Educational expectations for practicing surgeons will continue to evolve in the future as concerns regarding quality of patient care and health care reform propel the field into innovative directions.1 At its core, continuing medical education (CME) for surgeons is the acquisition of new knowledge and skills after completing residency or fellowship training in an ongoing effort to provide optimal patient care. Over the past two decades, exceptional advancements in surgical technologies have compelled physicians to pursue a kind of “technical retooling,” motivating them to become “knowledgeable in areas of science that did not even exist during their medical school or residency years.”2
The CME opportunities of tomorrow will help surgeons become acquainted with new surgical techniques and devices and learn how to apply that technology in their day-to-day practice—a key component in providing consistent, high-quality care. In fact, the future of lifelong learning, according to education experts, will be shaped by content that is easily accessible and up to date and will include robust CME activities, telesurgery, and simulation-based training.
ACS Fellows interviewed for this article
Training across a lifetime
Lifelong learning has been a top priority for surgeons since the turn of the 20th century, when, on July 3, 1900, Sir William Osler gave a speech titled The Importance of Post-Graduate Study—a presentation that is generally accepted as the birth of continuing medical education (CME).3 In fact, the American College of Surgeons (ACS), founded in 1913, was launched as a scientific and educational association with the goal of improving quality of care by setting high standards for surgical education. This goal was met in part through the launch of Surgery, Gynecology & Obstetrics, now the Journal of the American College of Surgeons, and with the organization’s annual Clinical Congress.
Today, surgeons continue to maintain, develop, and increase their knowledge and skills, while facing new challenges that Sir Osler and the College’s founders probably couldn’t have imagined more than 100 years ago.
In a presentation to the Society of American Gastrointestinal and Endoscopic Surgeons titled the Role of ACS in Advancing Surgical Education and Training, Ajit K. Sachdeva, MD, FACS, FRCS(C), Director of the ACS Division of Education, said the “underpinnings of the new and innovative direction of the division” include rapid advances in surgery and surgical education and training, new national imperatives and regulatory mandates, and unprecedented scientific discoveries.4 These are the basis of the new and innovative directions of the division, noted Dr. Sachdeva.
“There was a time when we finished residency training, we thought it was the end of our training, and that one just needed to refine certain skills across one’s lifetime,” explained Dr. Sachdeva. “But now, as rapid advances in science, emerging technologies, and new approaches to treating diseases continue to reshape surgical care, it is imperative that we focus on education and training across the entire span of the professional careers of individuals to help them continue to acquire new knowledge and skills and remain current with the latest advances.”
“Change is inevitable, and change is here to stay—and the pace of change will only increase in the future,” added ACS President-Elect Carlos A. Pellegrini, MD, FACS, FRCS(I)(Hon), The Henry N. Harkins Professor and Chair, department of surgery, University of Washington, Seattle. “Once that principle is accepted, we must then create a system that addresses that need,” said Dr. Pellegrini, who also called for a commitment to lifelong learning on the part of the individual surgeon. “The ‘system’ that I am talking about requires coordination of all the stakeholders: professional organizations like the College, hospitals, insurance carriers, and national institutes devoted to the improvement of care,” explained Dr. Pellegrini. “What we have now, in terms of surgical education, is oriented primarily toward the instructional aspects related to a new device or a new technique. But the current system is incomplete because it does not entirely address the change of practice. This component has a lot more to do with process, how we treat the patients, for example, or how we evaluate the results of therapeutic applications than with learning a new device or technique.”
ACS Program for Accreditation of Education Institutes
The Division of Education launched the innovative ACS Program for Accreditation of Education Institutes in 2005. A network of ACS-accredited Education Institutes (AEIs) has been created to offer state-of-the-art simulation-based surgical education and training at regional levels and to address the needs of surgeons throughout their careers. These accredited institutes provide practicing surgeons, surgery residents, medical students, members of the surgical team, and other health care professionals with the opportunity to participate in programs to acquire skills in new procedures and emerging technologies and to refresh their skills in infrequently performed procedures.5 As new simulations and simulators are developed and introduced into education and training programs, the need for wet laboratories, animals, and cadavers should progressively diminish.5
The goals of the network of 76 ACS-accredited institutes are to promote excellence in surgical care, address the core competencies, enhance access to contemporary surgical education and training, and support surgeons’ efforts to meet the requirements for Maintenance of Certification (MOC) and other national mandates.5
The efforts at the AEIs also include pre-course and post-course interventions. The pre-course interventions enable surgeons to acquire relevant knowledge before participating in on-site skills training, thus reducing the time physicians need to be away from their practices, and post-course interventions help in transfer of new knowledge and skills to practice.5 According to Dr. Sachdeva, these accredited education institutes are also heavily engaged in research and development to advance the field of simulation-based surgical education and training. “This network offers a range of surgical skills courses that complement the skills courses offered at the Clinical Congress. Regional implementation of the courses enhances access to these programs,” he said.
