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Surgeons at Yale reform residency training

Photo by Yale University Manuscripts and Archives
William Stewart Halsted helped revolutionize the clinical practice of medicine in the 19th and 20th centuries. One of his legacies that may have outgrown its utility, however, is an uncompromising culture within surgical residencies.

William Stewart Halsted, who graduated from Yale College in 1874, had a storied career. He helped found the Johns Hopkins School of Medicine, helped revolutionize modern surgery, and trained Harvey Cushing. Halsted’s impact on the field of surgery was dramatic—titanic even.

Despite the positive achievements Halsted left to posterity, however, one creation of Halsted’s may have endured beyond the point of utility. When he started the first formal surgical residency training program in the United States, Halsted drew heavily on German and Austrian models at the time, authoritarian structures in states that emphasized hierarchy and obedience. Strict and punitive, his residency program produced a very specific type of surgeon: relentlessly driven, obsessed with detail, procedural, and, above all, successful.

Halsted’s legendary residency program was replicated throughout the United States, and its graduates—his adherents—were accorded great respect and authority. During the 20th century, the American “Halstedian” model for training surgeons became the international standard. The methods worked better than anything that had been seen before, and, importantly, were reproducible. For an aspiring surgeon, admission to an Halstedian residency was a high accomplishment in and of itself, though the completion of training was far from assured. Until recently, surgical training programs were structured as pyramids, admitting a large group of interns, relying upon Darwinian competition and selection to identify a select few to graduate. Annual attrition rates of 30-50% were not unusual.

As a result, surgical residencies have long been training grounds for the learning culture and workplace habits that engender physician burnout. In recent years, training programs across graduate medical education, including surgery, have attempted to reverse the century-old culture of cutthroat competition, self-deprivation, and personal sacrifice that have been their hallmarks. Yale School of Medicine’s surgical residency is one in a growing group of programs that is undergoing a transformation.

Peter Yoo, MD, associate professor of surgery (transplantation and immunology) and program director of the surgical residency, is one of the surgeons trying to improve the culture and climate of surgical training at Yale, and nationally. His ongoing efforts to promote the well-being of trainees has been bolstered by the recent arrival of Nita Ahuja, MD, William H. Carmalt Professor of Surgery and Chair, Department of Surgery, who shares his passion for modernizing the culture and practice of training surgical leaders.

“Earning the privilege of a career in surgery is not, should not, and never will be easy.  That said, there is no doubt that certain vestiges of the Halstedian model simply had to go. Halsted wanted young surgeons to think of themselves almost like initiates in a monastic order, where self-deprivation was taken as a demonstration of single-mindedness. Over generations, the psychological cost of this strategy has become apparent, and current trainees know better than to accept this status quo,” says Yoo. “Our department is committed to producing the best surgeons and leaders possible, and that means creating space for residents not only to succeed as surgeons and scholars, but also to thrive as human beings.”

In the past, accounts of work/life dissatisfaction among surgeons was limited to anecdotes, and assumed to be offset by high compensation. Recent research into the phenomenon of physician burnout has highlighted disparities between doctors and other professionals when it comes to job satisfaction, and raised important questions about how to foster healthier physicians.

“When you look at outcomes for the field—the high investment to train surgical physicians, the need for more surgeons as the population grows and ages, and the high rate of burnout that they encounter as a result of the training—these reforms are not just necessary, but overdue,” says Yoo.

The changes to Yale’s surgical residency program are designed to give residents a chance to live better-balanced lives while learning their craft. Says Mollie Freedman-Weiss, MD, a current resident in the Yale Surgical Residency, “The idea is to make sure we feel comfortable asking for time off to attend to personal requirements; go to the dentist, vote, register our cars—routine tasks that might in the past be seen as signs of weakness by attendings or the chief resident.”

Freedman-Weiss says that she has witnessed this approach work in her program, and that while it’s novel, faculty and trainees are adapting. “Nobody wants to be the one to leave work early because they’re feeling ill or experiencing a family emergency,” she says, “but having encouragement from higher-up makes it easier.”

Careful to emphasize Halsted’s contributions to medicine, and his continued legacy within the field, Yoo says that the surgical pioneer, a scientist first and foremost, would likely not be upset by the changes. “Ultimately Halstead was committed to creating the best surgical outcomes for patients. His style worked for a while. But it’s time for a change.”