Early surgical subspecialization: A new paradigm? Part II

Interviewees

Barbara L. Bass, MD, FACS, is the John F. and Carolyn Bookout Distinguished and Endowed Chair of Surgery at Methodist Hospital Research Institute, Houston, TX, and professor of surgery at Weill Cornell Medical College, New York, NY.

John J. Ricotta, MD, FACS, is the Harold H. Hawfield Chair of Surgery and professor of surgery at Georgetown University, Washington Hospital Center, Washington, DC.

Keith A. Delman, MD, FACS, is the general surgery residency program director and associate professor of surgery at Emory University-Winship Cancer Institute, Atlanta, GA.

Michael A. Awad, MD, FACS, is an assistant professor of surgery, the associate dean for medical student education, program director of the general surgery residency, and director of the Institute for Surgical Education at Washington University School of Medicine, St. Louis, MO.

Thomas H. Cogbill, MD, FACS, is the program director for the Transition to Practice Fellowship at Gunderson-Lutheran Hospital in La Crosse, WI, and the chair of the American Board of Surgery.

The practice of general surgery is constantly evolving. Numerous factors such as advances in surgical knowledge, techniques, and technology, as well as patient and physician preferences, have driven an increasing numbers of surgeons to specialization. More general surgery (GS) graduates are specializing; in fact, more than 80 percent of graduates of general surgery programs are pursuing additional training beyond the five-year surgical residency.1

To accommodate these trends, a number of early-specialization training models have emerged.  Models vary with respect to time of entry, board certification process, and length of training. The most well-established approach is the fully integrated model, which is used in plastic, vascular, and cardiothoracic surgery. In 2004, the American Board of Surgery (ABS) approved the Early Specialization Program (ESP), whereby residents interested in vascular or cardiothoracic surgery would receive one year of fellowship credit for pursuing 12 months of their respective subspecialty training during their fourth and fifth years of general surgery residency.2 For approval, programs must demonstrate that residents are able to complete the caseload requirements for general surgery board certification and must have a fellowship program in vascular or cardiothoracic surgery, into which residents would track.

Most recently, in 2011, the ABS approved a flexibility in surgery training option (or FIST), which allows general surgery residents up to 12 months of flexible rotations within postgraduate years (PGY) 3–5 to tailor training to a resident’s future career interests.3 Although there has been a strong trend toward specialization, a countervailing movement has advocated for the strengthening of broad-based general surgery. This year, the American College of Surgeons (ACS) began pilot testing the ACS Transition to Practice Fellowship in General Surgery for trainees who plan on becoming community or rural surgeons at five sites around the country.4

The authors of this article had the opportunity to discuss early specialization options and the transition to practice program with residency directors and national leaders in surgical education.  (For the full names and titles of the surgeons interviewed, see the sidebar.) Through the following excerpts from our interviews, we hope to convey some prevailing thoughts on current experiences with early specialization, the challenges encountered, and the future of early specialization and general surgery training paradigms.

What are the practical considerations in deciding whether it is prudent or feasible to begin a new training pathway?

Integrated programs
Dr. Bass: “For our integrated vascular track, which we started two years ago, we looked at three main criteria. First, it was really the endovascular revolution that pushed us over the top. We had already started to see it as a natural evolution of this surgical subspecialty. When certain subspecialties mature into their own unique set of diagnostic and therapeutic tools, they are ripe for picking.  Second, I think it’s a matter of what the needs of your community are. In Houston, and in probably the vast majority of large cities, what you need are deep and narrow surgeons. If you’re in rural Texas, that’s probably not the case. Third, we had the volume, the faculty expertise, and a track record of teaching by the faculty. In addition, we had a general surgery residency that was able to lend the foundational aspects of all surgery: wound management, critical care, etc., to the vascular residency.”

Dr. Ricotta: “I see the gulf between skills needed for vascular and general surgery residents widening. Over the last decade, general surgery residents are less well-trained in vascular surgery than they were; often, even those who have had an interest had little experience in the operating room, especially in aortic procedures. Paradoxically, the experience was often the worst where vascular surgery was the strongest, because of the vascular fellows.”

