Residency reform Halsted-style.

The current structure and principles of surgical residencies in the United States originated from reforms begun by Dr William Halsted a century ago. The benefits of Halsted’s reforms over apprenticeships and other unregulated training experiences were to add structure, uniformity, and quality. A pyramidal structure with a large number of interns and junior residents and a few senior residents became the rule. Although residency pyramids have largely been abandoned, few other changes have occurred in the past 100 years. Currently, residents are divided into teams named after a particularly prominent surgeon, a color, or a number. A senior or chief resident who is answerable to the attendings on that team has charge of the team and uses the junior residents on the team to get the work done. The residents on that team must look after every patient assigned to that team regardless of number. The senior resident has the opportunity to have a prominent role in the lives of the more junior residents and often is more of an influence on their training than the attendings. This organization has allowed surgical residencies and medical centers to coexist and flourish for many decades. Academic and community surgeons participating in surgical residencies benefit because they do not have to supervise a surgical trainee’s every move, and their involvement in postoperative care can be supervisory only. Time that a private practice surgeon without residents spends in postoperative care and paperwork can be spent by the faculty surgeon in research or in operating on additional patients. Surgical residents benefit from a system that makes sure their training is adequate and gives them graduated responsibility. Residents working as teams have the opportunity to develop camaraderie that can, in the best circumstances, provide social support during difficult years. Medical centers and surgeons benefit from the government-supported residents providing a great deal of professional service. Slowly but surely, however, a significant percentage of the general public, politicians, bureaucrats, nurses, surgeons, and residents in this country have come to believe that there is something inherently wrong about a system that works residents exceedingly long hours, pays them so little, and expects so much of them. What has changed that has placed Halsted’s reforms in disrepute? For one, modern surgical care is logarithmically more complex. The amount of medical and surgical knowledge that surgical residents of today are exposed to and expected to retain would probably overwhelm most individual attendings. I often marvel at how experienced our residents seem to be at taking care of complicated liver transplant patients. But I have also operated with chief surgical residents who had never heard of Cope’s five signs of appendicitis. Much has also changed for attending surgeons participating in residency programs. Money is very tight. In spite of having residents to streamline our programs, we scramble to perform the necessary maneuvers to capture every possible patient care dollar. Government audits of medical records and the threat of future audits send us more frequently to the patient’s bedside and to the chart to prove our direct supervision than in years gone by. At our institution, faculty-driven care was born not so much from the realization that residents needed better education or the patients needed better care than by the fact that payment for medical services was no longer occurring without evidence of direct faculty supervision. So time is ripe for a reform—Halsted-style. Just as Halsted’s residency program radically improved surgical training in the 20th century, we could use this opportunity to devise a program to proactively improve it in the 21st century. Work-hour limitations on residents are here to stay. We need to accept the fact that a resident’s willingness to give a pound of flesh will no longer be required to become a surgeon. Individuals desiring our profession must be educated and trained without abusing their eagerness. So we either have to force our current organization with its nonoperative workload into an 80-hour work week or we have to make the diminished amount of time residents spend in the hospital pithy and more beneficial. In addition, we have to give up the idea that residents exist to help us with our practices. Legally, they are trainees, not employees. I agree with Dr William Silen that the first step in the right direction should be the abolition of large resident teams. My recollection of positive teaching experiences garnered by being responsible for the postoperative care