100 years of surgical education: The past, present, and future

Until the 19th century, the most common and well-established method of training surgeons—if any training was pursued at all—was through apprenticeships. Length of training and the starting age of the apprentice could vary, but a typical apprenticeship in the mid-16th century lasted five to seven years and would start around the age of 12 or 13.¹ Further training, in the form of a journeymanship, was available under the tutelage of the same master or a different one but was not required for the practice of surgery. In the most basic form of this model, the student learns surgery through direct observation and then by imitating the actions of a skilled mentor, both in the operating theater and in the clinical environment.

As surgery slowly evolved from a trade into a profession, the apprenticeship model remained the standard of surgical education. Still, there were no principles or guidelines for what knowledge or skills were to be taught, who should be trained, when training should start, or how long training should last. The end of the 19th century and beginning of the 20th marked the first major shift from the apprenticeship training model to more formalized and structured education. The method used to train surgical residents in the U.S. for the last century is, in large part, due to the influence of William S. Halsted, MD, FACS.²

Halsted model

Until nearly the turn of the 20th century, direct patient contact was considered beyond the abilities of medical students, but Sir William Osler, MD, firmly believed in the value of learning from patients. In the early 1890s, Dr. Osler introduced the concept of clinical clerkships to the Board of Trustees at the Johns Hopkins School of Medicine, Baltimore, MD.³ Dr. Osler also incorporated bedside rounds into all of his student classes, a rare practice in the U.S. at that time.

At this point, Dr. Halsted moved to Baltimore and was appointed the first chief of the department of surgery at Johns Hopkins Hospital. His two years in Europe, in particular his observance of the significant differences in European and North American surgical training, had a profound influence on his future career. He was impressed by the formal training of German surgeons with close integration of basic sciences into the curriculum. By embracing Dr. Osler’s concept of bedside rounds and the German curriculum, he fathered the Halstedian training model (see Table 1). In 1904, Dr. Halsted delivered a landmark lecture at Yale University, New Haven, CT, on the training of surgeons, whereby trainees received increasing responsibility with each advancing year.⁴

The Council on Medical Education conducted a survey, led by Abraham Flexner, on medical education in U.S. and Canada. His findings were published in 1910 as the Flexner report, which triggered much-needed reforms in the standards, organization, and curriculum of North American medical schools.⁵ During the same year, the first national postgraduate surgical meeting, the Clinical Congress of Surgeons of North America, convened. This meeting led to the formation of the American College of Surgeons (ACS) in 1913.

Since its inception, the ACS has been a formidable force in advancing graduate surgical education. One of the founding objectives of the ACS was to improve training opportunities for surgeons. Surgical training has been propelled further through the College’s activities over the course of the last century, beginning with the establishment of qualifications for Fellowship.

Transformation during the 20th century

This Halstedian training model produced several leaders in the field of surgery who went on to establish training programs at various distinguished institutions. The deepening understanding of the educational process during this period led to significant developments, which became the foundation for surgical education in the 21st century. The Council on Medical Education and the American Medical Association (AMA) became among the first professional organizations to set standards for graduate medical education (GME), and in 1927, the ACS published the Fundamental Requirements for Graduate Training in Surgery as its own surgical education standards.⁶

In 1937, the AMA, the ACS, and the American Board of Surgery (ABS) formed a Committee on Graduate Training in Surgery to investigate, analyze, and evaluate the opportunities for the training of surgeons in hospitals in the U.S. and Canada. The committee’s findings led to the guidelines set forth in 1940 in the ACS’ Manual of Graduate Training in Surgery, prepared by Assistant Director Harold Earnheart, MD, FACS, which contains and explains the Minimum Standard for Graduate Training in Surgery. The ACS published a list of 200 hospitals in the U.S. and Canada that met the standard and were approved for graduate training in surgery.⁷ This directory was the first to identify graduate training programs available to assist in the selection of a training institution that will best prepare residents for surgical practice. It included detailed descriptions of the provisions for basic science study, supervision, and opportunities for practical experience, enabling residents to locate the program best-suited to the individual’s needs.

