Surgical education and training at the crossroads between medical school and residency

The landscape of surgical training is changing. Faced with numerous challenges, including duty-hour restrictions, patient safety issues, cost-containment in the operating room (OR), and the medicolegal climate, operative exposure and autonomy during surgical residency have decreased.1-11 Accordingly, numerous strategies, such as simulation and early specialization, have emerged to combat the potential deficiencies in training that may arise from these limitations.12-19 Increased attention also has been directed toward the transition between medical school and surgical residency. Given that an ever-expanding complement of new surgical technologies increases the number of skills trainees are expected to acquire during residency, the interface between undergraduate and graduate medical education provides an opportunity for early skill development with the goal of achieving the proficiency levels necessary to optimize patient care, operative experience, and skill refinement. Innovative curricular approaches have been introduced to prepare incoming surgical trainees to deliver the highest quality of care to patients by leveraging the flexibility of the final year of medical school, the pre-internship period, and the first several months of the surgical internship year.

Many of the same challenges seen in surgical residency, including limited operative exposure and a lack of autonomy, also are present in medical school. These issues may limit medical students’ opportunities to learn or apply technical skills intraoperatively or in the course of their surgical rotations.10,11,20 Contributing to the challenge of ensuring that medical students have achieved adequate technical proficiency are the heterogeneous experiences that different institutions, services, or even surgeons offer.21,22 Hence, even students graduating from the same medical school may enter residency with differing levels of proficiency in knot tying, suturing, and handling of laparoscopic instruments.4,5 Simulation and structured preparatory skills sessions have emerged as interventions to standardize developing proficiency in basic surgical skills and serve as an adjunct to potentially limited intraoperative application.1,4,5,17,23-27

Programs for graduating students

Medical schools have begun to provide structured experiences to fourth-year medical students to build technical proficiency in basic surgical skills; several studies have demonstrated the effectiveness of surgical skills curricula.1,4,5,23,25,26 At Washington University in St. Louis (WUSTL), MO,  for example, fourth-year medical students applying to a surgical specialty program attend a two- to three-hour session for seven weeks, with most of the session dedicated to instruction in technical skills such as suturing, knot tying, chest tube and line placement, intubation, and basic laparoscopic skills.23 Pre- and posttesting of the students in this cohort demonstrated a significant improvement in all five tested suturing and knot-tying skills.21,23 These improvements also extended to basic laparoscopic skills. By the end of the course, students’ tested proficiency scores were not found to differ significantly from those of second-year surgical residents in three of the five suturing and knot-tying tasks.23

Educators at The University of Texas Southwestern (UT-Southwestern), Dallas, also have created a curriculum to develop surgical skills proficiency among graduating medical students entering a surgical field.2,17,19 This curriculum emphasizes attaining proficiency on 12 open tasks for suturing and knot tying.2,17 It also includes the Fundamentals of Laparoscopic Surgery (FLS™) curriculum.19 These students demonstrated significant improvement in both open and laparoscopic skills, with all students meeting the criteria for FLS certification criteria by the end of the course.4 In addition to improving technical skills, curricula such as those implemented at WUSTL, UT-Southwestern, and other institutions have also been shown to increase students’ confidence as they enter their surgical intern year.4,21,25,26

In addition, educational researchers have sought to evaluate factors that optimize the effectiveness of skills training sessions for medical students. Gershuni and colleagues demonstrated that medical students retained technical proficiency longer on basic suturing and knot-tying skills if the surgical skills training occurred at the beginning of the fourth year of medical school as opposed to the spring—possibly due to the application of learned skills in the OR during subsequent surgical sub-internships.1 Regarding methods to provide the best practice for different surgical skills, one group has shown that certain practice patterns are superior to others. When learning laparoscopic percutaneous endoscopic gastrostomy (PEG) transfer, medical students who underwent the proactive interference protocol (for example, practicing a dissimilar task, such as open suturing, between blocks of PEG transfer practice) performed better than students who underwent mass practice (for example, completing all PEG transfer practice blocks in a row).28

It has been shown that when medical students learn laparoscopic skills, expert coaching can positively influence certain performance outcome measures, such as clinical knowledge and error frequency.29 Given that faculty time is a valuable commodity in the structuring of curricula, targeting the tasks that provide the most benefit from faculty instruction will help to optimize efficiency in surgical skills training. Future research may further illuminate which factors enhance medical students’ acquisition of technical skills and which maximize retention of skills.

