Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, November 23, 2006


Stop the presses! A conviction I have held deeply for quite a long time has been effectively challenged, thanks to Dr. Sid.

Here is the excerpt (full post here) that got me thinking:
Sick and brutal as it may be, the constant haranguing of trainees -- the endless reminding them that they know nothing, that they're a bunch of screwups, that there's a chain of command they must follow, that if something goes wrong they are responsible -- all that stuff that's unique in its severity in surgical training makes for a deep and abiding sense of limits. More than anything else, that's what keeps patients safe and their doctors out of trouble.
Wow. He's right.

Until the moment I read this, I felt strongly that the inhumanity of surgical training was nothing but gratuitous hazing that was unnecessary at best and cruel at its worst. What good could possibly come of brutal head games? What does humiliation and browbeating have to do with acquiring surgical judgement and skills?

I won't go so far as to say, "Now I get it." I will say that I better understand that one of the results of this training is recognition of one's limits. Apparently it works. I still wonder if it's really the only way to inculcate these values, or even, if there are other ways, whether it's the best. How would we know? Generate a "new paradigm" in surgical training, randomly assign trainees to one or the other, then compare how much trouble they get into once they're out in practice? Yeah, sure.

Still, I do believe the harshness of the training would be more palatable if it were made clear from the outset that this treatment was not personal, but that the internalization of limits was the true goal. And for what it's worth, the present system does not appear to work flawlessly. There are still far too many stereotypically arrogant and personally dysfunctional surgeons around who I'm sure were harmed more than they were helped by the abusiveness of their training.

But thanks, Dr. Sid, for the first rational justification for surgical training I have ever heard. You have given me a lot to think about.


At Thu Nov 23, 03:55:00 PM, Blogger 593 said...

It sounds like a longer version of the Army's "basic training."

Anyhow, I just stopped by to say "HAPPY THANKSGIVING!"

(Now go eat some turkey . . . sheesh)

At Fri Nov 24, 08:27:00 AM, Blogger MedStudentGod (MSG) said...

Actually the surgical residency does have some historical tracings in basic training.

William Lewis Halsted advocated that residencies for surgical training should follow a very rigorous and demanding course akin to basic training for the army in order to train surgeons.

The process has lessened in the years, but it's still apparently quite draining.

Hope you had a good Turkey day.

At Fri Nov 24, 12:35:00 PM, Blogger Sid Schwab said...

Thanks!! I mean it in all seriousness; knowing one's limits is the eye of the storm. Hearing alarm bells is what keeps us -- as long as we listen -- from veering too far into danger. I don't think I necessarily appreciated it in full at the time, but as I trod the path I came to understand. I intend to post about the opposite side of the coin, the observation of which is what led me to realize the value of what I'd been through...

And I'm not certain, in reference to your thoughts about it, that it's not personal, in fact. If my profs were indeed committed to making me a competent and safe surgeon, and to inculcating boudaries by which I'd stay out of trouble, it could be seen as deeply personal. Like you, I wonder if it has to be so brutal (in fact, I sense it no longer is, and I wonder about the consequences); all of my mentors were highly demanding. Not all were a$$holes.

At Sat Nov 25, 11:15:00 AM, Anonymous Anonymous said...

Likewise, I think it can be said that Family Medicine training is probably too much of the opposite of surgical training. The lack of rigor and the overwhelming "touchy-feely" attitude in many of the residency programs has produced too many family physicians who practice at the level of nurse practitioners. Perhaps that is one reason why the specialty is slowly dying and will probably give way completely to mid-level practitioners in another generation.


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