EDITORIAL
Getting to 10,000 Hours Don K. Nakayama, MD Department of Surgery, West Virginia University School of Medicine, Morgantown, Morgantown, West Virginia.
The first years in practice after graduation from a 5-year residency are an overlooked phase in the development of a surgeon. A successful career often has at its start a senior partner who took a fresh graduate into a busy practice, provided a welcoming office and staff, introduced his junior partner to referring physicians, and perhaps most important, was there for help during the day and if there was trouble at night. Calls for help and advice became less frequent as skills developed over the next 2 or 3 years. The relationship matured into a collegial and life-long friendship. Learning during first years in practice after residency goes unnoticed. For more than a decade, program directors have debated the effects of duty-hour restrictions imposed by the Accreditation Council for Graduate Medical Education. Frank Lewis,1 executive director of the American Board of Surgery, used one regulation, the 80-hour workweek, to estimate the time lost to training over 5 years. Simple math provides a rough figure of 6 to 12 months. The lost time during formal residency training is important. What is the effect from the perspective of the time it takes to master the field? In his bestseller, Outliers author Malcolm Gladwell2 contemplates superlative achievements. His survey suggests that it is not genius, natural ability, or an ineffable “gift.” The anecdotes and research he cites indicate that it takes 10,000 hours of concentrated, directed practice. Bill Gates laid the foundation of Microsoft's enormous wealth as a teenager immersed in computer programming long before anyone foresaw personal computers. The pop phenomenon Beatles evolved in seedy dives in Frankfurt, where the lovable lads from Liverpool had to entertain inebriated patrons for hours at a time. The common denominator is that both Gates and the Beatles spent 10,000 hours perfecting their craft. Surgeons have a sense that it takes that long, without counting the exact numbers of hours one spends in training. Mastery of surgery comes during the first years in practice after residency as the surgeon hones skills, gains experience, and builds confidence. Recently, we counted the actual number of hours that residents at each postgraduate level spent in the operating room (OR) as a part of a timework study.3 Although the goal was to study the effects of recent intern work-hour restrictions, the project gave an accounting of the number of hours residents actually spent in the OR (Table).
Extrapolation from the 2-month survey period over full year for each of the 5 postgraduate levels gave an estimate of total time in the OR over the 5 years of residency. The sum was 3552 hours, which falls far short of 10,000. The difference in magnitude is still startling, especially considering that not all the time in the OR was spent actually doing an operation. Residents sense the deficit. Amid the celebration and congratulations that come at graduation, there remains doubt whether one is really prepared to do a tough case without the trusted mentor across the table, down the hall, or in the office. More than one-fourth lack confidence in their ability to operate independently following training.4 One manifestation of their anxiety is that more than threefourths of residents pursue additional specialty fellowship training after graduation5 to provide an additional year or 2 of training so they feel ready for independent and autonomous practice. Even with the additional 1 or 2 years in a surgical specialty, would additional training allow the graduating chief to reach 10,000? Assuming that the operative experience in a specialty fellowship gives the same OR time as a chief resident, each year adds only another 960 hours, which comes to 1920 hours over 2 years. After 2 years, the cumulative total comes to 5472, just over halfway to the threshold. The trainee still has not experienced independence or autonomy. A fellowship is a formal training situation where the senior surgeon has to be present at the operation to bill and assume liability, the same requirement that governed the first 5 years of residency. So when does a young surgeon reach 10,000? Put the brand new surgeon in practice, finally out of training, and make him or her as active as a chief resident. It is a generous assumption because few surgeons have the good fortune to start a new practice operating every day for hours at a time as senior and chief residents often do. The total sum, counting from July 1 of the intern year, does not reach 10,000 for another 6.7 years after 5 years of formal training, or 4.7 years after a 2-year fellowship. This year the American College of Surgeons (ACS) introduced its Transition to Practice program to address the challenge of postresidency education.6 Organized by former board of regents’ chair J. David Richardson, MD, FACS, Louisville, KY, and ACS first vice-president R. Philip Burns, MD, FACS,
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.10.001
159
TABLE. Time in OR During Residency and Fellowship Training Hours in OR
Postgraduate Year
Each Week Each Year Total
I II III IV V Total after residency First year fellowship Second year fellowship Total after fellowship
6 14 14 20 20
288 672 672 960 960
20 20
960 960
3552 5472
3
Note: Data from Dennis et al.
