July 1 marks the beginning of the medical school academic year in Medicine. Newly minted medical graduates begin their residency, those in the midst of their program advance one year in seniority, and those who have completed their program move on to practice or further training in a specialized field. That final point is a real change from my residency days. Yes, some finishing their general surgery residency then transitioned to a specialized surgical residency program such as thoracic surgery, my own choice. The great majority of those finishing their five-year general surgery residency, however, simply began to practice general surgery, usually by joining an established group or beginning an academic career by joining a medical school faculty. It’s quite different now.
A marked change is that the majority of graduates of general surgery residencies now enter a year of further training rather than directly starting their practice. Why this change? This new pattern is an unanticipated result of changes in the rules established by the body that governs residencies, the Association of American Medical Colleges. In its wisdom this body introduced regulations limiting the number of hours—both total and consecutive—that residents could work. This action was aimed to reduce the effect on residents of insufficient sleep so that fatigue would not impair their clinical acumen and this in turn would improve patient care. What resulted? All studies of the effect of these regulations have failed to identify any impact on the quality of care. On the other hand, the diminished operative experience caused by the time restrictions has resulted in graduating surgical residents whose lack of confidence in their skills has created the need to acquire further training and operative experience before taking on the responsibility of their own independent practice. Some enter true specialty programs. Many find unofficial fellowships. All spend at least one year more in training than they bargained for when residency began. Nobody is really better off.