National efforts

Beyond single institution initiatives, there have been national efforts to address standardization of skills development in medical school graduates.30-32 Since the 1950s, undergraduate medical education has largely consisted of a year of core clinical rotations, followed by a year of elective experiences. Consequently, graduating medical students often have variable clinical experiences and disparate clinical skill proficiency. Since the late 1980s, several landmark reports from blue-ribbon committees decried the lack of a standardized skills curriculum for medical student training.30-32 The Association of American Medical Colleges (AAMC) has spearheaded ongoing efforts aimed at standardizing the fourth-year experience with the goal of producing cohorts of medical students with comparable basic clinical and procedural skills. To this end, the AAMC published a list of skills to which medical students must be exposed and have performed prior to graduation (see Table 1). The AAMC also sought to benchmark curricula and rotations across medical schools to promote a more uniform experience for students from school to school and between rotation sites through curriculum inventory and reports (CIR), part of the AAMC’s Medical Academic Performance Services (MedAPS) initiative.

Table 1. Recommended Undergraduate Medical Skill

Body handling and positioning in OR Aseptic/sterile technique
Venipuncture/venous cannulation (needle, catheter) Pleural aspiration
Arterial puncture Nasogastric intubation
Pulse Doppler examination Anoscopy
Basic cardiopulmonary resuscitation PEG tube replacement
Cardiac defibrillation Paracentesis technique
Advanced cardiac life support Skin biopsy and closure technique
Needle decompression of tension pneumothorax Applying/changing dressings
Subclavian/femoral puncture Joint fluid aspiration
Central venous catheter placement Suturing technique
Chest tube insertion Surgical knot tying

Note: Adapted from Appendix B of AAMC Recommended Skills for Clinical Skills Curricula for Undergraduate Medical Education, AAMC 2005.

In a joint effort, the American College of Surgeons (ACS) and Association for Surgical Education (ASE) produced an online curriculum—the ACS/ASE Simulation-Based Surgical Skills Curriculum for Medical Students—which addresses common clinical and procedural skills relevant to surgical practice, stratified by level of training (see Table 2). This online curriculum includes a step-by-step description of the skills, a discussion of common errors, instructional videos, and various assessment tools for scoring student performance and providing feedback. Most recently, a surgical internship preparatory curriculum was developed in a collaborative effort between the ACS, the ASE, and the Association of Program Directors in Surgery (APDS). This program, the Surgery Resident Prep Curriculum, is currently being pilot-tested across the country. Unlike the curricula described earlier in this article, which emphasizes technical skill development, this initiative also provides hands-on training in domains where experience may be limited in other medical school rotations, such as answering mock pages/common calls, order entry/prescribing, interpreting radiographs, and serving as a first responder to acute/emergent presentations.

Table 2. ACS/ASE Progressive Simulation-Based Skill Acquisition

Year 1 modules Year 2 modules Year 3 modules
Abdominal exam Basic airway management Arterial puncture and blood gas
Basic vascular exam Communication—H&P, case presentation Basic knot tying and basic suturing
Breast exam Foley bladder catheterization Central venous line insertion
Digital rectal exam Intermediate vascular exam Communication—during codes, and safe and effective handoffs
Female and pelvic exam Nasogastric tubes Airway management
Male groin and genital exam Sterile technique—gloving and gowning Interosseus access
Universal precautions Surgical drains—care and removal Local anesthetics
Venipuncture and peripheral IV Paracentesis and thoracentesis

Surgical interns enter their residencies with broad variations in exposure, experience, and skill. Accordingly, structured curricula are necessary to bolster and standardize incoming intern skills and knowledge and to prepare them for the demands of training. The ACS and APDS have developed one such curriculum for implementation at the beginning of internship, which allows first-year residents to demonstrate proficiency in several skills before applying them on the wards and in the OR.18 The Surgery Resident Skills Curriculum includes three progressive phases over the course of residency: (1) attainment of basic skills, such as suturing and knot tying; (2) instruction in advanced procedures, such as laparoscopic/open colon resection and laparoscopic/open bile duct exploration; and (3) refinement of team-based skills, such as patient handoff and trauma team training (See Table 3).17 The use of lifelike simulation is fundamental to the curriculum, with the goal of having residents demonstrate proficiency in each skill set before operating on patients. Additionally, the ACS has introduced the Fundamentals of Surgery curriculum—an interactive, case-based, online curriculum that addresses the essential content areas that all surgical residents should master in the early years of training.