FIST
Dr. Delman: “When the opportunity came to join a group of programs [that] will not only jointly pursue the FIST option within their institutions, but study it and collect data to see the impact on resident education, we jumped at the chance. The big issues for us were: first, making sure that the fellowships at our institution and the specialty divisions were supportive and willing to work towards this end; second, ensuring that we could do this while not compromising the resident who wanted the traditional Emory [Atlanta, GA] training experience; and finally, the actual scheduling of the residents into these flexibility options while still covering all of our services.”

ESP
Dr. Awad: “There are a couple of things that are important when you have an ESP.  It is important to have a traditional 5+2 or 5+3 in vascular or CT [cardiothoracic] surgery, respectively.  The reason for this is in case you do not have residents in a given year that are interested in pursuing vascular and CT surgery ESP. We have actually had a fairly persistent track of folks [who] have wanted to pursue those specialties, so it has not been a terribly big issue, but you do need to have that backup option such that in a given year if you do not have a resident [who] wants to pursue that, you can still match a senior trainee through a traditional fellowship match.

“In vascular ESP, one pursues four years of general surgery, such that in the PGY-5 year, all rotations are in vascular surgery.  It is your chief year, but really your first year of vascular fellowship.  So, if you had a year where you did not have anybody slotted for that position, then presumably you could still match somebody through the formal match. Cardiothoracic is split up differently, with six months as a PGY-4 and six months as a PGY-5, then that together is considered one year of fellowship. Then they do two additional years, PGY-6 and 7, of formal cardiothoracic fellowship. That does trim it down a year, but their first year is split up, instead of contiguous like in vascular surgery.

“I do think that it does take a certain critical mass of categorical residents, because if you had a smaller program, say five categoricals, and two or three of them went into a cardiothoracic or vascular ESP, then you are down that many chief residents and that can have significant impact on your program.”

Transition to practice
Dr. Cogbill: “There were four major considerations. First, protection of our GS residents. We have a small program of three chiefs each year and we wanted to make sure that the fellows would not be competing for the same high-level cases as our senior residents. Second, protection of our young faculty. These faculty [members] are also trying to build their practices, so we wanted to make sure that the fellows would have enough cases that they wouldn’t start affecting the young faculty. Third, coordination and buy-in from other specialties. We needed orthopaedics/hand, obstetrics-gynecology (OB-GYN), gastroenterology (GI), otolaryngology (ENT) on board to agree to help train a fellow. And fourth, balance autonomy with supervision.

“Our intake process for our new fellow would look like this: we would examine his or her current level of skill and experience, consider his or her career goals, and design a one-year curriculum to fit those needs. Six months would be spent in the fields of orthopaedics/hand, OB-GYN, GI, ENT, and up to six months would be spent on a rural surgery rotation in community hospitals based in towns with populations of less than 10,000 people.”

What are the advantages to establishing these new tracks?

Integrated programs
Dr. Ricotta: “Exposure to vascular surgery for a number of months every year for five years has a number of advantages. The total exposure to both open and endovascular cases and the exposure to the outpatient practice of vascular surgery are much more complete with a 36-month experience through the vascular integrated program than it is in the independent program. Graduated responsibility is much more easily achieved than it is in a two-year program. Also, our vascular residents attend our conferences for five years instead of two and the breadth and depth of their experience should be anticipated to be better than a two-year program. Finally, I also saw a different source of vascular trainees to tap into. The number of general surgery residents choosing vascular has been static for about a decade. We were not going to train more vascular surgeons if we did not tap into a new source of trainees.”

FIST
Dr. Delman: “Next year, we will have flexibility options in endocrine, surgical oncology, plastics, comprehensive general surgery/global health, minimally invasive/advanced foregut, and transplant.  We have always supported the concept that learners learn better when pursuing an area of interest, and teachers are more enthusiastic when the learners are engaged.  As a result, I have always supported the idea of electives and have believed that, within the constraints designed by the ABS, it is nice to allow residents some opportunities to garner ‘personalized education’ that will enhance their career.”