This Committee on Graduate Training in Surgery was the basis for the establishment of the Residency Review Committee in Surgery (RRCS) in 1950, the first official RRC among all specialties.⁸ As result of the RRCS’ formation, the responsibility for the certification examination process and for accreditation of training programs was divided between the ABS and RRCS, respectively. The formation of the RRCS also led to the establishment of organizational bodies to oversee and control the training process. To ensure coordination between all organizational bodies, the Coordinating Council of Medical Education was established in 1972.⁹ This council subsequently created a Liaison Committee for GME in the same year, which was the forerunner to the independent accrediting organization now known as the Accreditation Council for Graduate Medical Education (ACGME), established in 1982.⁹

Since its establishment, the ACGME introduced several landmark changes in graduate surgical education. For example, in 1999, the ACGME defined six core competencies that residents must achieve and master during their training (Table 2).⁹ The accreditation model used by the ACGME shifted from a focus on process measures to one that focuses on evaluation of outcomes.¹⁰ Another ACGME regulation that has had a major impact on the training of surgery residents is the restriction on resident work hours mandated in 2003 that was further modified in 2011.¹¹ Residency programs had to substantially restructure their education and service activities to comply with this regulation.

The development of minimally invasive surgery over the last few decades has been remarkable. Minimally invasive surgery has become an integral part of operative management in virtually every realm of surgery, including urologic, gynecologic, and thoracic specialties. Technological advances in surgery ranging from laparoscopic instruments, to stapling devices, to endoscopic technology, brought new challenges for operating room (OR) nurses, surgical residents, and surgeons alike. Consequently, surgical trainees are responsible for a significant amount of technical knowledge and training for the safe and effective use of this vast array of instruments.

The American Surgical Association (ASA), in partnership with the ACS, ABS, and RRCS, appointed a Blue Ribbon Committee on Surgical Education in June 2002. After two years of deliberations, the committee proposed several far-reaching recommendations.¹² For medical students who are interested in surgery, the committee proposed restructuring the fourth year of medical school and the development of a curriculum that would adequately prepare students to enter surgical training. The committee suggested implementing a standardized, national curriculum for residency education in surgery. This recommendation resulted in the development of the Surgical Council on Resident Education (SCORE), a voluntary consortium of six organizations with the responsibility for monitoring resident education in surgery and improving the training of surgeons (see Table 3). SCORE’s mission is to improve the education of general surgery residents in the U.S. through the development of a standardized national curriculum. With the current shift in data acquisition and the revolution in information technology, SCORE created an online General Surgery Resident Curriculum portal to deliver educational content aligned with the standard curriculum to general surgery residents and residency programs.¹³

Current status of surgical training

In 2011, in the U.S., 1,756 individuals applied for a total of 1,108 positions, meaning that the total number of applicants per position was 1.6 and indicating that surgery remains a highly competitive and desirable field.¹⁴ A long-held misconception was that female medical students found surgical training unappealing. However, from 2000 to 2006 the number of women entering medical school increased from 43 to 46 percent and the number of women entering general surgery residencies also increased from 32 to 40 percent during the same period.¹⁵

Training occurs in a variety of settings including university, university-affiliated, military facilities, and community hospitals in rural, suburban, and urban locations, each with varying strengths, patient populations, and exposures. Under current ABS and RRCS standards, surgical residency consists of 60 months of training in an accredited program. At least 54 months are devoted to clinical training, 42 of which center on various categories deemed essential to training. Surgical residents are expected to log their cases into the ACGME resident case log system. Graduating residents must log 750 major operative cases, with at least 150 major cases performed during the chief resident year.¹⁶

Many traditional components and philosophies of surgical training continue to apply today. The concept that surgery and medicine are founded on scientific knowledge and the overarching principle of apprenticeship with progressive transfer of patient care responsibilities and graded autonomy in the OR is still the building block of residencies. The morbidity and mortality conference, a cornerstone of surgical education since the inception of formal surgical training programs, continues to be a vital component of training programs today. The current landscape of surgical residency education also includes protected education time for didactic lectures and journal clubs to develop the tools to critically analyze and appraise. Feedback is incorporated into all training programs and is a critical component to assessing and improving resident skills.

The ACS Division of Education developed the ACS Fundamentals of Surgery Curriculum, a highly interactive, case-based, online curriculum that addresses the essential content areas that all surgical residents should master in the early years of training. There has also been a recent push to include more competency-based assessments beyond the traditional ABS In-Training Examination and ABS qualifying and certifying examinations as part of progressive surgical education reform efforts.¹⁷ Through a collaborative arrangement with the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the ACS Division of Education has been involved in dissemination of the Fundamentals of Laparoscopic Surgery (FLS) Program, both nationally and internationally. Subsequently, ABS included FLS in its requirements for initial certification in 2010.

