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    Surgical residency: Swap the white coat for a scarlet letter?

    Dr. Winter is chief resident in urology at Weill Cornell Medical College in New York. Follow her on Twitter at @AshleyGWinter.

    I am currently a chief resident at a high-profile academic institution in Manhattan. 

    Two populations are at odds in that environment. At an “academic institution,” house-staff training is imperative. At a “Manhattan institution,” we garner some high-intensity clientele who envision medicine as one more in the litany of service industries they consume. As a young doctor growing up in a Manhattan teaching hospital, I am not new to the patient who finds my presence undesirable. With no qualm (and in my earshot), these patients tell attendings, “I don’t want any residents to do my surgery.” With patience and honesty, my mentors respond, “I cannot perform surgery without assistance.”

    We move forward, the cases get done, and the patients receive (dare I say) excellent care. My sense of propriety, of deserving my education, is unscathed. I know I am supported.

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    But there is a growing and dangerous turn in how the medical community envisions surgical training. In what I consider “dogmatic anti-paternalism,” we may be unfurling a slippery slope that undermines the belief that surgical residents deserve their education.

    Let me explain. This past June I read a New England Journal of Medicine editorial titled “Breaking the Silence of the Switch-Increasing Transparency about Trainee Participation in Surgery” (2015; 372:2477-9). The article, written by an ophthalmologist (but intended to address all surgical specialties), is a thoughtful treatise that suggests patients should meet the resident involved in their case at the time of consent (generally an outpatient setting). Trainee participation is referred to as “a struggle… with… a fiduciary commitment to patient care,” and proposals are made for “mitigating and identifying outcome deficits” associated with surgical teaching.

    Aside from the logistical difficulties inherent in predicting which resident will assist in a case (oftentimes before they are scheduled), the entire article is belied by a fundamentally flawed argument. The author implies that somehow, trainee participation in surgery is deceptive. But this involvement can only be deceptive if surgery can be performed in isolation, if trainee participation is not an organic part of academic center operations.

    NEXT: "Are surgical residents less a cog in the wheel than any other part that makes the engine roar?"

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    • Anonymous
      This commentary by Dr. Winter is nothing short of excellent. As a surgeon, I am still fortunate to have many patients who are simply grateful to receive timely access to good care, but there is a growing trend toward a shared decision making (and consenting) approach that borders on excessive. It requires not a small sense of entitlement as a patient to make your preferences for music, personnel, and even suture material known to your surgeon in advance these days. Rather than trusting in the abilities of the surgeon, and his or her judgement in selecting his or her team and equipment, some feel justified in involving themselves in every detail of their care, whether they have the expertise to do so or not. The most disappointing part of the overheard conversations that Dr. Winter reports is that, if these people don't want residents to assist in their care, the implication is that someone less important, less valuable than themselves should bear the "brunt" of physician education. Not only is that arrogant and unfair, but it also has the not-too-subtle hint of elitism as well. Thank you, Dr. Winter, for your article.

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