A real challenge is brewing in surgical education, and the American College of Surgeons (ACS) is taking action to ensure that surgical patients will continue to receive high-quality care from competent and confident surgeons. More specifically, under the leadership of J. David Richardson, Immediate Past-Chair of the Board of Regents, the College has developed a Committee on the ACS Transition to Practice Fellowship in General Surgery. This committee is charged with developing fellowships for young surgeons who are leaving residency and entering into the practice of general surgery. The fellowships are intended to help fill perceived gaps in training today.
“A crying need”
Dr. Richardson, other members of the Committee on the ACS Transition to Practice Fellowship in General Surgery, and the ACS leadership believe that the College needs to establish this program for several reasons. As Dr. Richardson noted, “80 percent of all surgical trainees go on to pursue advanced fellowships in the surgical specialties.” Consequently, the profession could be “rightly accused of training too many surgeons in specialties for which there is a lesser need and not training enough people in general surgery for which there is a crying need,” he added. Young surgeons themselves offer perhaps the most telling rationale for establishing the fellowship program: at least one-quarter of all fifth-year general surgery residents say they feel inadequately prepared to enter practice.
The members of the Committee on the ACS Transition to Practice Fellowship in General Surgery and other ACS leaders maintain that current fifth-year residents often lack confidence in their capabilities and may be ill-prepared to enter practice due to a lack of general surgery mentorship and limited exposure to open surgical procedures. They attribute this deterioration to a number of factors, including reduced work hours, fewer hands-on experiences, and reduced volume of cases, especially emergency cases. Of particular concern is the lack of continuity of care and supervision.
As committee member Don K. Nakayama, MD, FACS, Milford B. Hatcher Professor and chair, department of surgery, and general surgery residency program director, Mercer University School of Medicine, Macon GA, said, “The transition from being a chief resident on June 30 to a surgeon in independent practice on July 1 is a daunting step. They haven’t done an operation without an attending across the table. Far worse, the gaps in the current training paradigm have left graduating residents uneasy and insecure about a general surgical practice, much less one where they’re more isolated, such as in a smaller or a rural community.”
The College steps in
As an organization that is dedicated to ensuring the delivery of safe, effective, high-quality surgical care, and given the College’s considerable experience in accreditation and surgical education, the ACS is uniquely positioned to work with surgical training centers to establish and oversee general surgery fellowships. The committee, operating under the aegis of the ACS Division of Education, has developed a model for the fellowship, which will be distinct from other fellowships. “This will really fill a very important educational gap,” said Ajit K. Sachdeva, MD, FACS, FRCSC, Director of the Division of Education.
These fellowships will offer considerable flexibility and allow the fellows to pursue opportunities tailored to their individual practice interests. Fellows will work with strong mentors, who will encourage their gradual autonomy. The committee members agreed that several basic experiences should be included in the curriculum, including endoscopic procedures, critical care, common general surgery operations, obstetrics-gynecology, and practice management.
Although the fellowships will not be subject to approval from the Accreditation Council on Graduate Medical Education, they will need to be approved by the graduate medical education committee at each institution. They will be designed in collaboration with the general surgery residency program director to ensure that this advanced training paradigm achieves its goals without interfering with the training of general surgery residents.
Roll out begins
The College is pilot testing the fellowship program at several sites in regions currently underserved by general surgery trainees. The rationale for launching the fellowships in these locations is to help address the shortage of general surgeons. At press time, the following institutions had committed to begin pilot testing the ACS Transition to Practice Fellowship in General Surgery on July 1, 2013:
- Gundersen Lutheran Health System, La Crosse, WI
- Mercer University School of Medicine/Medical Center of Central Georgia, Macon
- Ohio State University (OSU) Wexner Medical Center, Columbus
- University of Louisville School of Medicine, KY
- University of Tennessee College of Medicine, Chattanooga
The leaders of these programs have developed excellent plans for introducing the fellowships at their institutions. According to Thomas H. Cogbill, MD, FACS, general surgery residency program director emeritus, department of general surgery, Gundersen Lutheran Medical Center, that institution’s fellowship will provide experience in emergency general surgery, outpatient care, practice management, surgical subspecialty (obstetrics/gynecology, otolaryngology, urology, orthopaedics) skills, and outcomes tracking. “For fellows interested in rural general surgery preparation, Gundersen Lutheran Health System includes four sites at which regional surgeons would provide mentorship and experience in the practice of general surgery in communities with populations between 5,000 and 10,000,” Dr. Cogbill added.
According to Dr. Nakayama, the Mercer general surgery fellow will be a junior partner in an established three-surgeon surgical practice in Cordele, GA, population 23,439. He or she will operate with an attending for a month or two, and by the end of the year, they’ll be practicing independently and relying on senior partners only for weekly case reviews. They will also attain practice management skills. “The fellow will set up a practice, visiting referring doctors, communicating about referrals, and being a member of a broader medical community,” he added. Opportunities will be available to pursue added experiences in high-demand specialties, such as otorhinolaryngology, urology, orthopaedics, and obstetrics and gynecology.
Likewise, the general surgery fellowship program in Chattanooga will focus “on the specific needs and career objectives identified by each prospective fellow in preparation for a fulfilling and sustainable career,” said R. Phillip Burns, MD, FACS, chairman and professor of surgery, department of surgery, at the University of Tennessee College of Medicine. ”It will provide an expanded opportunity to gain autonomous experience in a protected environment in both clinical decision making and operative case completion,” added Dr. Burns, First Vice-President of the ACS.
The OSU fellow will complete two six-month rotations at two hospitals that are part of Wexner Medical Center: University Hospital and University Hospital East. University Hospital serves as a Level 1 trauma center and houses a burn center. University Hospital East is a community hospital staffed by OSU physicians and offers a full range of hospital services, according to E. Christopher Ellison, MD, FACS, Robert M. Zollinger Professor of Surgery, chairman of the department of surgery, and general surgery program director at OSU. “The key elements of the fellowship include autonomy, mentoring, greater responsibility, flexibility, and outcomes measurement,” Dr. Ellison said.
In addition, Eastern Virginia Medical School, Norfolk, will launch a program in 2014. According to L. D. Britt, MD, MPH, FACS, FCCM, FRCSEng (Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), the Eastern Virginia program will be built on rotations with faculty in busy general surgery practices in the Norfolk area. During committee meetings, Dr. Britt said, “The purpose of these programs is to emphasize transition to practice, and rotations need to focus on this important feature.”
As of press time, several other institutions had expressed interest in establishing the fellowships.
Building on tradition
The ACS was founded a century ago largely to ensure that surgeons were properly trained to provide safe, competent, high-quality, effective surgical care. As the profession and surgical education have evolved over the last 100 years, the means of fulfilling that objective have changed and fluctuated.
The College’s leadership believes that the present training paradigm and the increased interest in the pursuit of subspecialty training have left many young surgeons lacking the confidence to provide high-quality general surgery care. Given the organization’s longstanding involvement in education, the College is singularly qualified to assist in the establishment of a general surgery fellowship that will fill the gaps in training and perhaps inspire young people to pursue careers in general surgery in currently underserved areas.
I would strongly encourage all surgical educators to consider introducing this fellowship in their institutions. Our goal is to make this program more widely available in 2014. To learn more about each of the fellowship programs that are being pilot tested, contact the surgeons listed in the sidebar.