For the past several years, the ongoing ability of patients to have access to high-quality surgical care has been of increasing concern to the American College of Surgeons (ACS) Board of Governors (B/G). The Governors and their constituents have noted dual problems: (1) a relative deficiency in generalist surgeons, and (2) questions about the preparedness of newly trained surgeons and their ability to embrace practice immediately. Although a lack of generalist surgeons is a problem in several surgical specialties due to increasing subspecialization, these issues have been particularly acute in general surgery. With the clear recognition that the problem was broader than general surgery alone, the ACS Board of Regents initiated a program designed to address both the shortage of general surgeons entering practice and their preparedness for such an undertaking.
Concerns about residents’ preparedness for general surgery practice have been present for several years and range from anecdotal conversations among senior surgeons hiring young partners to statistical evidence suggesting a fundamental lack of experience with managing common general surgical problems. The annual survey of the B/G has noted problems with residency training and issues with some recent graduates for the past several years.1 Concurrently, while the American Board of Surgery (ABS) qualifying examination (written) pass rate has remained consistent over time, the certifying examination (oral) failure rate has increased from 15 percent in 2003 to more than 25 percent at the present time.2 The latter examination traditionally has been viewed as a better test of a trainee’s judgment, operative experience, and ability to ensure patient safety.
Several recent papers have surveyed the operative experience of recent surgical trainees and noted worrisome trends.3-5 Bell presented an excellent presidential address to the Central Surgical Association titled Why Johnny Can’t Operate, in which he outlined the problems and root causes underlying the lack of preparedness for a surgical career. The main finding was the widespread disparity in operative experience among residents. Indeed, surgeons entering practice reported performing only 20 operations more than 10 times in their residency (n = 114).3
Additionally, many trainees note that they do not feel prepared for broad-based general surgical practice. Bucholz and colleagues reported on a survey of a large cohort of general surgery residents, noting that 25 percent of senior residents felt unprepared for independent practice.6 Data from a more recent survey presented at the 2012 Southern Surgical Association meeting demonstrated similar concerns.7 Finally, a recent paper presented at the American Surgical Association reported on a survey of fellowship program directors, which noted that 30 percent of fellows were not prepared for operative cases and nearly two-thirds could not work unsupervised for a significant period of time (n=91/145).8 The fact that 80 percent of general surgery graduates pursue fellowships likely stems, at least in part, from a feeling of inadequacy to pursue broad-based practice.9
A 2012 survey of practicing surgeons that the Southeastern Surgical Congress (SESC) conducted revealed that 37 percent disagreed or strongly disagreed with the statement, “Graduates of surgery residencies today are prepared to enter into the clinical practice of surgery,” compared with 40 percent who agreed with the statement (n=177/1,008).10
One must be careful in interpreting such studies, however. There are no comparative surveys of the performance of new graduates trained before duty-hour restrictions were imposed in 2003, and there is considerable bias in opinion surveys that is not based on direct experience. In the SESC survey, for example, 50 percent of surgeons whose group had hired a surgeon trained under duty-hour restrictions (that is, after 2008, the first cohort of residents whose five years of training fell completely under the requirement) felt that general surgery residents were prepared to practice.10 Only 20 percent of surgeons who had not hired a recently trained surgeon felt the same way.10
Program directors who follow the careers of their former trainees know that the surgeons who are most successful in their first jobs out of residency are chief residents who enter practices with senior surgeons who are generous with his or her time and experience and willing to actively mentor young surgeons. In the SESC survey, three-fourths of surgeons adding a recently trained surgeon gave their new associate first assistant help during their first year in practice, and more than 80 percent came in and helped out on a case that came in on one of their new associate’s nights on call.10 Far from being an indictment of the inadequacy of today’s surgical training, these data reflect the fact that surgical training continues after residency. The best situations for surgeons who are new to active practice have always been those in which senior surgeons act as their mentors, often for years after graduation.
The potential reasons for the perceived lack of preparedness are myriad and have been well articulated in multiple venues. Duty-hour restrictions have effectively taken one year out of surgical training, and the micromanagement of the hours worked within the 80-hour limit has further complicated the progression of graded operative responsibility. The nature of surgical residencies has changed from one in which general surgery role models were the norm to one in which specialty services have primacy. Most academic centers have few, if any, broad-based surgeons for mentors, and experiences with community surgeons were often jettisoned as a reaction to the duty-hour restrictions. Chief residents once had significant autonomy and actually ran services. In many institutions today their autonomy is limited and the first truly independent decisions chief residents make may occur after they enter practice. A combination of factors likely have contributed to this loss of autonomy, including hospital concerns, the medico-legal environment, billing pressures regarding supervision, legitimate ethical issues, and the patient safety movement.
