Issues in General Surgery Residency Training—2012

The operations which are done by general surgeons, and the way in which they are done, have undergone radical change during the last 2 decades, yet the impacts on residency training have not been generally recognized. The change has come about because of 2 principal factors—evolutionary and technological changes, which have occurred in the treatment of several common diseases, and the conversion of a major proportion of abdominal surgery from an open to a laparoscopic approach. In addition to the change in the nature of the surgery done, the impact of the 80-hour workweek on resident experiences with urgent and emergent conditions has also been significant. The impact of this on the development of resident independence and autonomy has not been analyzed. This article will attempt to describe qualitatively the nature of the changes, the negative impacts on resident training, and some proposed measures to mitigate the impact. ENVIRONMENTAL AND TECHNOLOGICAL CHANGE IN DISEASE MANAGEMENT Four common disease categories, which involve intraabdominal pathology, have undergone major technological change in management during the last 20 years. Benign Peptic Ulcer Disease Benign gastric and duodenal ulcer disease has been a staple of general surgical management for decades, for treatment of the complications of bleeding, perforation, and intractability. Three advances in medical treatment have markedly altered the incidence of these complications, and the consequent need for surgical intervention: H2 receptor blockers, proton pump inhibitors, and treatment of Helicobacter pylori gastric infection. As a result of medical management with these 3 modalities, intractability of ulcer disease has virtually disappeared, and perforation and hemorrhage have been markedly reduced. The result is that surgery is infrequently necessary today for treatment of peptic ulcer complications and resident experience with gastric surgery is largely limited to malignancy and other less common conditions. Interestingly, the increase in laparoscopic bariatric surgery has provided the bulk of a typical resident experience in gastric surgery in recent years, but exposure to these procedures is highly variable, and residents are rarely the operating surgeon in these complex technical procedures.