While questions about experience can be uncomfortable for new surgeons, Nirmish Singla, MD, believes the process of mastering procedures is invaluable to conveying the confidence necessary to help patients feel comfortable.
“How many have you done?”
This question is likely familiar to most surgeons. For those in training or those early in their careers still building volume, it can be an uncomfortable one to answer while trying to convince a patient to consider intervention.
Rather than perceiving this inquiry as one intended to challenge a surgeon’s skill and expertise, however, it is worthwhile to recognize that no patient wishes to be a guinea pig. After all, our profession demands that patients entrust their lives to us and surrender their bodies to allow us to cut and intervene on them to our discretion. It is hence no surprise that patients would seek confidence in their surgeon prior to allowing them such a privilege, in much the same way a passenger on a flight trusts his or her pilot. And just as a pilot is required to reach a certain number of flying hours before he is deemed competent to fly, urologic surgeons must achieve a number of training milestones as well.
In an academic hospital, there is a mutual expectation that trainees are to be involved in the surgical care of patients. While most patients seeking care in this setting understand this necessity-and we are, indeed, indebted to them for our training-there are inevitably those for whom this idea is unsettling. Of course, every surgeon has to start somewhere.
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In his book, “Outliers,” Malcolm Gladwell popularized the notion that mastery of any field requires 10,000 hours of practice. The challenge of residency-and undoubtedly the reason for its duration-is learning how to be competent. While obtaining a fundamental knowledge base relies heavily on independent reading (also see, , becoming adept in the operating room relies entirely on practice.
True, there are surgical atlases to read, videos to view, and surgical simulators to use. But without directly handling tissues, finding and dissecting the right planes, appreciating aberrant anatomy, and troubleshooting unanticipated complications, one’s surgical training can never be adequate. The classic “see one, do one, teach one” mantra of mastery is perhaps a bit of an understatement when interpreted literally, but it alludes to a similar point, in that in order to master a particular procedure, one must, at the very least, feel comfortable directing a novice through it.
Urology is a unique field in that it entails a wide breadth of surgical experience including endoscopic, laparoscopic, robotic, and open approaches. Different surgical cases are felt to have different learning curves, and there is a gradation of “level-appropriate” cases throughout training based on the perceived case complexity. The Accreditation Council for Graduate Medical Education mandates that a minimum number of cases of each type are performed in order to graduate from training, just as the pilot must surpass a specific threshold of flight hours. While the council derives these numbers based on a perception of what constitutes a reasonable learning curve, it is difficult to standardize operative competency across all trainees based on a single metric.
Next: "Maximizing exposure to the operating room is of paramount importance"
Nonetheless, it is fair to say that in the limited 5 to 6 years allocated to residency (the days are long, but the years are short), maximizing exposure to the operating room is of paramount importance before beginning practice. One of the primary goals of training is to achieve autonomy in one’s own operative abilities and overcome self-doubt. There will inevitably be a challenging case, complication, or suboptimal outcome along the way that will keep us humble and curb overconfidence, but repetition and practice are the key ingredients to mitigate such surprises.
That being said, it is plausible that the operations being learned by today’s residents may be very different from those they will perform in the future. With the constant emergence of new technologies and techniques, this is not an uncommon theme. Perhaps the most striking example is the evolution of the surgical management of prostate cancer. Whereas graduates from 15 to 20 years ago are well-versed in open radical prostatectomy, most residents today are performing this procedure robotically and have less familiarity with the open approach than their predecessors. Developing a solid fundamental surgical skill set and understanding of surgical anatomy enables one to adapt in a rapidly changing field, and also helps to convey a confidence that can help the patient feel safe and more comfortable.
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Lately, there has been growing concern over concurrent surgical cases booked under the same attending surgeon. In the academic world, this is often made possible by the assistance of residents and fellows, with the expectation that the attending surgeon be present during the “critical” portions of the case. Patient safety and outcomes are of course the primary goal of any intervention, but there must be some balance with training the next generation of surgeons under appropriate supervision.
So how does one who is less experienced command trust from patients that would benefit from surgery? First, let patients take control of their own decisions. Be clear about the alternatives to surgery, but be forthright about the risks and benefits of each option so they understand the potential consequences of their decision. Patients generally appreciate transparency. Become knowledgeable about contemporary literature surrounding the relevant disease processes and be able to quote the evidence when counseling patients. Finally, for trainees especially, being honest about your role as an ancillary yet valuable member of the surgical team can go a long way.
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