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Letters to the Editor

Patient-Centered Instruction

The Cornerstone of Surgical Education

Butler, Kathryn L. MD

Author Information
doi: 10.1097/ACM.0000000000000664
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To the Editor:

In a recent study, surgical fellowship program directors reported that a majority of their trainees could not operate independently or provide optimal care upon entry into fellowship.1 These results follow reports over the past decade that suggest surgical residents graduate with an inability to practice autonomously.1–3 The failure rate on the American Board of Surgery oral examination rose from 16% in 2006 to 28% in 2012, further warning of widespread degradation in surgical resident preparation.4 The future of surgery mandates immediate and critical attention to resident education.

Solutions proposed in the surgical literature focus on simulation. However, in an era of work hours regulations, such exercises serve as additive curricula to the daily workflow. When residents leave the simulation lab, the dynamic between mentor, trainee, and patient remains the backbone of surgical education and practice.

In addition to innovative curricula, efforts in surgical education must target the efficiency of patient-centered instruction. Resident training hinges upon faculty mentorship, but few surgeons undergo training as educators, despite a decade of extant research in perioperative teaching techniques. In one recent study, nonpunitive feedback of intraoperative instruction markedly improved surgeons’ teaching, and faculty retained these advances over time.5 Such data advocate for faculty development in education, as well as objective standards in clinical teaching. Additionally, improved educational incentives should accompany such mandates. Academic promotion currently focuses on research accomplishments and revenue, with talents in teaching and curricular development fading into the background.

Simulation modules can supplement, but not replace, the surgeon–apprentice dynamic. As we equip residents to place knife to skin, to support perfusion, and to deliver bad news, the teaching interaction between doctor, trainee, and patient must forge the cornerstone of our efforts.

Kathryn L. Butler, MD

Critical care surgeon, Massachusetts General Hospital, and associate director of the surgical clerkship, Harvard Medical School, Boston, Massachusetts;


1. Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: Results of a survey of fellowship program directors. Ann Surg. 2013;258:440–449
2. Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, Warshaw AL. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243:864–871
3. Debas HT, Bass BL, Brennan MF, et al.American Surgical Association Blue Ribbon Committee. American Surgical Association Blue Ribbon Committee Report on Surgical Education: 2004. Ann Surg. 2005;241:1–8
4. American Board of Surgery. . General Surgery Examination Statistics. Accessed January 11, 2015
5. Anderson CI, Gupta RN, Larson JR, et al. Impact of objectively assessing surgeons’ teaching on effective perioperative instructional behaviors. JAMA Surg. 2013;148:915–922
© 2015 by the Association of American Medical Colleges