Multiple attempts have been made to address current issues in general surgery training. Efforts to allow increased chief resident autonomy have been made with little positive effect. Multiple new training paradigms have been proposed, most touting the benefits of earlier specialization. The ABS has an initiative to “fix the five,” referring to the general surgery training length, while other stakeholders have espoused adding a sixth year of training. Although these efforts are well-intentioned, none has been completely successful.
Currently, 80 percent of general surgery graduates now pursue fellowships. Unfortunately, many trainees who pursue narrow, high-end specialties within general surgery now have difficulty finding a job.9 One could reach the seemingly irrefutable conclusion that the current U.S. training system is not producing the type of surgeon the country needs. We are producing too few general surgeons, and many of the general surgeons now embarking on their careers feel unprepared for practice. It also appears that market forces have had little impact in correcting this perceived imbalance between “generalist” general surgeons and specialties under the umbrella of “general surgery.”
The ACS leadership believes the College can play a part in achieving surgical preparedness for general surgeons without posing any conflict to the programs and requirements of the ABS, the Accreditation Council for Graduate Medical Education (ACGME), or the Residency Review Committee for Surgery. After discussing the issues with the leaders of these bodies, the ACS embarked on an endeavor designated as the Transition to Practice (TTP) in General Surgery program. A steering committee was formed consisting of a number of surgical educators, many of whom also hold leadership positions within the College (see sidebar).
Although 80 percent of current general surgery trainees pursue fellowships, we have refrained from referring to our program as a “fellowship” and have used the term “associate” to describe the participant because the young surgeons may already be in practice.
The elements of the TTP program are simple and may remind older surgeons of their own chief residency, which provided opportunities for autonomy with appropriate mentorship. Leadership by senior or more experienced surgeons who will mentor these younger associates is crucial to the viability of this program. If the junior associates emanate from a general surgery program other than the TTP program, a period of intake assessment to determine the skill set, judgment, and maturity of the new associate is vital. Ideally, the junior associate should progress and be given the graded responsibility that is key to developing safe, competent surgeons. While graded responsibility is a widely espoused tenet in residency training, its execution has become increasingly difficult.
In addition to having autonomy with appropriate mentoring available, some significant interaction with broad-based general surgeons is a mandatory component of the TTP program. Hopefully, this experience can be gained, at least in part, in a community practice. The clinical focus should be on problems encountered in a general surgical practice—not necessarily with involvement in high-end tertiary problems or operations. The ACS TTP Steering Committee would prefer that the institutions offering TTP programs be diverse and flexible in meeting the associates’ perceived needs. Some programs will undoubtedly prepare surgeons for a more rural or small community practice, while others might offer an urban or suburban experience. The committee believes associates also should have some experience with practice management responsibilities, such as coding, billing, contract negotiation, and so on.
It is essential that the director of the TTP program or a responsible surgeon in the program conduct an ongoing evaluation of junior associates to ensure that their educational needs are met.
Defining the TTP program
Clearly, the TTP program must not interfere with the current training of general surgery residents. If that occurs, current residents may find their training and autonomy even further impeded. Therefore, if an ACGME-accredited general surgery residency program intends to implement a TTP program, it should use community resources or opportunities to practice that are not competitive with those of senior residents. To that end, the committee also encourages TTP opportunities at institutions that do not offer residencies. Institutions that would like to design a TTP program should have as strong a commitment to mentoring young associates as they would a new partner in their practice.Although some programs will use rural surgeons in the TTP experience, rural surgery is not exclusively the focus. There is a need for general surgeons in many urban and suburban areas of the country, and the committee anticipates that programs can be developed in disparate geographic areas with diverse population densities.
The committee stresses that the TTP program is not envisioned as a requirement for general surgical practice. Certainly many trainees are well-prepared after their residency and do not need this experience. Likewise, TTP programs are not intended to be remediation for subpar general surgical residents. In fact, many residents who have excellent fundamental training would benefit from an additional year of mentoring to increase both their competence and confidence. The ACGME process must, by necessity, be heavily rules-oriented. The application and review process for TTP programs is meant to be the opposite, with a focus on practical experience rather than on rules and checklists.
