It’s 8:20 on a Friday morning, and surgical resident Jennifer LaFemina, MD, is in Massachusetts General Hospital’s operating room number 10, alongside attending thoracic surgeon, Henning Gaissert, MD, and the rest of the operating room (OR) team.
In this, her first case of the day, Dr. LaFemina will replace a tracheal “T-tube” in a 47-year-old patient who relies on this simple device to keep his airway open. Under the watchful eye of Dr. Gaissert, Dr. LaFemina does most of the hands-on work, occasionally getting tips on technique from her more experienced mentor, who has performed this procedure countless times.
Inserting the T-tube — typically a straightforward procedure — turns out to be a challenge in this patient. The usual approach just isn’t working.
Undaunted, Drs. Gaissert and LaFemina discuss and agree on an alternate strategy and, after a few attempts, the T-tube is properly in place. The patient is moved to the recovery area, where Dr. LaFemina checks his vital signs and tells him that all went well.
Dr. LaFemina, who is now in her fourth year of clinical training, has been up since 4:30 am and at the hospital since 5:45 am. Before arriving in OR 10, she checked in on eight patients throughout the hospital, many of whom are seriously ill; logged notes in the patients’ charts; conferred with nursing staff and her first-year mentee, Jonathan Greer, MD; and reviewed the specifics of her five upcoming surgical cases. Knowing it might be many hours before she has a chance to eat, she’s also managed to grab a soda and some crackers.
Before her work day is over, Dr. LaFemina will participate in four more thoracic procedures and, prior to passing the baton to the night surgical resident, check in on all those patients. Most days, she’ll also attend a lecture or a clinical case conference. Each week she’ll officially log in around 80 hours — the maximum now permitted for residents — and get just one day off.
The days of a Mass General surgical resident are undeniably long and challenging. But the metamorphosis from a newly minted MD to a well-rounded and highly skilled general surgeon demands this — there is, after all, so much to master, so much to learn, in a profession that, quite literally, requires taking peoples’ lives in one’s hands.
The ‘brass ring’ of surgical residencies
Dr. LaFemina is one of 56 residents, half of whom are women, undergoing surgical training at Mass General in a program that accepts eight applicants a year. Despite its rigors, the hospital’s renowned Surgical Residency Training program is the “brass ring” for medical school graduates who aspire to become top-flight surgeons.
According to program director Charles M. Ferguson, MD, the program received a record number of applications for this year’s class — 1,083, to be exact — compared to the usual 800 to 900. There are a number of reasons so many medical school graduates, most of whom excelled at top medical schools, vie for the opportunity to train at Mass General.
“We have world leaders in each surgical division, so residents get to learn from the best in their fields,” explains Cristina R. Ferrone, MD, assistant director of the training program. “Our patients also tend to be sicker, so residents have the opportunity to perform more complex procedures. And we have a well-earned reputation for supporting our residents’ career goals, including their research interests.”
Scott Regenbogen, MD, MPH, who is in his fourth clinical year, wanted to train at Mass General for all those reasons. He also was attracted to the program because of the faculty’s obvious commitment to teaching.
As residents, says Dr. Regenbogen, “We’re encouraged to grow, but also to ask for help when we need it from faculty who clearly love to teach and work with residents.” Dr. LaFemina agrees. “There’s an open-door policy here that makes residents feel comfortable calling on faculty at all levels for advice and direction,” she says.
What does Mass General look for when vetting candidates? “We look for intelligence, persistence, honesty and selflessness — an ability to put the good of others above one’s own,” says Dr. Ferguson. “We want to produce excellent surgeons, of course, but also surgeons whose careers will have a positive impact on the broader community.” Indeed, whether working in academic medicine, government or community settings, many alumni hold leadership positions where they have a far-reaching impact.
A broad range of surgical specialties
The Mass General surgical residency encompasses five clinical years and, typically, two years of research.
According to Andrew L. Warshaw, MD, surgeon-in-chief and chairman of the Department of Surgery, the idea of devoting five years to clinical training (which is now the standard internationally) was the brainchild of the late Edward D. Churchill, MD, chief of Surgery at Mass General from 1948 to 1962. Prior to that innovation, surgical residents trained for just two, or perhaps three, years.
The five clinical years are designed to provide residents with experience in a broad range of surgery, so they spend from one to three months rotating through all surgical divisions at the hospital and sometimes also at affiliated hospitals.
The rotations vary according to what year the resident is in, but encompass virtually every surgical specialty: general, pediatric, orthopaedic, transplant, thoracic, plastic, burn, urology, neurosurgery, vascular, surgical intensive care, cardiac, head and neck, and emergency/trauma (acute-care), as well as anesthesia and general surgery in community hospitals.
In the first clinical year, residents (also called “interns”) learn to perform comparatively simple procedures like hernia repairs, small biopsies or gallbladder removal. By their final years, residents are performing far more complex operations, such as organ transplants and the Whipple procedure for patients with pancreatic cancer. Regardless of their level of experience, by law residents must always be supervised by an attending surgeon in the OR.
Steep learning curve
Learning to perform any type of surgical procedure has a steep learning curve, which faculty take into account when determining what aspects of a particular procedure residents can manage on their own. “We provide our residents with what we call ‘graded autonomy,’ which gives them increasing levels of responsibility as they acquire new skills and knowledge and allows them to grow into their role,” says Dr. Warshaw.
By the time Mass General residents have concluded their final year of clinical training, they have performed an average of 1,200 procedures — many of them complex operations — and are more than prepared to take their examinations to become certified by the American Board of Surgery.
While the bulk of surgical training takes place in an OR, the education of a Mass General surgeon also entails
attending lectures; keeping up with articles in scientific journals; and participating in specialty-specific clinical case conferences during which residents discuss their most challenging cases with faculty.
“One of the most educational things we do is the weekly GI [gastrointestinal] clinical case conference,” says Dr. Regenbogen. “It’s reassuring to see that even among a group of highly experienced surgeons, there can be differences of opinion. Residents may sometimes come to the GI conference feeling lost at sea, but we always leave with lots of ideas.”
The value of research education
Nearly 90 percent of Mass General surgical residents also devote a few years to research, typically after the third clinical year. This experience broadens their understanding of their specific area of interest and also enables them, if they choose, to conduct research pertaining to their specialty as a complement to their clinical practice.
While research is not a requirement, it is encouraged at Mass General. Residents are not only financially supported by the department if they are unable to obtain adequate grant funding, but also have free rein to choose what type of research they want to pursue and where to do it.
Reflecting a nationwide trend toward specialization, when their residency ends, most Mass General residents decide to continue their education for another year or two by doing a fellowship in a specialty area, such as surgical oncology, thoracic surgery or minimally invasive surgery (see sidebar). Dr. Regenbogen will apply for fellowship training in colorectal surgery. And Dr. LaFemina plans to do a fellowship in hepatobiliary surgery, which encompasses disorders of the liver, bile ducts and gallbladder.