California's medical schools may be inadequately preparing future surgeons because a high proportion—nearly one in three— require remediation programs, including having to repeat a year of training, according to a report in the Archives of Surgery.
The research paper finds that 31% of 348 general surgery residents in six California medical schools required additional studies or attendance at conferences or had to repeat a clinical year.
While 15% of the residents in the study cohort were lost to attrition, nearly all left voluntarily, however, and that 15% is somewhat lower than in other studies of surgical residency programs.
"The take-home message is in some respects a positive one in that yes, the rate of remediation is high," says senior author Christian de Virgilio, MD, "but if you look at when this occurred, most residents required it in their first or second year out of five, and by identifying this and putting them in a remediation plan, we were able to successfully get them to graduate. In addition, most of them were able to pass their boards on their first attempt."
De Virgilio, the director of the general surgery residency program at Harbor-UCLA, notes that an anomaly in the researchers' findings is that students who received an "honor" recognition during their six to 12-week surgical clerkship were more likely to need remediation than students who did not receive that honor.
"That's counterintuitive," de Virgilio says, and may point to the need to re-evaluate the measures used to determine who such recognition. Also predictive of a student having to adhere to a remediation regimen was a relatively low score in the US Medical Licensing Examination, Step 1.
The fact that 31% of surgical residents needed additional help, however, puts a burden on these academic medical institutions.
The report looked at surgical resident training between 1999 and 2010 at Harbor-UCLA, the University of California Davis Medical Center, Loma Linda University, Stanford University, Cedars Sinai Medical Center, and the University of California Irvine Medical Center
The researchers wrote that the rate of remediation is of concern because it is several percentage points higher than similar studies of this type.
"Resident remediation places additional strain on the program director and entire clinical faculty," they wrote. It may complicate patient care, load more work on other providers, increase the need for communication and faculty supervision.
De Virgilio says an open question is whether the 80-hour work-week limitation for such medical school trainees is to blame. The researchers did not compare periods before that limit took effect in 2003. But de Virgilio says it raises an important question about whether the end result may be that "our surgeons in the future come out of these programs with the same amount of training as in the past."
But he and his fellow authors wrote that the 31% remediation rate for these residents is "surprising given that the resident cohort was a relatively high-achieving group," which picks the top students from high school and undergraduate institutions.
Additionally, de Virgilio says, "California has one of the more competitive areas for surgery in the country and surgery is one of the more competitive fields in medicine, so we have the fortune to be educating the top students of the future. I would say that the vast majority of them are very trainable, they have the intelligence and skill. It's just a matter of carefully trying to tweak them to get to that point."
For students who required remediation, nearly three in four were found to have significant deficiencies in medical knowledge rather than any of the other five competencies on which their competencies are judged.
In an invited critique in the same issue of the journal, Karen Deveney, MD, of the Department of Surgery at Oregon Health & Science University in Portland, asked:
"These surgical residents were a smart, high-achieving group of people. Why did so many stumble during residency and require remediation? The authors suggest deficient preparation during medial school for the rigors of surgical residency, inadequate education during residency, or the increased efficiency needed to compress required tasks into a shorter timeframe with decreased work hours.
"All of these are likely contributors." She added that these residents must care for patients who are sicker and more complex than in the past and fast-track them through the system.
"There is little time in the work day for contemplation or for learners who require a bit more time to master concepts or skills."
She called for the a renewed effort for educators to create systems that "eliminate nonessential tasks so that residents can devote more attention during the compressed work hours to learning what they need to become competent surgeons."