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Judgment and Experience

July 28, 2010

Good judgment, it is said, comes from experience.  And experience, in turn, comes from bad judgment.

In a true sense, this principle is how we trained our surgical residents for nearly a century.  They were primarily responsible for the patient’s care, including their surgical procedures.  Experienced attending surgeons were available to assist or guide the resident when the need arose.  But mostly, senior residents taught and supervised junior residents, and junior residents taught and supervised interns.  Because of their responsibilities, surgical residents had to make decisions they could justify, and they were accountable for any poor decisions they made.

This all changed between the 1980s and the 1990s when Medicare refused to pay attending surgeons who weren’t physically present during operations.  This produced a paradigm shift in medicine, providing significant cost savings for the Medicare program.  Yet, it crippled the educational value of surgical residencies.  By making the attending physician be physically present for every operation, the resident is no longer in a position to make independent decisions.  In most cases, the attending calls all the shots, leaving the resident as an assistant or even an observer.  Surgical decision-making and judgment are no longer being learned to the same degree.

Consequently, many surgical residents finish their training feeling unqualified to practice on their own.  Some opt for fellowships in order to gain more experience in a supervised environment.  Once they have completed their training and enter practice, however, they often state that it took them 5 to 7 years of practice – which is, coincidentally, the range of time spent in most residencies – before they felt entirely comfortable as an independent operator.  It’s really too bad they couldn’t get that training during their residency, where they had actual supervision and support.

It’s true that we’re talking about patient care.  And in previous eras, we let incompletely trained and experienced physicians manage those patients more independently.  But how should these young physicians gain their experience?  How else can they acquire the ability to exercise good judgment under pressure?  Should this happen when they are out on their own, trying to build a practice and recruit patients when they have no structured supervision?  Or should it be during their residency program where those financial pressures do not exist and attending physicians are built-in as available resources to supervise and guide them?

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