REFERENCES 1. Lewis FR. Surgical resident training: The urgent need
Chattanooga, TN, the program brings together experienced surgeons and recent trainees in a 1-year clinical practice at a site separate from training hospitals. The latter, a junior associate under program terminology, comes under the mentorship of senior associates in the practice. The junior associate is a full member of practice, responsible for seeing consultations, taking call, and participating in all business aspects of the office. During the first months, the senior associates are in the OR across the table or immediately available in the hospital. Each week the associates meet to review cases. As confidence grows, the junior associate begins independent practice with a partner only a phone call away. After 1 year, the associate is still short of 10,000 hours. But the goal is independence and autonomy so that the surgeon can take the final steps toward mastery with confidence. Every year program directors have weighty discussions about practice options with chief residents as graduation approaches. Invariably, the conversations turn to negotiations and contracts: compensation, benefits, paid time off, and noncompete clauses. However, a topic of equal
160
importance is who are the other surgeons in the practice. A surgical mentor who fosters the development of independence, autonomy, and maturity is a crucial factor in the development of a career. The ACS Transition to Practice program addresses the challenge of the first years in practice after residency, a phase of a surgeon’s experience equal in consequence to any of the years of formal residency training.
for reform. Presented at the 132nd annual meeting of the American Surgical Association, San Francisco, CA. April 27, 2012. 2. Gladwell M. Outliers. The Story of Success. New York:
Little, Brown and Co., 2008. 3. Dennis BM, Long EL, Zamperini KM, Nakayama DK. The
effect of the 16-hour intern workday restriction on surgical residents’ in-hospital activities. J Surg Educ. (in press). 4. Yeo H, Viola K, Berg D, et al. Attitudes, training
experiences, and professional expectations of US general surgery residents: a national survey. J Am Med Assoc. 2009;302(12):1301-1308. 5. Borman KR, Vick LR, Biester TL, Mitchell ME.
Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery. J Am Coll Surg. 2008;206(5):782-788. 6. Hoyt DB. Looking forward. Bulletin of the American
College of Surgeons. Available at: 〈http://bulletin.facs. org/2013/02/looking-forward-february-2013/〉. Accessed September 6, 2013.
Journal of Surgical Education Volume 71/Number 2 March/April 2014
Getting to 10,000 Hours Don K. Nakayama, MD Department of Surgery, West Virginia University School of Medicine, Morgantown, Morgantown, West Virginia.
The first years in practice after graduation from a 5-year residency are an overlooked phase in the development of a surgeon. A successful career often has at its start a senior partner who took a fresh graduate into a busy practice, provided a welcoming office and staff, introduced his junior partner to referring physicians, and perhaps most important, was there for help during the day and if there was trouble at night. Calls for help and advice became less frequent as skills developed over the next 2 or 3 years. The relationship matured into a collegial and life-long friendship. Learning during first years in practice after residency goes unnoticed. For more than a decade, program directors have debated the effects of duty-hour restrictions imposed by the Accreditation Council for Graduate Medical Education. Frank Lewis,1 executive director of the American Board of Surgery, used one regulation, the 80-hour workweek, to estimate the time lost to training over 5 years. Simple math provides a rough figure of 6 to 12 months. The lost time during formal residency training is important. What is the effect from the perspective of the time it takes to master the field? In his bestseller, Outliers author Malcolm Gladwell2 contemplates superlative achievements. His survey suggests that it is not genius, natural ability, or an ineffable “gift.” The anecdotes and research he cites indicate that it takes 10,000 hours of concentrated, directed practice. Bill Gates laid the foundation of Microsoft's enormous wealth as a teenager immersed in computer programming long before anyone foresaw personal computers. The pop phenomenon Beatles evolved in seedy dives in Frankfurt, where the lovable lads from Liverpool had to entertain inebriated patrons for hours at a time. The common denominator is that both Gates and the Beatles spent 10,000 hours perfecting their craft. Surgeons have a sense that it takes that long, without counting the exact numbers of hours one spends in training. Mastery of surgery comes during the first years in practice after residency as the surgeon hones skills, gains experience, and builds confidence. Recently, we counted the actual number of hours that residents at each postgraduate level spent in the operating room (OR) as a part of a timework study.3 Although the goal was to study the effects of recent intern work-hour restrictions, the project gave an accounting of the number of hours residents actually spent in the OR (Table).