One AEI network member, University of California-Davis Center for Virtual Care, uses patient simulation that is based on flight-simulation technology and features devices that are programmed to react like real patients, blink, speak, breathe, and have heartbeats and other anatomical features, allowing students to practice intravenous drug delivery, cardiopulmonary resuscitation, airway management, and other procedures.
“Accreditation by the American College of Surgeons serves as an acknowledgement of the high-quality and multidisciplinary nature of the training opportunities offered by the Center for Virtual Care,” said Aaron Bair, associate professor of emergency medicine and director of emergency medicine simulation for the center.6
“We now have a system that ensures each one of our accredited institutes is offering education and training of the highest quality, and has the requisite tools, resources, and trained faculty to achieve the best outcomes,” noted Dr. Sachdeva.
“There can be no quality improvement or excellence in surgery without innovative education and training; that is absolutely key,” he said. “The path to supporting practice of state-of-the-art surgery and to providing the best possible patient care is through education and training.”
As for the future of the AEI consortium, Dr. Pellegrini said he wouldn’t be surprised if it became an essential part of a comprehensive system of continued professional development for surgeons. “I think eventually, in my opinion, the AEI will become an essential component of a larger system that addresses the overall needs related to remaining current in the midst of constant change,” said Dr. Pellegrini, outgoing Chair of the ACS Committee for the Accreditation Review of Education Institutes. “The College has created the consortium—which all AEI members are invited to participate in—to provide high-quality continuous learning not just of a new device or technology, but with a focus on the process, which would include patient satisfaction, for example. The future of these institutions and of the consortium is bright as we develop a system that addresses the continuing education of practicing surgeons,” he said.
Changes in MOC
Another factor guiding renewed interest in lifelong learning and participation in CME activities is MOC. In 2003, the American Board of Medical Specialties (ABMS) and its 24 member boards “formally committed to evolve the recertification programs into maintenance of certification programs.”7 In 2005, the American Board of Surgery (ABS), a member of the ABMS, began MOC at the time of initial certification or recertification.7 The MOC program was developed by surgeons for surgeons to assess physician competencies on a continuous basis in four key areas: professional standing, lifelong learning and self-assessment, cognitive expertise, and evaluation of performance in practice.
In 2012, the ABS introduced changes to the MOC program with the goal of simplifying the requirements while offering basic guidelines as to appropriate CME for Part 2—lifelong learning and self-assessment. As of July 2012, ABS diplomates must complete 90 hours of Category I CME over a three-year MOC cycle. Of those 90 hours, 60 must comprise self-assessment. For the CME to count as self-assessment, a score of 75 percent or more must be attained on the self-assessment portion of the CME activity.8
According to Dr. Sachdeva, several programs of the ACS Division of Education include robust self-assessments. The Surgical Education and Self-Assessment Program (SESAP®), the ACS Comprehensive General Surgery Review Course, and Selected Readings in General Surgery (SRGS®) are examples of renowned ACS programs that include state-of-the-art self-assessment models. “In addition, when there is a need to demonstrate mastery of the content or skill, we expect learners to achieve 100 percent. Learners repeat the learning or training exercises until they achieve this benchmark,” explained Dr. Sachdeva. “The ACS Division of Education is ahead of the curve in providing practicing surgeons a broad spectrum of innovative education and training programs to support lifelong learning and address national mandates.”
MOC and the future of surgical education
The future of MOC and its success are tied to an issue that’s been a priority for Frank R. Lewis, MD, FACS, executive director of the ABS since the program’s inception—collecting accurate outcomes data. Dr. Lewis noted that the MOC program “represents a major philosophical shift by the American Board of Medical Specialties, [and is] intended to provide a more continuous monitoring of physician performance rather than intermittent “snapshots.” This change is fully as important as the earlier shift from initial certification to the need for recertification every 10 years, according to Dr. Lewis.9
In the last five to six years, the Centers for Medicaid & Medicare Services has issued quality indicators that, according to Dr. Lewis, “principally address chronic medical conditions, but that have minimal relevance to surgical issues.” “Most of these fall into the category of “process” measurements—when what is actually needed in surgery in order to define quality are outcome measurements,” explained Dr. Lewis.