Dr. Awad: “The ability to do the flexibility option will be very attractive and will draw some of the best applicants. Certainly in our own institution we have seen that…some of the really top-notch applicants coming to our program have come in the last few years because of the ability to do vascular or cardiothoracic ESP. Now that the word is out in this coming year when we have a flexibility option and we are really implementing it across the board, we are curious to see, with our applicant pool, whether or not that impacts their decision to come to our institution or others that offer this [option] as well.

“This [option] will allow more exposure and more experience earlier, and as the name implies provide you with flexibility. In the past the Resident Review Committee (RRC) and ABS have been very strict about making sure that everyone looks the same (in fact, you get a citation by your RRC) and that all your residents should have the same rotations—that they should have similar case numbers for any given year of residency—whereas now, it allows folks to look different from each other, and that is something fairly new and exciting.”

ESP
Dr. Awad: “The benefits are that the ESPs can shorten a year of your training. In those two specialties [cardiothoracic and vascular] in particular, the residents are still eligible for general surgery boards, but if they found out that they were not able to or that they did not want to sit for their boards, it would not jeopardize their careers; they could still pursue a career in vascular surgery or cardiothoracic surgery…. We have really studied our experience with those two programs, carefully looking at the in-service training exam scores and the board passage rates, as well as their qualifications to sit for the boards, such as their case numbers and so forth.  We found that they were able to meet all their case numbers even if they did one less year of general surgery, they were still doing well on the American Board of Surgery In-Service Training Exam, and they were still passing their vascular and cardiothoracic surgery board exams.”

TTP
Dr. Cogbill: “One-third of graduating chiefs do not feel comfortable practicing independently. I think there is a clear need for a fellowship program such as ours for the new graduate who wants to perhaps practice in a rural or underserved setting.”

What concerns do you have about these new programs?

Integrated programs
Dr. Bass: “There has certainly been some angst about whether the final surgeon produced from these new integrated training pathways will be as good as [those surgeons who trained under] the traditional 5+2 model, and it’s too early to tell. But the same concerns existed for plastic surgery when they began integrated programs, and now most people would agree that the final surgeon product is equivalent. There is also angst about whether medical students coming out of residency know what they’re committing to. The average general surgery resident will change their minds several times about the type of fellowship they want to pursue.  But again, we had the same concerns about orthopaedics, urology, etc., in the past, and the people who go into urology stay in urology.”

What have been the challenges in implementing your new programs?

Integrated programs
Dr. Bass: “In the beginning, our general surgery night float system took vascular call, but it became clear that the volume of vascular care required at night required an extra resident in house, so we split the system and now vascular takes their own calls. We’ve had some lateral moves out of general surgery residency into the vascular residency in the beginning. One drawback is that we have probably seen a decline in interest in our own general surgery residents in going into vascular surgery, and since we no longer have a vascular fellowship, we currently have no pathway for them here if that’s what they want to do; they’ll have to go somewhere else.”

Dr. Ricotta: “The operative experience in the first three years and, in particular, on the core surgery rotations have been lower than anticipated. Part of this [equation] is the desire to “save” cases for general surgery residents, but part is because junior general surgery trainees simply do not operate much in most programs. It has also been a challenge to have our vascular faculty let junior trainees, even in vascular surgery, do major parts of vascular reconstructive operations such as carotids and distal bypasses or open aortic exposures. We are used to not allowing junior residents to do much, and this now has to change. Finally, some of the core rotations we chose have had to be altered because they did not give the residents the experience that we thought they would.”

ESP
Dr. Awad: “You have to really map out carefully the resident block or resident cohort in any given year for the next couple of years for people who are going to do the ESP so that you are not going to be short in that given year.  We have to pick these folks in their third year of residency, and for CT it is fairly early in the third year when that decision is made. We have to march out our grids and look at what our resident complements will be a year from now, two years from now, and make sure there is not a significant impact there, and if there is, [determine] how we are going to mitigate that.  Sometimes it works out…we have somebody coming out of the lab earlier and it just happens to march out. But we have to be very careful and that’s one of the challenges we identified early.”

TTP
Dr. Cogbill: “This is the first cohort of five programs piloting transitions to practice. There will be some leeway in the start time, it may not be in the traditional academic year, but there will be standardization in terms of total length of the fellowship (1 year).”