Historically, surgical training programs have emphasized a broad-based curriculum intended to train residents to pursue a variety of career paths, and most graduates entered general surgery practice without additional subspecialty training. However, an increasing number of surgery residents are pursuing fellowship training. Since 1992, the proportion of general surgeons pursuing fellowship training increased from more than 55 percent to more than 80 percent.¹⁸ Hence, the Blue Ribbon Committee also proposed a new structure for resident education, which includes a core basic education program leading to pathways for further specialization and subspecialization in surgery. A number of new approaches, including early specialization programs, are being evaluated and introduced.¹⁹

21st century training

The first decades of the 21st century are bringing new challenges to the surface. With the ever-expanding range of diseases that are treated surgically and the development of new therapies, residents are expected to learn more in a limited period of time. In light of the work-hour restrictions and increasing demand for documentation and other “service-related duties,” less time is available for learning or education.²⁰ The Blue Ribbon Committee recommended that changes be made in surgery residency programs to emphasize education above service activities that are of little or no educational value. To counter this, many hospitals have increased the number of advanced clinical practitioners to help improve the balance between service and education for surgical residents.

An active effort is under way to develop new approaches to surgical training and evaluation. There is now more emphasis on increasing the efficiency of the learning process. OR time is too valuable to permit acquisition of basic technical skills.¹⁶ Deconstructing complex operative tasks into component skills became fundamental to current surgical training paradigms. Simulators, inanimate skills training stations, and animate models have all provided opportunities to acquire familiarity with instruments, improve dexterity, and have offered surgeons the chance to become knowledgeable about surgical management, techniques, and potential complications. In fact, these developments have been validated by an increasing body of data demonstrating transference of these skills to the OR.^10,17 Residents would thus be trained in the laboratory until pre-set criteria have been met and only then would be allowed to participate in the performance of procedures in the OR. Competence-based advancement, rather than time served, would become the standard in surgical training. The RRCS has mandated that residents perform 35 upper endoscopies and 50 colonoscopies before completion of general surgery residency training. SAGES has established a Fundamentals of Endoscopic Surgery (FES) task force to create a comprehensive program for the training and evaluation of basic flexible endoscopic skills. The FES task force recently introduced valid and reliable tools to assess clinical endoscopic skills for both upper endoscopy and colonoscopy. ²¹

The impact of robotics on surgical training is enormous (see related article). Computer-integrated surgery using robotics can provide additional information that is less available to surgeons through human senses. For example, the robotic visualization can overlay a reconstructed computed tomography scan of a tumor on the operating site. Robots with intelligent sensors can address humans’ physiological limitations, such as poor vision or hand tremor. Even the best surgeons can use intelligent assistance to improve performance. State-of-the-art virtual reality simulators that are currently in development hold enormous potential in improving learning and efficiency. Simulators will allow for alteration in an operation for educational purposes. It will be possible to repeat steps, demonstrate anatomical anomalies, and to repeat tasks when failure occurs—all without putting patients at risk.

It is not only the introduction of simulation for skills training, but also the structured objective assessment of skills performance with benchmark metrics, that has enabled simulation to transform surgical education from subjective judgment to objective measurement of performance. National efforts are under way to develop standardized, simulation-based surgical skills curricula for surgical trainees. The ACS Division of Education is spearheading efforts to design and implement three national simulation-based surgical skills curricula in collaboration with the Association of Program Directors in Surgery and the Association for Surgical Education. The ACGME and American Board of Medical Specialties are engaged in a project called Milestones, in which the RRC will evaluate training programs based on the ability of residents to successfully achieve specialty-specific goals. A surgery working group is engaged in this project, and the ABS is also independently evaluating individual resident achievements.²²

Overall, this era of surgical education is characterized by rapid and dynamic changes in knowledge, understanding of surgical disease, new procedures, and technologies. Furthermore, public demand for greater accountability and patient safety, with greater scrutiny in institutions where training occurs and heightened requirements for oversight in training programs, is increasing.¹⁰ Novel educational and training paradigms will be necessary to navigate the current waters, meet the challenges of the 21st century, and ensure the production of professional, capable, competent, and versatile surgeons.

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