SESAP: Advancing the boundaries of self-assessment
A nationally and internationally renowned learning and self-assessment program of the ACS, SESAP is available to practicing surgeons and surgery residents, and is recognized by the ABS as a resource that meets Part 2 of the MOC requirements, according to John A. Weigelt, MD, DVM, FACS, Medical Director of SESAP. It is also useful in preparing for the recertification or certification examinations.
SESAP 14 consists of 655 newly constructed multiple-choice questions with discussions and references to the current literature in 15 major areas of general surgery. The 14th edition includes a completely redesigned self-assessment model that is eligible for credits by providing the equivalent of a closed-book test on the material. “This unique self-assessment model makes SESAP a standard-setting learning and self-assessment tool,” said Dr. Sachdeva.
“SESAP 14 was a major shift in content compared to previous versions,” explained Dr. Weigelt. “Up to that time, it was a CME product that could be used by Fellows in any way they saw fit to study it. SESAP 14 was a major shift because we designed it to be compliant with the rules for self-assessment.
“The content for each SESAP is new—we do not recycle anything,” added Dr. Weigelt. “Each cycle we start anew.”
Along with content development updates, the future of surgical education will continue to trend away from the traditional print format toward an increase in electronic and Web-based offerings.
“Based on a recent survey of our customers, we are seeing a slow move to the electronic format as the preferred format. Previously, it was a 50/50 split, compact disc (CD) versus print copy. For SESAP 12, users were still favoring print, even though we had the CD available for that version,” said Dr. Weigelt. There has been a “slow migration” toward the electronic format, said Dr. Weigelt. “SESAP 15 will continue to be available in all three formats: hardcopy, CD, and online. I think the trend will be a continued push to CD and Web formats for self-assessments,” he said.
“With the electronic format, you can feature more audio and video learning tools in SESAP. For instance, we have a few video clips now, but unfortunately, if you get the paper form those are obviously not available. One of the complaints about the book is that when we feature a computed tomography scan within the stem of a question, users have said they need to see more than one cut. In an electronic format we can upload more than one cut, but in the book we aren’t able to do that,” Dr. Weigelt said.
Beyond the electronic versus print conundrum, SESAP developers face other challenges when designing new SESAP content. “At times, one of the difficulties in developing SESAP has to do with new advances in treatment,” observed Dr. Weigelt. “For instance, there was one topic we considered including in SESAP 14, and we had multiple questions on this topic, but eventually it was decided that it was too soon to ask questions on it. We have the same topic in SESAP 15 and it has been determined that it is, in fact, the appropriate time to include it. I think it is simply good stewardship.”
Another new consideration for developing the next edition of SESAP is related to the organization of material and the overall user experience. “The other thing we have learned from this first go-around as we are getting ready to put ‘15’ together is that with SESAP 14 you had to go through all of the material to qualify for CME, and the feedback that we got was that it was much too onerous a task. For SESAP 15, we will break down some of the larger modules into smaller parts, which we hope will enhance the learning value,” explained Dr. Weigelt. “We are trying to divide the material into approximately one-hour learning blocks. We believe this will allow surgeons the ability to manage their time better and identify which modules and parts are most important to their medical knowledge needs.” The system to earn CME credits will also be different for SESAP 15. “Individuals will be able to claim CME credits as they complete each module and then receive a final Certificate of Completion for the entire program. This will help them meet various regulatory requirements,” said Dr. Sachdeva.
The role of telemedicine
Barrett G. Haik, MD, FACS, a member of the ACS Board of Regents and Chair of the ACS Committee on Emerging Surgical Technology and Education (CESTE), embraces telemedicine as an integral part of lifelong learning today and in the future. Dr. Haik is Hamilton Professor of Ophthalmology and director of the Hamilton Eye Institute at the University of Tennessee Health Science Center in Memphis, which houses the Freeman Auditorium, a state-of-the-art facility that was one of the first eye centers in the nation to offer three-dimensional (3-D) video capability. According to Dr. Haik, there is evidence that 3-D surgical video enhances learning in some individuals, perhaps because it provides a more realistic view of tissue depth and tool manipulation as it will be seen through the binocular operating microscope.
