Second-place essay—revolution: Five-year general surgery residency: Reform or revolution?

Surgical residents are in a unique, privileged position. Why? Because we are here; we beat the odds; we are surgeons in training. In 2012, there were 1,613 four-year university programs with 1.5 million first-time, full-time students, of which 21.1 percent (approximately 300,000 students) declared pre-med as their major.1,2 That same year, all of the available 1,146 surgical categorical positions were filled. All things being equal, if you were a college freshman, one of the 300,000 with a desire for a surgical categorical position in one of 1,146 spots, then you had a 0.4 percent chance of attaining your goal.

To top that off, the attrition rate for general surgery was 12 percent, the pass rate on the written qualifying exam was 81 percent, and the pass rate on the oral certifying exam was 72 percent. Combined with the high standards for entry into the College, these statistics mean that of the 1,146 residents starting residency, only 588, or 0.2 percent of the original 300,000 college freshman, became Fellows of the ACS.1,2

According to my calculations, based on data collected from the Association of American Medical Colleges and the National Resident Matching Program, we are the 0.4 percent who made it into surgery and the 0.2 percent who will qualify to become Fellows of the American College of Surgeons (ACS).1,2

Clearly we are in a privileged position, and our training is of the utmost importance. Very few people have the chance to acquire surgical training, and fewer successfully become Fellows of the College. With such a small product (surgeons) produced by this system, we must ensure that our training process produces surgeons in a timely manner, who are also “of the times” in terms of competency and skill level.

Product of the times

In 1889, William S. Halsted, MD, FACS, was named chair of the department of surgery at Johns Hopkins University, Baltimore, MD, an act that put into motion the basis of surgical education. Think of how technology evolved from the late 19th century to the early 20th century—from Bell’s telephone in 1875 to the smartphones devices of today. Yet, what advances have we made in surgical education? Surgical educators in Halsted’s era used the pyramid system, which resulted in the training of one outstanding individual. This was the only model used until 1931, when Edward Delos Churchill, MD, FACS, was named chief of surgery at Massachusetts General Hospital, Boston, and he developed the rectangular surgical residency model. The philosophy of this model was to “create a group of masters, in which no single personality dominates the institution.”3 So, what happened in surgical education between the 1930s and the early 1980s? Essentially nothing—it was the proverbial quiet before the storm.

Sea change

It could be said that “the flood” regarding developing education strategies for today’s surgical resident started with the Libby Zion case in 1984, followed by the New York State resident duty-hour restriction in 1989, and then the nationwide 80-hour workweek restrictions issued by the Accreditation Council for Graduate Medical Education (ACGME) in 2003. The restrictions on trainable hours continued in 2011, when the ACGME limited intern work hours to 16 hours per shift. Most of us will agree that a 120-hour workweek is too much, but the limitation to 80 work hours per week for residents leads to a cumulative amount of six months to one year of trainable time, resulting in the loss of more than five years; residents today have less time in training.

Adding to these challenges, residents are now asked to learn a broader range of surgical procedures. What were once open procedures are now laparoscopic, endovascular, endoscopic, and even robotic. There is also the issue with resident independence in the operating room; some say we have lost our autonomy. How often do we hear the elder attending say, “When I was the chief resident, I never saw my attending unless I needed him.” So, here we are, now with less training time during the same “classic” five-year residency, and yet we are asked to learn more skills in expanding subspecialties while the opportunities for surgical independence dwindle. How does the resident of today fill these multiple gaps? The answer is fellowship training.

Do these challenges make any sense? How have we tolerated these conditions? We must draw a line in the sand—it’s time for our surgical revolution! We are wasting time producing physicians who are half trained in many subspecialties—
physicians who will never be general surgeons. An article in the January issue of the Journal of the American College of Surgeons stated that general surgeons performed an average of 23 different types of operations.4 Why spend hours doing deep inferior epigastric perforator procedures with plastic surgery, thoracic robotic lobectomies, or endovascular aortic repair? These are great cases to see as a junior resident, to experience a subspecialty in order to see if that could be your passion, but once you discover these cases are not part of your career goals, why scrub in on these cases again? It’s not time spent wisely, and it may be taking the opportunity to practice the procedure from a fellow who is being trained in that subspecialty.

The revolution

How does the revolution start? We regulate ourselves, which means the ACS becomes the sounding board for the advancement of surgical education, and oversees the multitude of current regulatory bodies. The College needs to revolutionize the structure of surgical education to include direct admission to all fellowships for medical students who know what subspecialty they desire to pursue. Medical students who are unsure of their specialty may enter a two-year surgery residency position, where they will rotate through all of the subspecialties. At the midpoint of the second year, they will enter a standardized application process for all of the surgical subspecialties, including rural general surgery. The following fellowships would then be for the duration of three years, for a total training time of five years. Training under this model would produce a more proficient surgeon in less time.

Strong training models require excellent teachers, and we need to acknowledge that great surgeons do not always great teachers make. Every program needs a surgical educator—someone who is a trained teacher and can monitor the academic progress of his or her students. Currently, the attending surgeon is overstretched; between clinic, operating, and endless paperwork, it’s an impossible expectation to ask these surgeons to take hours out of their week to teach.

With respect to curriculum, we need standardization during the first two years of surgical education so that every resident in the country has the same academic baseline. Although the Surgical Council on Resident Education-based module system has helped immensely with addressing this challenge, a lack of standardization continues, and with approximately 679 modules, this system provides an overwhelming amount of information. If we can formulate a standardized curriculum for our elementary students, then we can do the same for surgical residents. The ACGME milestones are a step in the right direction, but this program, at best, sets an expectation without providing the necessary tools to accomplish these goals. The curriculum should also provide simulation training. With today’s technology, a second-year resident who scrubs their first laparoscopic cholecystectomy should have already made the necessary intraoperative moves 20-plus times on simulation.

The revolution will not be simple; it will require taking the path less traveled. It will take the two things of which we do not have an abundance—time to restructure the system, and monetary resources—to make these changes possible. However, if we do not support the revolution, then we will continue down the path of least resistance, which is simply to try to make our old system work in training new surgeons. The simplest way to do work in the current training model is to make the residency period longer—again, the easy way out. Surgeons have never taken the easy way. Let’s take ownership of our training process and take the power back. It’s time for a revolution.


References

  1. Association of American Medical Schools. Results of the 2012 Medical School Enrollment Survey. Center for Workforce Studies. May 2013. https://members.aamc.org/eweb/upload/12-237%20EnrollmSurvey2013.pdf. Accessed September 18, 2014.
  2. National Resident Matching Program. Results and data: 2012 main residency match. National Resident Matching Program. April 2012. http://sls.downstate.edu/student_affairs/documents/NRMP2012Results_Data.pdf. Accessed September 18, 2014.
  3. Grillo HC. Edward D. Churchill and the “rectangular” surgical residency. Surgery. 2004;136(5):947-952.
  4. Decker M, Dodgion CM, Kwok AC. Specialization and the current practices of general surgeons. J Am Coll Surg. 2014;218(1):8-15.

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