Currently on the sub-I trail and disenchanted with what I’ve seen from majority of faculty. At both places I’ve been, the majority of faculty don’t give residents much autonomy — in many cases, just seems like they’re used as an overqualified suction holder and occasional bovie handler. Even being able to open without the faculty scrubbed in is reserved for the chiefs and that has been rare. Rarely are they the ones handling the drill.
Is this just the standard everywhere due to fear of mishaps/trying to get through cases quickly? I understand you can’t just let the residents go loose and make mistakes but it seems like there should be some actual teaching going on and letting the resident learn from experience in some low stakes scenarios (eg, junior resident learning how to expose the lamina in a spine case). They could be learning so much faster this way. I want to shoot for somewhere like this — where I’ll understand through my own experience the ins/outs/nuances - rather than just some picky attendings variation without explanation. Anyone have a list?
This isn’t all faculty with this approach, but at both places it’s been the majority. I feel 7 years is too long to spend mostly as a glorified first assist and want to avoid having to do a fellowship just because I was never given legitimate operative experience.
To my knowledge, both of these places are regarded as clinically strong. I won’t name them to avoid being identified.
Can you at least tell us if these programs are considered top 20 on this forum.
This is why SubIs are important. We need to be honest about these things, unlike the degenerate above. We’ve all seen what attendings who’ve trained at such programs are like. Nervous wrecks, it breeds more insecurity and less autonomy for their residents.
Pay attention in the OR. Go to a program where the chief acts like the attending. Come graduation its all on you.
Is Iowa a good program? It seems they have only 9 faculty, one of which is retired and a fair number that aren’t even trained in the US.
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06-15-2023, 08:20 AM
(This post was last modified: 06-15-2023, 08:21 AM by Focus.)
Autonomy across the board is diminishing. There is no one specific reason for this. It's a combination of pressure by hospitals to produce as much as you can as quickly as possible with no complications, increased competition in areas with academic centers, patient expectations, litigation risk, and the fact that ultimately a grueling 7-year surgical experience is out of style. If the average competency of residents decline's due to doing less cases and getting to do less of each case then it becomes somewhat of a deadly cycle where the amount attendings let residents do becomes less because of that decreased competency. The irony is all we are doing is pushing those critical learning experiences into the independent practice phase. You have to take the pain sometine and if we as a culture or no longer willing to get our lumps during residency then we will get them in practice. My advice is seek out jobs where you have a senior partner who is willing and able to help you continue to develop as a junior attending. Even if you lose a few RVUs over it in the long run, it will be worth it and safer for your patients.
PS fire up for a 60 hour maximum work week. Brought to you courtesy of the ACGME very soon.
About to head into sub-Is as well but I've seen similar things happen in other surgical fields. I've seen PGY3s in gen surg triple scrub with a fellow and a chief on a lap chole and ultimately, doing nothing more than opening and closing.
Please tell me the 60 hour work week is a joke
Senior resident here. This is not a standard everywhere, certainly not at my program. Unless you're dying to be in academics or have a basic science lab, i would recommend ranking these big name academic/research programs lower. In most programs, you don't operate much intern year and then these research-heavy programs make you do 2 entire research years within your residency So you have 4 years to learn how to be an attending while managing triple/quadruple scrubbing, plus fellows, plus the in-bred attendings being hands on and all the stuff you mentioned. Columbia is a great example of this issue that's frequently talked about on this forum and it's no surprise their graduates need fellowship+several years of mentorship by senior attendings to get on their feet. And yet it's somehow a highly desired program for med students.
Choose operative-heavy programs where you see residents doing enfolded clinical fellowships and a good mix of grads going into fellowship plus private practice jobs off the bat. "Operative-heavy" programs that get talked about a lot here: BNI, USC, Udub, Miami, UPMC. You should look into areas with a less litigious environment. On average, I'm sure the residents in states like Alabama or Texas get to do more than those in California and New York. There are also a lot of medium-size 2/yr or 2-3-2/yr underrated programs that don't get mentioned much on this forum but will train you very well. My program is never talked about on this forum yet the autonomy we get is excellent. Not letting junior residents exposed the lamina????? That's wild to hear, our attendings rarely even scrub for that part. The mid level and senior level residents teach the interns+juniors that at my program.
To answer the original question, I would say the degree of autonomy witnessed at those particular institutions seems quite bad. At every institution there are attendings who do the entire case, but in general a chief resident should be doing everything before and after dura is open/closed with independence and ease. For cranial cases, the appropriate amount of intra-dural work will obviously depend on the case, and as a sub-I it is hard to determine what a resident should or should not be capable of doing. One metric I think is useful is scope time, I.e., how long does a chief resident get to work under the scope. If that time is consistently zero, I’d say the degree of autonomy is poor. For spine cases, residents should be exposing/closing and hopefully putting screws on their side of the spine at minimum. In general the degree of autonomy granted in spine cases is usual higher, and at many places senior residents will do spine cases skin to skin. My perspective having seen two well regarded programs as a resident and fellow.
During my sub-I at Hopkins, I heard the junior residents claim autonomy when they were only opening, suctioning, and closing, similarly when I went to mayo az.