“Surgical procedures will be totally different 20 years, even 10 years from now. The whole field will change,” asserted Dr. Haik. “In ophthalmology, career longevity depends on adaptability to rapidly evolving medical technology, [and] adopting new procedures and technologies once they are proven safe and effective.”
As 3-D video instruction and other types of “immersive” teaching technologies continue to evolve, they will emerge as a trend in future CME initiatives, noted Dr. Haik. “These are additive, however, and will never overshadow the importance of basic skills instruction lectures or the standard binocular surgical assistance experience,” Dr. Haik added.
“Because ocular tissue is generally transparent, it is possible to provide surgical mentoring over the Internet,” explained Dr. Haik. “Currently, we provide consults based on case reports and still images, but our goal is to enable international outreach centers to broadcast surgeries in real time so we can observe, discuss technique, and provide feedback.”
The Hamilton Eye Institute is a leader in ophthalmic telesurgery and has established collaborative relationships with centers in Guatemala, Honduras, and Panama. The institute also holds grants from the U.S. Department of Defense to develop new technology for remote assessment of patients in the field.
“There is no question that people learn and retain knowledge and skills better through multimedia and interactive education programs, as compared to the traditional teacher-centered models,” said Dr. Sachdeva. “Technology allows us to create interactive programs and provides flexibility through which we can tailor interventions to meet the specific needs of the individuals. It also allows us to readily deliver pretests and posttests. In addition, technology helps us to offer a range of programs and products that learners can mix and match based on their specific needs.”
Dr. Sachdeva said technology-based CME offerings must be placed within the context of a rigorous educational framework, one that involves basic tenets of good education—needs assessment, learning objectives, effective content delivery, assessment, and so on.
Simulation-based education and training
A wide spectrum of simulations is available for surgical instruction and for assessment of knowledge and skills. These include computer-based case simulations, standardized patients, part-task trainers, simulators, and virtual reality.5 Both low- and high-fidelity simulations are helpful in technical skills training and maintenance of skills for procedures not performed on a routine basis.5 “Simulation is being used across a variety of different programs of the Division of Education to address cognitive, technical, and non-technical skills and the division is recognized as a national and international leader in this field,” said Dr. Sachdeva.
“I think simulation is going to play an even greater role as we go forward,” asserted Dr. Sachdeva. “Simulation-based education and training are closely linked to future advances in CME and lifelong learning. Use of simulation allows learners to be trained in controlled environments without compromising patient safety or comfort and offers surgeons and surgical trainees the opportunity to be exposed to complex and life-threatening events in controlled settings. Added to that, simulation-based education allows individuals to ‘practice until they are perfect,’ which should positively impact learning curves and permit verification and documentation of skills uniformly.”
Simulation training has been particularly successful in the areas of upper and lower gastrointestinal endoscopic procedures, according to Dr. Lewis, as well as for some endovascular procedures.
“Where simulation isn’t as successful is in the duplication of actual operations,” explained Dr. Lewis. “Virtual reality programs can’t duplicate tissue characteristics with any realism, and it is not as successful in the duplication of the characteristics of bleeding and [the mastery] of other skills that are necessary in managing the operative field.”
Simulated procedures that involve “geometric operations” or “mechanical exercises” where the learner is using a simulator to learn how to manipulate objects in a geometric space—such as teaching them how to tie and suture knots—tend to work quite well in getting someone initially trained, explained Dr. Lewis.
“Surgical simulation is a tremendous educational tool,” concurred Dr. Haik. “It provides a high degree of realism as well as a progressive, graduated experience with a personalized, postoperative assessment of efficiency and competence, preparing the learner for the next level of training. Ophthalmic microsurgery requires simultaneous, precise coordination of both hands and feet, and the simulator provides a safe and effective method for surgeons to develop this skill. The simulator cannot yet duplicate the tactile sensation of actually penetrating or manipulating tissue, however, so the simulator has not yet invalidated the importance of working with animal tissues in wet labs.”
Dr. Sachdeva cautioned against the use of simulation without a rigorous educational design. “Also, simulation does not replace experiences in real environments,” he said. “There is real value in face-to-face interactions. Simulation is an adjunct, but a very valuable adjunct. The bottom line is the curriculum has to drive simulations—not the other way around.”