Challenges and hurdles
Developing such a program is a daunting task, but the College has an excellent track record of promulgating and verifying a variety of endeavors that have enhanced surgical care in the U.S. One only has to review the history of the Committee on Trauma’s Trauma Center Verification Program and the enormous growth of the Advanced Trauma Life Support® course to imagine the possible success of the TTP initiative. The College’s leadership has committed major financial resources to the development of this program and the infrastructure for establishing the initiative is well under way.
A few pilot programs will begin in 2013, and it is anticipated that more programs will be developed in 2014 and beyond. Financing is an issue as these positions do not have ACGME accreditation, but the services that associates provide should be billable. Credentialing and licensing timelines are problematic and potential associates should ideally make an early decision in the year preceding the onset of the TTP year to allow for appropriate documentation of the ability to practice.
The steering committee has been encouraged by the interest surgical educators have shown in developing such programs and believe there is an unmet need on the part of general surgery trainees for additional experience. Clearly, enormous practice opportunities in general surgery are available throughout the country.
Despite the challenges, if successful, the ACS TTP program will offer a structured experience for the first critical year after graduation from residency. More than doing additional cases, the new associate will take the necessary steps of autonomy and independence under a formal mentorship with his or her senior associate—a relationship that characterizes the best practice situations for any surgeon entering the practice of surgery.
Application process and site visits
Applications for initiating a TTP program will be available through the ACS website. (For more information, visit www.facs.org/ttp/.) The application process consists of a few pages in which a narrative describing the program can be entered online. The ACS will then conduct a site visit to ensure that those individuals who are sponsoring the program are committed to the effort. For more information, contact the ACS Division of Education at firstname.lastname@example.org or 312-202-5491.
- Napolitano, LM. Report on the ACSPA/ACS activities: October 2012. Available at: www.facs.org/about/governors/acspa-acs1012.html. Accessed July 25, 2013.
- American Board of Surgery. General surgery examination statistics. Available at: www.absurgery.org/default.jsp?statgeneral. Accessed July 25, 2013.
- Bell RH. Why Johnny can’t operate. Surgery. 2009;146:533-542.
- Kairys JC, McGuire K, Crawford AG, Yeo CJ. Cumulative operative experience is decreasing during general surgery residency: A worrisome trend for surgical trainees? J Am Coll Surg. 2008;206(5):804-811.
- Bell RH Jr, Biester TW, Tabuenca AW, Rhodes RS, Cofer JB, Britt LD, Lewis FR Jr. Operative experiences of residents in the U.S. general surgery programs: A gap between expectations and experience. Ann Surg. 2009;249(5):719-724, 2009.
- Bucholz EM, Sue GR, Yeo H, Roman SA, Bell RH Jr, Sosa JA. Our trainees’ confidence: Results from a national survey of 4136 U.S. general surgery residents. Arch Surg. 2011;146(8):907-914.
- Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV. Early subspecialization and perceived competence in surgical training: Are residents ready? J Am Coll of Surg. 2013;216(4):764-771.
- Mattar S, Minter RM, Alseidi A, Jeyarajah DR, Swanstrom LL, Wexner SD, Aye RW, Martinez J, Franklin ME, Ross SB, Arregui ME, Jones, DB, Schirmer BD. General surgery residency inadequately prepares trainees for fellowships: Results of a North American survey of program directors. American Surgical Association 133rd Annual Meeting, Indianapolis. April 2013. Abstract available at: http://meeting.americansurgical.info/abstracts/2013/8.cgi. Accessed July 22, 2013.
- Jancin B. Surgical fellowship directors: General surgery trainees arrive ill prepared. The Oncology Report. May 1, 2013. Available at: www.oncologypractice.com/oncologyreport/news/top-news/single-view/surgical-fellowship-directors-general-surgery-trainees-arrive-ill-prepared/acff138f720e8c206897ecdf0bb04353.html. Accessed July 25, 2013.
- Nakayama DK, Taylor SM. SESC Practice Committee Survey: Surgical practice in the duty-hour restriction era. Am Surg. 2013;79(7):711-715.