The evolution of surgical training in the U.S. is best described as punctuated equilibrium—periods of stasis followed by abrupt change. In 1889, William S. Halsted, MD, FACS, rejected homespun apprenticeships and standardized surgical education with a pyramidal residency model.1 Inevitably, this model fueled competition, as the mastery of skills requisite for independent practice was only guaranteed to the single resident reaching the pyramid’s peak until Edward D. Churchill, MD, FACS, developed a rectangular model at the Massachusetts General Hospital, Boston, in 1938.2 This core training model remained relatively unchanged until disciplines such as neurosurgery and orthopaedics, driven by expanding knowledge in their disparate fields, began to forgo general surgical training altogether. In the current era, laparoscopy and the endovascular revolution, individual interests, health care reform, evidence-based practices, and quality initiatives are bringing surgical leaders to realize that mastery of the entire breadth of traditionally defined general surgical practice cannot be achieved by a single individual or training paradigm.
The first three years of current training provide a solid foundation with exposure to the major subspecialties, core surgical techniques, critical care, and perioperative management of complex patients. The latter years, however, are inadequate in refining the technical skills and mastery required for independent practice, in part due to restrictions associated with the 80-hour workweek and decreased resident autonomy.3,4 Adding to these challenges is an unspoken requirement to pursue a niche if one desires a successful academic career. Consequently, 80 percent of current general surgery graduates pursue fellowship training, resulting in a training paradigm that lasts far too long in the face of burgeoning student debt and that counterintuitively allocates less than a quarter of total training time to the ultimate field of practice.5 It is also important to note that five years of training ingrains technical habits that may have to be partially unlearned in specific fellowships. These issues likely contribute to the decline in caliber of general surgery applicants and the difficulty some training programs have in filling positions.6
Current fellowship training also is flawed. Health care is embracing a disease-based approach to patient care, blurring the line between surgical and medical specialists. Surgeons have always taken pride in acting not as mere technicians, but as physicians who can offer operative therapy. Upholding this standard in the current era demands interdisciplinary knowledge and is epitomized by the vascular surgeon who has evolved into a specialist in the diagnosis, medical management, and operative management (open and endovascular) of vascular diseases. Similarly, surgical oncologists have become integral to the multidisciplinary cancer team and have acquired knowledge of radiation oncology and chemotherapy. Trauma and acute care surgeons have mastered critical care and are pursuing training in echocardiography and basic endovascular techniques for resuscitation, while rural surgeons seek training in rudimentary urology, orthopaedics, and gynecology.7-9 Interdisciplinary knowledge is also essential for minimally invasive and colorectal surgeons who have reclaimed endoscopy and are advancing the field with robotics, transanal endoscopic microsurgery, and natural orifice transluminal endoscopic surgery.10,11
Today, offshoots of general surgery demand mastery of a body of knowledge as expansive as the parent field. In officially recognized subspecialties such as vascular and cardiothoracic surgery, the result has been longer fellowship training. In other areas, there is a push toward distinct board recognition in breast, endocrine, bariatric/minimally invasive, colorectal, transplant, oncology, pediatric, hepatic/biliary/pancreatic, and acute care surgery, though only four of these areas had official certification as of 2012.9 The trend toward subspecialization is here to stay, and the means to this end must be consolidated.
Plastic, vascular, and cardiothoracic surgery have adopted integrated pathways recruiting trainees directly from medical school, attracting a higher caliber of applicant.12,13 Reallocation of time provides formal exposure to pertinent areas such as noninvasive duplex imaging, vascular medicine, echocardiography, cardiac catheterization, and critical care that is not currently obtained in traditional fellowships while simultaneously shortening training time.
These nascent training paradigms, however, are by no means without shortcomings. There is a natural concern that medical students, having only been exposed to a few months of surgery, may not be certain about the desire to pursue such highly specialized training. Surveys demonstrate that approximately 78 percent of 12,000 postgraduate year-one residents changed their predicted subspecialty focus by the fifth year of training and raise concerns about mid-training resident attrition.14-16 Additionally, faculty in these programs face the challenge of training residents with minimal technical skill and clinical acumen compared with traditional trainees who have had five years of surgical maturation.15-17 These integrated models raise concerns for the eventual direct recruitment of medical students into the array of subspecialties, noted earlier, and consequently, the demise of core general surgery training that unifies these fields.