What additional specialties will be ripe for new tracks?

Dr. Ricotta: “I would like to see advanced minimally invasive surgery, which I see as the basis of general surgery, brought back into the core general surgery training, along with enhanced endoscopy and good training in bariatric surgery.  I think that advanced surgical oncology and hepatopancreaticobiliary  should probably merge.”

Dr. Bass: “The wish list would be thoracic and perhaps then, further down the line, colorectal. For thoracic, we have an existing co-managed fellowship that we would have to evolve first. It may be best for that [fellowship] to live in the 3,4,5 tailored modification [flexibility option] for a few years before fully integrating the track. Again, a lot of this depends on our community and the local resources/expertise over the next couple of years.”

Conclusion

Since 1968, surgical specialties such as urology, ENT, and orthopaedics have reduced or eliminated their time in general surgical training to accommodate increased exposure to their subspecialty.1 In similar fashion, there is presently a trend toward the development of alternative tracks or pathways to provide earlier or increased exposure to subspecialties and disciplines that were traditionally two- to three-year fellowships after the completion of five years of general surgery training.

There is certainly an interest in and place for early specialization in surgery today.  Various early specialization routes are attracting highly competitive medical student applicants. Many of these applicants are interested in completing their training sooner, paying off medical school or undergraduate debt faster, and developing a more focused area of expertise.2,5  This [option] is particularly relevant in a medical world with rapidly expanding knowledge and advancing technology.  Furthermore, an increasingly well-informed public frequently seeks advanced and specialized care.5 Moreover, some evidence indicates that complex operations performed by specialized, high-volume surgeons have better outcome.1

The enthusiasm for early specialization is tempered with a pragmatic understanding and mindfulness of the importance and need for broad-based general surgeons. There is also concern that increased focus on early specialization will reduce interest in general surgery. The fact of the matter is that the need for general surgeons is increasing as community-based general surgeons provide the majority of surgical care delivered in the U.S.1 Consequently, there is a growing need for more broadly trained surgeons capable of addressing a diverse array of surgical conditions.1 Concerns have also been raised regarding accountability for the surgical patient as a whole, as one job of specialists is often to determine whether a problem falls within their scope of expertise or practice.6 As Dr. C.M. Ferguson, former director, Massachusetts General Hospital, Boston, cautions, “as a surgeon concentrates on a single disease and becomes more specialized, he or she becomes less competent in treating other diseases. The specialist becomes disease centered rather than patient centered.6

Dr. Awad noted that much of the current training paradigm is based on tradition and history and not necessarily educational theory or practices. Early specialization is still young, and the outcomes that these new models may yield will certainly have a significant impact on future surgical training. As Walter Longo, MD, professor of surgery at Yale University School of Medicine, New Haven, CT, reaffirmed in stating the principles of surgical training, “It is the goal of general surgery residency training to produce competent surgeons who will be able to meet the challenges of innovation, new technology, difficult pathology, and above all, to be safe, compassionate doctors.”5 The challenge rests in developing training paradigms that satisfy and reconcile surgical history and tradition with educational rationale, as well as with the needs of physicians, patients, and society.


References

  1. Stain SC, Biester TW, Hanks JB, Ashley SW, Valentine RJ, Bass BL, Buyske J. Early tracking would improve the operative experience of general surgery residents. Ann Surg. 2010;252(3):445-449; discussion 9-51.
  2. Klingensmith ME, Valentine RJ. Early experience with alternative training pathways: A view from the trenches. J Surg Educ. 2009;66(2):80-84.
  3. The American Board of Surgery. Flexible rotations during general surgery residency. Available at: www.absurgery.org/default.jsp?policyflexrotations. Accessed May 20, 2013.
  4. Hoyt DB. Looking forward. Bull Am Coll Surg. 2013;98(2):7-10.
  5. Longo WE, Sumpio B, Duffy A, Seashore J, Udelsman R. Early specialization in surgery: The new frontier. Yale J Biol Med. 2008;81(4):187-191.
  6. Ferguson CM. The arguments against fellowship training and early specialization in general surgery. Arch Surg. 2003;138(8):915-916.

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