practically, general surgery in rural and remote places not to mention many community centres, is a generalist practice. Case logs from these practices indicate that the workload has not changed as compared to a decade ago. These surgeons are still performing many of the common cases such as carpal tunnels and ganglion excisions, saving their patients from year-long wait lists at tertiary centres.

In Canada, surgeons are not being trained as generalists any more. This is certainly illustrated in a survey of 5th-year residents across Canada which just came out in the American Journal of Surgery recently. Comfort levels were extremely low for procedures not normally performed by general surgeons in teaching hospitals (lower limb fasciotomies for example) but which would be expected of a general surgeon outside of the city. And further down the page you read that over 50% of these graduating residents intend to practice in the community and 25% in rural centres!1 Surgical education is at a crossroads right now. As people are realizing that the traditional models of training may not be well suited in today’s environment, changes are on the horizon and particularly the move to a “competency-based curriculum”. For those of you not familiar with the concept, competency-based training aims to define a specialty by a discrete number of observable abilities, termed competencies. A resident’s training will be deemed complete when he or she is able to demonstrate a minimum standard in each of the competencies in his or her specialty. The problem in general surgery is, how do you define the specialty when it varies so much from setting to setting? There is a danger of establishing a narrow set of competencies based on the work common to all general surgeons, rather than a wide set of competencies based on the true breadth of the specialty.

I believe that general surgery suffers as we gradually drift away from our generalist roots. The surgeons practicing today have benefited from a strong, well-rounded residency which prepared them to practice in any setting. Those who have subspecialized after residency have also benefited from this solid grounding. Certainly, this has provided them with the skills and versatility needed to deal with complex cases and unexpected intraoperative situations that inevitably come up even in their focused practices. If we must transition to competency-based training, I would urge the schools to establish a broad range of competencies for general surgery residents. I hope this would include things like skin grafts and vascular anastomoses that would normally fall under the domain of another surgical specialty. And I believe it’s not just those ending up in rural practice who would benefit, but all of us.

If they’re going to call us “general surgeons,” let’s make sure it continues to be for a good reason. As always, if there are any resident related issues you would like to be brought to the OAGS or discussed here, please contact me or the OAGS at info@oags.org or contact your local OAGS Resident Liaison. (see below)

1Gillman LM, Vergis A.- General surgery graduates may be ill prepared to enter rural or community surgical practice, Am J Surg. 2012 Jul 30. [Epub ahead of print]
Kellen Kieffer, OAGS Resident Representative
PGY 3, General Surgery, Northern Ontario School of Medicine (NOSM)

There has been much talk across the country in recent years surrounding upcoming changes to residency education in all specialties. Models of training residents across the disciplines are in flux, and programs are looking outside their fields and home countries for the “best” way to train residents. In Ontario, the current resident contract with the Professional Association of Internes and Residents of Ontario (PAIRO) is expired and under negotiation. It is predicted that the new contract will place new and more stringent limitations on resident work hours in Ontario. Surgical programs will not be excluded from these limitations.

Work Hours Restrictions
The issue of resident work hour restrictions in North America came to the forefront of the public press in the United States in 1985, when Libby Zion died in a New York City hospital after being treated by interns and residents for an unknown febrile illness. This young woman’s death prompted legal action, which attributed errors in the interns’ decisions to a lack of appropriate supervision by attending physicians and perhaps lack of sleep. A subsequent report by the Institute of Medicine concluded that resident fatigue was a significant health issue affecting both patients and the residents themselves. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) put into place national restrictions on weekly work hours for residents in the United States. In Canada, work hour restrictions for trainees vary by province and are set by provincial residents associations’ contracts. Recently, changes to the Quebec resident contract have resulted in stringent work hours restrictions in the province, including a 5 consecutive work days restriction, and a 16-hour work day restriction. That is, a resident may not work the day and then stay overnight for call, or work the week and then continue on as the weekend on-call resident. Many predict that similar restrictions will be implemented in the upcoming contract in Ontario.

Sleep Deprivation
Clearly, restricting work hours and achieving adequate training may be competing issues. Data on the impact of sleep deprivation on patient outcomes widely varies in the medical and sleep literature. One finds as many studies showing a detriment as those that show no impact. It is clear that surgical residents, when compared to the general population, have higher rates of chronic sleep deprivation and psychological distress. Many argue though that the surgical resident is not the same as other types of residents. The surgical resident is perhaps self-selected to be more resilient and less at risk to be affected by physical and mental fatigue. There is, in fact, some data to support this theory! Interestingly, in population-based surveys, public opinion would favour both residents and surgeons working significantly fewer hours than is current practice. One also wonders if trainees are working shorter hours during residency, will they then expect to work shorter days and do fewer calls once in surgical practice?

Maintaining Quality Training In a Restricted Model
The over-arching goal of any residency program is to produce competent surgeons capable of independent practice. Data from the United States is now available, as the first generation of residents training under 80-hour work week restrictions have now completed residency. Many new models have been implemented to include night float systems, increased use of surgical hospitalists and nurse practitioners, and simulation programs. There is hope that quality may be maintained as more restrictive work hours limitations become mandatory in Ontario. With proper foresight and modifications to the training model, operative volumes and test scores can be maintained. One cannot simply cut out training hours. Many centres in the United States have successfully maintained or increased case volumes by streamlining resident activities during their time in the hospital. The reality is that new resident work hours restrictions will soon be a part of Ontario residency training. They will likely universally apply to all disciplines. Surgical training programs must be proactive and look to national and international solutions that have been successful to ensure that future residents receive quality training. Surgical residents want to be excellent surgeons, and the restrictions placed on their training by PAIRO must not be misinterpreted by mentors and trainers as lack of motivation. We must work together to maintain quality in our volume-important surgical specialty training.

As always, if there are any resident related issues you would like to be brought to the OAGS or discussed here, please contact me or the new Resident Representative at info@oags.org or contact your neighbourhood OAGS Resident Liaison. (see below)
Julie Ann Van Koughnett, OAGS Resident Representative
PGY 5, General Surgery, University of Western Ontario