The future is now
All surgeons face the ongoing challenge of maintaining their knowledge and skills, keeping up with changes in the pathophysiology of disease, becoming acquainted with new or improved surgical techniques, and improving day-to-day medical and surgical care practices.3 Keeping up with this information can be challenging, but there are some important concepts surgeons should consider to ensure they are engaging in lifelong learning activities that are cutting-edge yet practical.
Dr. Sachdeva recommends that surgeons continually assess their specific education and training needs through ongoing analyses of their practices and benchmarking to determine any gaps. He noted that professional organizations such as the ACS have a key role in providing individuals the tools to conduct such analyses and then offering appropriate education and training programs to address these needs.
“The large national meetings, such as the Clinical Congress, will continue to play an important role in the future, but they must continue to evolve,” added Dr. Sachdeva. “If you look at these meetings, they alone are not sufficient to change practices and address the continuum of lifelong learning. They need to be linked to post-activity follow-up and offer support for the transfer of new knowledge and skills to practice. Such a comprehensive approach is necessary to ensure the greatest impact.”
“One of the things I find disconcerting when I attend CME meetings is that the lowest in attendance are those who are out of training in their first 10 years,” observed Dr. Haik. “This could be because new surgeons have a certain confidence, and maybe giving up weekends, along with the financial pressure of being out of the office, is not something they choose to do unless they are really certain a course is going to be extremely valuable to them.”
Attracting young surgeons to educational activities involves offering content that is unbiased and relevant, particularly when it comes to technological advancements, according to all of the surgical education experts interviewed for this article.
“CESTE and the College ensure that new technologies being developed are in the best interest of patients, which is key because there are so many industry-driven advancements that it would be incredibly difficult and time-consuming for an individual surgeon to assess everything. Objective analysis and filtering is needed,” explained Dr. Haik. “The College provides that. It is one of the few sources of unbiased, continuous information for the surgeon.”
The future of surgical education will involve innovations in telemedicine and immersive instruction, increased emphasis on simulation, and lifelong learning opportunities that are customized to the individual surgeon’s training and knowledge gaps. The learning needs of surgeons can vary greatly, but through state-of-the-art educational programming and training, the ultimate goals of lifelong learning—patient safety and quality of care—are obtainable.
- Van Harrison R. Systems-based framework for continuing medical education and improvements in translating new knowledge into physicians’ practices. J Contin Educ Health Prof. Available at: http://deepblue.lib.umich.edu/bitstream/2027.42/35027/1/1340240508_ftp.pdf/. Accessed October 15, 2012.
- Bass BL, Polk HC, Jones RS, Townsend CM, Whittemore AD, Pellegrini CA, Busuttil RW, Lillemoe KD, Trunkey DD, Mulholland MW, Grosfeld J. Surgical privileging and credentialing: A report of a discussion and study group of the American Surgical Association. J Am Coll Surg. 2009;209(3):396-404.
- Burney RE, Van Harrison R. Continuing education for practicing surgeons. In: Mulholland MW, Doherty GM, eds. Complications in Surgery. Philadelphia, PA: Lippincott, Williams & Wilkins; 2007:18-24.
- Sachdeva AK. Role of ACS in Advancing Surgical Education and Training. Panel presentation. The Society of American Gastrointestinal and Endoscopic Surgeons. March 8, 2012. Available at: www.youtube.com/watch?feature=player_embedded&v=RjzFy3Yr6Hg. Accessed October 31, 2012.
- Sachdeva AK, Pellegrini CA, Johnson KA. Support for simulation-based surgical education through American College of Surgeons-Accredited Education Institutes. World J Surg. 2008;32(2):196-207.
- University of California Davis Health System. UC Davis Health System Center for Virtual Care recognized by the American College of Surgeons. Press release. February 9, 2011. Available at: www.ucdmc.ucdavis.edu/welcome/features/2010-2011/02/20110209_virtual_care_recognized.html. Accessed October 31, 2012.
- Nussbaum MS. Invited lecture: American Board of Surgery Maintenance of Certification explained. Am J Surg. 2008;195(3):284-287.
- The American Board of Surgery. MOC Part 2—CME and self-assessment resources. Available at: www.absurgery.org/default.jsp?exam-moccme. Accessed October 15, 2012.
- Lewis FR Jr. Maintenance of Certification: American Board of Surgery goals. Am Surg. 2006;72(11):1126-1148.