Length of surgical residency programs.

D Waddell and I are delighted with the discussion and correspondence that has resulted from the Editors’ View “Education versus service — the resident’s dilemma?” (Can J Surg 2000;43[5]:326-7). Opinions and thoughtful approaches have fallen on both sides of the issue. One of the principal questions arising from the editorial relates to the length of the residency program. Is the program long enough to teach the specialties’ purely clinically oriented curriculum and the evolving curriculum (i.e., what gets added on)? The clinical curriculum in all procedure-based specialties (all of surgery) is expanding as new solutions to old problems become available, new technology begins to insert itself and new techniques are added without the equivalent elimination of older approaches to the clinical problem. The prime example from general surgery is cholecystectomy. In the last decade, laparoscopic cholecystectomy has almost completely replaced open cholecystectomy in the elective setting and largely in the emergency setting. Yet to safely serve their patients, general surgeons must learn how to do both procedures. We must ask ourselves, how many of these instances can a 5-year program absorb before it should become 5fi or 6 years? The American Board of Surgery has recognized an enlarged curriculum and had recently increased the clinical training period from 4 to 4fi years, thereby eliminating the “research year” option. Cardiovascular and thoracic surgery was a single specialty well into the 1990s. It is now 3 specialties, with all residency programs being 7 years long. It is therefore hard to believe that the program before separation was long enough to cover the desired curriculum. With respect to general surgery and to orthopedics, Should the program length be the same for an academic surgeon as for one who will work in a medium-sized town where he or she will be expected to know all the answers and do most procedures locally? In both the United States and Canada similar events have expanded the curriculum along the lines that Dr. Wright in the February issue (Can J Surg 2001;44[1]:65) argues as very important. Of the 6 competencies of the American Board of Medical Specialties, 2 are highly clinical but 4 relate to systems, professionalism, communication and continuous professional development. They run quite parallel to the Royal College of Physicians and Surgeons of Canada’s Can MEDS 2000 project and the maintenance of certification program. These curricular thoughts are “top down” in the US (i.e., for practitioners and moving to residents), and in Canada they are “bottom up” — for residents and now demanded of practitioners. So let me return to the question of time. Time is about the only commodity that we have left with which to manipulate our own lives. Time management is crucial to sanity and productivity. Is there enough time in the procedure-based specialties — I remind you that the way to Carnegie Hall is by Practice — to learn the procedures well and the cognitive and Can MEDS 2000 material? I doubt it. But then I have finished my residency and approach the latter stage of my career — and therefore I can say these things.