Aaron Nilhas wore a suit and University of Kansas tie to his most recent exam. His instructors pretended not to know Nilhas, so he will be more prepared when he actually takes the exam with a stranger: They shook his hand and sat at a small table across from him.
Nilhas is one of 30 surgery residents from the University of Kansas School of Medicine-Wichita. He’s in the fourth year of a five-year residency in general surgery, so he has only one more year left to learn everything he needs to pass the exam for real.
He’s already spent four years in college and four years in medical school, in addition to the first four years of his residency, so he’s in the middle of his 25th year of schooling. He works 80 hours per week during the residency, with only four days off a month, and sometimes comes home to study more after work. He will be given one written test and one oral test to determine whether he will be licensed to practice surgery.
One in five residents in the U.S. like him, even after more than nine years of intense preparation, will fail to pass the surgical certification exam.
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But not in Wichita.
The KU Medical School in Wichita has one of the highest passing rates of surgery training programs in the country at 93 percent. Of the 242 programs that prepare students for the American Board of Surgery certification exam, only 11 programs currently have a higher passing rate.
That’s better than 95 percent of surgery programs, including some Ivy League programs. Back in 2014 the results were even better: the program had a perfect pass rate, meaning its last 30 surgeons passed their exams on the first try, tied for tops in the country.
One of the ways the surgical residents prepare is by taking practice oral exams like the one Nilhas underwent in his third and fourth years. His instructors presented him with sample cases.
In one case, he was told that a victim had been brought into the hospital with a stab wound to the neck.
“What do you do now?” his teachers, not showing any emotion, asked him.
“A-B-C,” Nilhas thought to himself. “Airway, breathing, circulation: the first steps to any trauma victim.”
Then he told his examiners he would locate and assess the severity of the injury. One of the two major arteries from the heart to the brain was severely damaged, he discovered.
He thought about ordering a CT scan, to get a better view of the injury, but based on the location of the stab wound, told them he would operate right away. He would remove the damaged portion of the artery, pull a vein from the patient’s leg, place the vein like a bridge across the missing portion of artery and sew it up. He talked his examiners through every step, as if he were actually doing it.
The patient should recover, but his examiners threw him a curve ball: There was no vein in the leg after all. Maybe the patient had it removed, or maybe it wasn’t suitable; his examiners didn’t tell him. Nilhas had to think on his feet and find another way to save the hypothetical patient.
Nilhas and his colleagues spend a couple of hours every Wednesday being pushed on their knowledge of cases like this one. Six of them will present challenging cases they’ve seen in Wichita during the past month, and about 15 of their teachers will show up to grill them on what can be learned.
The questions come rapid-fire, he said: “What would you have done differently, what do the statistics say, what is the gold standard for care, what operation could you have done instead, should you have even done that surgery in the first place?”
Wichita’s program is relatively unusual in that about 80 percent of the 50 teachers are volunteers from local surgical practices. At KU’s program in Kansas City, the teachers are mostly paid, full-time staff and the residents work almost entirely at the university’s hospital there.
But in Wichita the residents are spread around the community. They’ll spend time at Via Christi and Wesley hospitals. If one of the hospitals starts seeing more patients, the resident can be shifted back and forth. They may work a stint at the Veteran’s Affairs hospital, at an indigent health care center or at the local reconstructive breast center. At the breast center, Nilhas said, he learned how to tell patients with cancer about bad news.
In part because he has been grilled so much the past four years, Nilhas was used to being pushed past the obvious answer. He told his teachers that he would tie part of the patient’s non-essential artery in the cheek and sew it back into the damaged artery itself.
The grilling continued, including questions about how he would follow up with the patient months after the surgery is over.
Nilhas passed his practice exam.
More than 500 people will apply for one of these spots, 70 will receive interviews and only six will receive invitations into the prestigious program every year. But the program is not taking the cream of the crop in the nation, according to physician Jacqueline Osland, the director of the program since 2004.
“We get good people, but they’re not geniuses top to bottom,” Osland said. “But we get unselfish people and have built this culture of teamwork and camaraderie.”
And unlike many other programs at university hospitals, Nilhas was in the surgery room his very first year. He might start off with a simple procedure, like a hernia operation, according to Osland, but by the fifth year the residents are leading many critical surgeries, with a certified physician closely watching.
The more academic institutions tend to be more specialized, according to physician Alex Ammar, the chair of the program, so students in Wichita receive more practical care with patients in a wider variety of issues. As a result, he said, more of Wichita’s graduates feel ready to go into surgery after their five years are up.
Osland is famous for grilling the residents with question after question, according to her administrative assistant, Dawn Fountain. The residents call it “pimping.”
“That’s not a comfortable thing for the residents, but they learn so much,” Fountain said. “They probably dread it, but they learn so much.”
Osland said she’s tried to put a more human touch on a practice that can be tough at some other institutions.
“Being a surgeon is hard so the training should be appropriately challenging and people need to be pushed,” Osland said. “But I don’t think going out of your way to be cruel is not really justified or effective.”
This prepares them for real surgery.
The toughest people on them is not going to be us, it’s going to be patients and families.
Jacqueline Osland, physician, KU School of Medicine, Wichita
“The toughest people on them is not going to be us, it’s going to be patients and families,” Osland said.
By their second year, some residents will be as skilled as a fifth year at some technical skills, but others will require a lot of feedback.
“There will be sometimes gnashing of teeth and frustration because nobody likes to get negative feedback,” Osland said.
Although it’s not tested on their exams, the residents are constantly watched for the physical skill of their hands, and the program has to certify that its graduates have the dexterity and skill to be successful.
“One person described them like those clown things that you can punch and stand back up,” Osland said. “They are pretty resilient; they need to be. They have to be able to receive criticism and improve and not be devastated by that.”
The residents provide $7 million worth of benefit to the community, according to Ammar’s estimate, even though the total cost to train them is only $2.3 million.
That’s because they replace physician’s assistants, nurse practitioners and surgery assistants, and at least one spends the night at the hospital every day.
But their long-term value to the community is immeasurable, he said, because graduates of the program make up the vast majority of the surgeons in the Wichita area. It’s hard to recruit talent away from the mountains and oceans, according to Ammar, but the quality of the surgery preparation in Wichita, although still under the radar, has helped lure candidates to Kansas.
“We are with them several years and know what we’re getting as opposed to interviewing someone for 30 minutes and trying to make a decision,” Ammar said. “It’s extremely important for maintaining the quality of the medical community here and in this state for that matter.”
It’s extremely important for maintaining the quality of the medical community here and in this state for that matter.
Alex Ammar, physician, about the KU program
Nilhas said he hopes to practice in Wichita. His family owns a farm in western Kansas, where he grew up, and he hopes to one day teach surgery to a young student like himself.
But he’s still got a lot of review left before he’ll be ready for his written exam in July 2017. He and his classmates pored through two different surgery textbooks in their first two years. He could be asked any number of minutia, he said.
But the long hours of preparation are worth it. Nilhas said he’s faced a couple of real patients, just like the stab wound patient he was given during his practice exam. One time, the artery could be sewed back up without a transplant. Another time he helped transfer a vein from the leg, just like in the textbooks.
But he said he is prepared for more complicated cases, about as prepared as any general surgeon resident in the country can be.