For these reasons, residency reform cannot occur without concomitant fellowship restructuring. The ideal training model should be anchored by a core surgical residency program modeled after the first three years of the current training paradigm, followed by an additional one-to-three year fellowship in one of the areas mentioned in this article. Similar “3+3” pathways already exist in cardiothoracic and vascular programs, and this concept logically follows the recent adoption of early specialization pathways by the Accreditation Council for Graduate Medical Education. Because the first three years of this model would not lead to board certification, the greatest challenge for the American Board of Surgery would be to create certification for all of these various fields, which is already occurring and will ensure standardized training of the highest caliber.
This training paradigm would be apportioned properly and facilitate informed decision making in choosing subspecialty training, fostering the requisite skills for successful practice in the modern era. Even with these substantial gains, overall training time will be unchanged or reduced in some cases. Finally, a specific fellowship dedicated to training community surgeons, paralleling the fourth and fifth years of current training, will provide a path through which general surgery would survive among its offshoots. Dr. Churchill was indeed ahead of his time in 1938 when he said “a frozen five year curriculum is unthinkable as it allows no latitude for the development of individual interests and proficiency.”2
- Rutkow I. The education, training, and specialization of surgeons: Turn-of-the-century America and its postgraduate medical schools. Ann Surg. 2013;258(6):1130-1136.
- Grillo HC. Edward D. Churchill and the “rectangular” surgical residency. Surgery. 2004;136(5):947-952.
- Napolitano LM, Savarise M, Paramo JC, et al. Are general surgery residents ready to practice? A survey of the American College of Surgeons Board of Governors and Young Fellows Association. J Am Coll Surg. 2014;218(5):1063-1072.e31.
- Drake FT, Horvath KD, Goldin AB, Gow KW. The general surgery chief resident operative experience: 23 years of national ACGME case logs. JAMA Surg. 2013;148(9):841-847.
- Foley PJ, Roses RE, Kelz RR. The state of general surgery training: A different perspective. J Surg Educ. 2008;65(6):494-498.
- Cockerham WT, Cofer JB, Biderman MD, Lewis PL, Roe SM. Is there declining interest in general surgery training? Curr Surg. 2004;61(2):231-235.
- Velmahos GC. Acute care surgery: From de novo to de facto. Surg Clin North Am. 2014;94(1):XIII-XV.
- Villamaria CY, Eliason JL, Napolitano LM, Stansfield RB, Spencer JR, Rasmussen TE. Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) course: Curriculum development, content validation, and program assessment. J Trauma Acute Care Surg. 2014;76(4):929-35; discussion 935-936.
- Stain SC, Cogbill TH, Ellison EC, et al. Surgical training models: A new vision. Broad-based general surgery and rural general surgery training. Curr Probl Surg. 2012;49(10):565-623.
- Nussbaum MS. Surgical endoscopy training is integral to general surgery residency and should be integrated into residency and fellowships abandoned. Semin Laparosc Surg. 2002;9(4):212-215.
- Davis BR, Vitale GC. Endoscopy for the general surgeon. Adv Surg. 2008;42:277-297.
- Zayed MA, Dalman RL, Lee JT. A comparison of 0 + 5 versus 5 + 2 applicants to vascular surgery training programs. J Vasc Surg. 2012;56(5):1448-1452.
- Lee JT, Teshome M, de Virgilio C, Ishaque B, Qiu M, Dalman RL. A survey of demographics, motivations, and backgrounds among applicants to the integrated 0 + 5 vascular surgery residency. J Vasc Surg. 2010;51(2):496-502; discussion 502-503.
- Vick LR, Borman KR. Instability of fellowship intentions during general surgery residencies. J Surg Educ. 2008:65(6):445-452.
- Lebastchi AH, Tackett JJ, Argenziano M, et al. First nationwide survey of US integrated six-year cardiothoracic surgical residency program directors. J Thorac Cardiovasc Surg. 2014;148(2):408-415.
- Ward ST, Smith D, Andrei AC. Comparison of cardiothoracic training curricula: Integrated six-year versus traditional programs. Ann Thorac Surg. 2013;95(6):2051-2054; discussion 2054-2056.
- Flynn TC. How will the introduction of primary certificate training programs change vascular surgery training programs? Semin Vasc Surg. 2006;19(4):218-221.