One surefire way to lose a medical malpractice lawsuit is to have an unexpected complication after a surgical procedure on which you have no training. Surgery is a complex undertaking with many chances for complications, and lack of experience is difficult to defend. Is it ever reasonable to go beyond one’s training?

How do we obtain further skills if we never go beyond our residency education?

When is it safe to push our boundaries?

I agree 100% with your post. The 6 recomendations are a great list of do's and dont's. In our residency training we try build self confidence and esteem. However the ego can get a bit ahead of the skills. Nothing will do more damage to an ego then that malpractice claim. The learning process and development of skills should be lifelong commitment. New techniques and procedures build upon the knowlege and experience you already have. No man is an island and getting help or assitance demonstrates more intellegence than trying to go it alone and getting into trouble. As Clint Eastwood said in I believe Dirty Harry " A mans got to know his limitiations"

This topic highlights the need for standardization in training and core competency among Lower Extremity Surgeons. As a profession, we need to concentrate on putting out homogeneously-trained Foot, Ankle, and Leg Surgeons capable of serving all the needs of a community.

Once the patient is on the table, and the surgeon lacks the skills, training or confidence to execute, they have failed themselves and the patient. This is a scenario which should never occur.

Post-residency surgical training courses exist. ACFAS and the PI lead the way.

Sage advice on the “Within your Boundaries” piece, Dr. Shapiro.  There have always been responsible ways to increase your scope and improve your skills, that are permitted and respected, even in the context of the litigious society we practice in.  Education by trusted and respected peers is the standard, as you point out.  If this were not the case, we’d all get relatively stupider and less capable as the years since training elapse. 

Want to get hospital privileges to do a new porcedure ?  Form a relationship with someone who is already trained on the procedure, and ask to scrub in on his/her next case.  No one in your area doing the new procedure yet ?  Attend lectures, do your research and travel...That's always been the way.  You can then present your research and the basis for your education to the medical executive committee at your hospital.  If you get them to see the NEED, and substantiate your EDUCATION on the procedure, and the SIMILARITIES with other procedures that you do, they will give you APPROVAL.

Always interesting comments, Dr. Shapiro. Did you know this about obtaining new skills through continuing medical education programs.....

I am completing a CPME application for a group that wants to start doing cme programs. Their application basically says that you need to tell participants that these types of programs don't give them enough or adequate, supervised clinical experience in the technique or procedure to allow them to perform it competently.  

I don't know of any of us who have taken these courses who left feeling that way!

Sounds like the lawyers got involved in the CPME application.  There is no question that good judgement would have all of us get proctored on a new surgical procedure AFTER attending a good clinical lecture or reading a journal article about it, before doing one on our own, if such proctoring is available.  Sometimes, you are the first doc in your area to use a new technique, and you must get your training outside your local community.  I would also recommend attending as many wet lab workshops as you can.  Doing a new procedure for the first time on a cadaver makes a lot of sense.

And by the way, in the interest of full disclosure, do not put those plastic bags you get from the dry cleaner over your head, and cool the coffee a bit before spilling it in your lap.  You have been warned !

Here's an idea along the line of continuing education.  How about an ACFAS surgical skills course called "You Want It, We'll Teach It."  Here's how I'd envision the course.  Those who plan to attend the course fill out a questionnaire prior to the actual course date.  In this questionnaire you would suggest procedures or topics you want to learn more about.  The course organizers then compile the most requested topics/procedures, creating the overall content for the course.  This requires a pretty flexible structure, but may be quite beneficial.  Any thoughts?