Second-place essay—reform: Revisiting the visions of Halsted, Churchill, and Dudley to fix surgical training a century later

“We need a system […] which will produce not only surgeons, but surgeons of the highest type, who will stimulate the finest youths…to devote their energies and their lives to raising the standards of surgical science.”1

William S. Halsted, MD, FACS, delivered this statement at Yale University, New Haven, CT, in 1904, as part of his address on the Training of the Surgeon.1 Dr. Halsted crafted the first general surgery training system at the Johns Hopkins Hospital, Baltimore, MD, in 1889.2 In Dr. Halsted’s pyramidal system, only one resident in eight would complete training.2 Edward D. Churchill, MD, FACS, of Massachusetts General Hospital (MGH), Boston, on the other hand, wanted all of his trainees to finish as competent surgeons.3 Dr. Churchill, believing that “half a surgical training is about as useful as half a billiard ball,” and that residents should be able to develop their own proficiencies, did not adopt the pyramidal system, or the “frozen” five-year system.2-4 Allen Dudley, MD, FACS, in his presidential address to the American Surgical Association in 1907, commented that “the great misfortune of the specialist of the present day is the inadequate knowledge of other departments than his own.”4

Nowadays, becoming the consummate general surgeon is difficult—some would say impossible—with the expanding range of surgical diseases, disciplines, and the development of new therapies and techniques.5,6 In fact, since duty-hour restrictions were implemented, L.D. Britt, MD, MPH, D.Sc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon), Past-President of the American College of Surgeons, has expressed his concern with the increasing failure rate on the general surgery certifying exam.5,6 Dr. Britt further emphasized the importance of repetition in surgical training, which has become more challenging due to work-hour limits.5

Today, general surgery residents are pursuing fellowship training in a broad range of subspecialties, and an increasing number of these fellowships are becoming accredited, which requires board certification. Even as patients seek surgeons who are experts in a particular field, there is a growing concern that residents are finishing programs with less training and less independence.5

Rather than doing away entirely with the current training system, several improvements could be made. For example, surgical education, skill modules, and mentorship could begin earlier for those planning to apply for general surgery. Early specialization should uniformly be a part of surgical training programs while maintaining core general surgery rotations, and expanded use of “homework” assignments/self-assessments and simulation training courses should be incorporated into the general surgery training and education curriculum.

Early education and mentorship

When interest in surgery is expressed early in undergraduate and medical school years, it will continue and may even grow stronger by the time a student is ready to apply for a general surgery residency position.7,8 Various stakeholders have proposed that the fourth year of medical school should be restructured to implement a standardized curriculum for surgery applicants.9 If incorporated into education programs at an early stage, suturing workshops, skills labs, anatomy courses, and so on, can help facilitate the transition from medical school to a general surgery residency, making intern and junior years more efficient and productive. Mentorship and surgical education should begin even earlier in medical school, as soon as a student has expressed interest in surgery. Mentorship can help identify knowledge and skills gaps, and for this reason should certainly continue through residency. There may even be a benefit to providing mentorship after training to help facilitate the transition to independent practice.10,11

Early specialization

Early specialization, fast-track, or joint-specialization programs should be uniformly available, while maintaining a core general surgery knowledge base and skills set. These training programs usually offer several core years of general surgery training with the added benefit of pursuing a particular field of interest early in training as well as dual certification. Such programs now allow only certain fast-track options (such as cardiothoracic or vascular surgery) and are only available to residents within a particular institution. These programs should expand to allow early training in all specialties, including transplant and pediatric surgery, and should be available for outside residents who have completed and demonstrated competency in the core general surgery rotations, but who may be in programs that are unable to offer certain specialty tracks due to limited resources and volume.

Under this model, program directors will be tasked with tailoring surgical curriculum to specific specialization tracks. For example, after core general surgery rotations in the first few years of residency, a resident planning to pursue a career in breast surgery may spend more time on surgical oncology, breast, and plastic surgery rotations than another resident who is interested in trauma or cardiac surgery. This specialization may help to eliminate time spent in fellowship training. For those interested in nonspecialized general surgery careers, such as rural surgery, options should remain for completing a general surgery residency.

Expanded use of simulation, skills labs, and self-assessments

Programs should continue to incorporate and expand the use of simulation training and skills labs.12 Simulation allows for repetition in training, as mentioned earlier, and provides a way to measure skill acquisition.10 Additionally, using the Surgical Council on Resident Education program to structure surgical education along with required reading assignments, weekly quizzes, and periodic self-assessments may be effective in optimizing the learning experience and improving in-training examination scores.13

It has taken more than a century to create an effective and well-validated general surgery residency training system. Any attempt to make the current training system more efficient would necessitate increased help from the allied health professions to safely facilitate and coordinate patient-centered care. These improvements may also help with the increasing documentation requirements that accompany patient care and may help ensure safe sign-out exchange of patient information.14 Ultimately, the aforementioned ideas and concepts will improve the general surgery training system, producing stronger graduates, and perhaps reduce the additional time necessary for subspecialty training. We will have a system that will produce Dr. Halsted’s “highest quality surgeon,” providing an earlier opportunity to specialize, a concept Dr. Churchill supported, while maintaining core general surgery rotations and training, as Dr. Dudley would have wished.


  1. Johns Hopkins Medicine. Department of Surgery. History of Johns Hopkins Medicine. Accessed April 24, 2014.
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  4. Allen DP. The teaching of surgery. Trans Am Surg Assoc. 1907;25:1-14.
  5. Smith MJ. Are today’s surgical graduates prepared for real life practice? Gen Surg News. 2013;40(3):1-2.
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  7. Scott I, Gowans M, Wright B, Brenneis F. Stability of medical student career interest: A prospective study. Acad Med. 2012;87(9):1260-1267.
  8. Sutton PA, Mason J, Vimalachandran D, McNally S. Attitudes, motivators, and barriers to a career in surgery: A national study of UK undergraduate medical students. J Surg Educ. 2014;71(5):662-667.
  9. Debas HT, Bass BL, Brennan MF, et al. American Surgical Association Blue Ribbon Committee Report on Surgical Education: 2004. Ann Surg. 2005;241(1):1-8.
  10. Pellegrini CA. Surgical education in the United States 2010: Developing intellectual, technical and human values. Updates Surg. 2012;64(1):1-3.
  11. Sachdeva AK, Flynn TC, Brigham TP, et al. Interventions to address challenges associated with the transition from residency training to independent surgical practice. Surgery. 2013;155(5):867-882.
  12. Sachdeva AK, Bell RH, Jr., Britt LD, Tarpley JL, Blair BG, Tarpley MJ. National efforts to reform residency education in surgery. Acad Med. 2007;82(12):1200-1210.
  13. De Virgilio C, Stabile BE, Lewis RJ, Brayack C. Significantly improved American Board of Surgery in-training examination scores associated with weekly assigned reading and preparatory examinations. Arch Surg. 2003;138(11):1195-1197.
  14. Bell RH. Surgical council on resident education: A new organization devoted to graduate surgical education. J Am Coll Surg. 2007;204(3):341-346.

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