Extrapolation from the 2-month survey period over full year for each of the 5 postgraduate levels gave an estimate of total time in the OR over the 5 years of residency. The sum was 3552 hours, which falls far short of 10,000. The difference in magnitude is still startling, especially considering that not all the time in the OR was spent actually doing an operation. Residents sense the deficit. Amid the celebration and congratulations that come at graduation, there remains doubt whether one is really prepared to do a tough case without the trusted mentor across the table, down the hall, or in the office. More than one-fourth lack confidence in their ability to operate independently following training.4 One manifestation of their anxiety is that more than threefourths of residents pursue additional specialty fellowship training after graduation5 to provide an additional year or 2 of training so they feel ready for independent and autonomous practice. Even with the additional 1 or 2 years in a surgical specialty, would additional training allow the graduating chief to reach 10,000? Assuming that the operative experience in a specialty fellowship gives the same OR time as a chief resident, each year adds only another 960 hours, which comes to 1920 hours over 2 years. After 2 years, the cumulative total comes to 5472, just over halfway to the threshold. The trainee still has not experienced independence or autonomy. A fellowship is a formal training situation where the senior surgeon has to be present at the operation to bill and assume liability, the same requirement that governed the first 5 years of residency. So when does a young surgeon reach 10,000? Put the brand new surgeon in practice, finally out of training, and make him or her as active as a chief resident. It is a generous assumption because few surgeons have the good fortune to start a new practice operating every day for hours at a time as senior and chief residents often do. The total sum, counting from July 1 of the intern year, does not reach 10,000 for another 6.7 years after 5 years of formal training, or 4.7 years after a 2-year fellowship. This year the American College of Surgeons (ACS) introduced its Transition to Practice program to address the challenge of postresidency education.6 Organized by former board of regents’ chair J. David Richardson, MD, FACS, Louisville, KY, and ACS first vice-president R. Philip Burns, MD, FACS,
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.10.001
159
TABLE. Time in OR During Residency and Fellowship Training Hours in OR
Postgraduate Year
Each Week Each Year Total
I II III IV V Total after residency First year fellowship Second year fellowship Total after fellowship
6 14 14 20 20
288 672 672 960 960
20 20
960 960
3552 5472
3
Note: Data from Dennis et al.
REFERENCES 1. Lewis FR. Surgical resident training: The urgent need
Chattanooga, TN, the program brings together experienced surgeons and recent trainees in a 1-year clinical practice at a site separate from training hospitals. The latter, a junior associate under program terminology, comes under the mentorship of senior associates in the practice. The junior associate is a full member of practice, responsible for seeing consultations, taking call, and participating in all business aspects of the office. During the first months, the senior associates are in the OR across the table or immediately available in the hospital. Each week the associates meet to review cases. As confidence grows, the junior associate begins independent practice with a partner only a phone call away. After 1 year, the associate is still short of 10,000 hours. But the goal is independence and autonomy so that the surgeon can take the final steps toward mastery with confidence. Every year program directors have weighty discussions about practice options with chief residents as graduation approaches. Invariably, the conversations turn to negotiations and contracts: compensation, benefits, paid time off, and noncompete clauses. However, a topic of equal
160
importance is who are the other surgeons in the practice. A surgical mentor who fosters the development of independence, autonomy, and maturity is a crucial factor in the development of a career. The ACS Transition to Practice program addresses the challenge of the first years in practice after residency, a phase of a surgeon’s experience equal in consequence to any of the years of formal residency training.
for reform. Presented at the 132nd annual meeting of the American Surgical Association, San Francisco, CA. April 27, 2012. 2. Gladwell M. Outliers. The Story of Success. New York:
Little, Brown and Co., 2008. 3. Dennis BM, Long EL, Zamperini KM, Nakayama DK. The
effect of the 16-hour intern workday restriction on surgical residents’ in-hospital activities. J Surg Educ. (in press). 4. Yeo H, Viola K, Berg D, et al. Attitudes, training
experiences, and professional expectations of US general surgery residents: a national survey. J Am Med Assoc. 2009;302(12):1301-1308. 5. Borman KR, Vick LR, Biester TL, Mitchell ME.
Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery. J Am Coll Surg. 2008;206(5):782-788. 6. Hoyt DB. Looking forward. Bulletin of the American
College of Surgeons. Available at: 〈http://bulletin.facs. org/2013/02/looking-forward-february-2013/〉. Accessed September 6, 2013.
Journal of Surgical Education Volume 71/Number 2 March/April 2014