Table 3. Intern ACS/APDS-Based Surgical Skills Curriculum Modules

ACS/APDS phase

Clinical year

Module

1

1

Knot tying/suturing

1

1

Urethral and suprapubic catheterization

1

1

Airway management

1

1

Chest tube and thoracentesis

1

1

Central line insertion/monitoring and arterial lines

1

1

Basic laparoscopy skills

2

1

Open appendectomy

3

1

Patient handoff/preoperative briefing and checklists

1

1

Surgical biopsy

1, 2

1

Hernia anatomy/open inguinal/femoral hernia

Other boot camp-style curricula in surgical training—which are administered before the formal start of internship—have been implemented across the country.5,24,27 Most are tailored to fit the needs or priorities of a given institution, but boot camps may incorporate combinations of didactic sessions, actor-based clinical skills assessment, technical skill and clinical scenario-based simulation, and self-directed Web-based learning modules.18,24 In one study, Parent and colleagues found that a three-day intensive simulation-based boot camp improved interns’ competence and comfort level in central line and chest tube placement when compared with interns who did not participate in the program.5 Although a difference in ability was indiscernible between the groups by mid-year, the boot camp group attained proficiency earlier in their training.5 Furthermore, interns who participated in one boot camp described the intensive curriculum as both useful and relevant. In addition, nursing staff indicated that they believed that the boot camp made interns more respectful, better communicators, and more adept in patient assessment.5 Investigators also observed that more interns scored better on the American Board of Surgery In-Training Examination (ABSITE); this correlation between boot camp training and improvement on ABSITE scores has been demonstrated in other studies as well.5,27

Constraints

Despite the established benefits of simulation-centered, proficiency-based training for matriculating residents, there are certain barriers to adoption of such curricula.5,7,24 Reportedly, up to one-third of general surgery residencies lack an intensive boot camp program.33 Factors such as physical space, staff limitations, and resident time restrictions are commonly cited as impediments to adoption.5,17,34,35 Financial constraints are consistently cited as a barrier to implementation of a surgical skills teaching curriculum among various general surgery training programs.33 The ACS/APDS Surgery Resident Skills Curriculum, which provides free registration through the ACS website and emphasizes low-cost simulators, is estimated to have indirect costs of more than $30,000 per resident.17 Contributing to these expenses are the costs of OR instruments, porcine models, simulation space, simulation center staffing, and administrative costs.33

Limitations on physical space add to cost concerns as well as logistic challenges, particularly when an institution lacks a dedicated simulation center. Furthermore, proficiency or competency testing necessitates engaging faculty surgeons, who are increasingly pressured in the current health care environment to increase clinical productivity and are not necessarily compensated or recognized for educational efforts.33 Duty-hour restrictions, particularly those affecting interns, have likewise limited the time available for structured or mentored simulation-based technical training.35
Challenges notwithstanding, there is value in bridging the gap in knowledge, skills, and competencies among medical school graduates to better meet the overarching demands and expectations of a surgical internship. Efforts such as surgical boot camps and the ACS/APDS Resident Skills Curriculum have proven useful in optimizing this transition.

Pathway to the future of patient care

The crossroads of medical school and surgical internship provides a unique opportunity to meet the challenges of a shifting landscape in surgical education and training. With numerous factors limiting operative exposure and involvement, competency-based curricula allow for earlier proficiency in technical skills and clinical knowledge and provide worthwhile preparatory experiences. Collectively, these efforts serve to expedite the learning curve of early internship to optimize the delivery of patient care, refinement of pre-existing skills, and acquisition of advanced skills. As newer technologies and techniques, such as single-site laparoscopy, robot-assisted operations, and endoscopic procedures, become further incorporated into the training curricula, it will become exceedingly important for surgical trainees to arrive with a baseline level of proficiency in basic or fundamental surgical skills and knowledge. These abilities, after all, will serve as the foundation of their entire surgical career.


References

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