Early surgical subspecialization: A new paradigm? Part I

Early specialization in surgical training is a concept that has been evolving for as long as surgical training has been in place. It started with early specialists who provided only one procedure, such as lithotomy for bladder stones, to the point that now surgical trainees may have early systematic exposure in the field of their choice, with options including colorectal, pediatric, or transplant surgery.¹ The American Board of Surgery’s (ABS) Flexibility in General Surgery Residency Specialty-Specific Guidelines allow residents to spend up to 12 months of time on flexible rotations during their last 36 months of general surgery training to offer an opportunity for “early tracking” into the resident’s preferred subspecialty.¹

The paradigm of a residency program that would provide advanced training emerged in the 19th century and was formalized in the early 20th century by William Osler, MD, in medicine and later William S. Halsted, MD, FACS, in surgery, both at Johns Hopkins University in Baltimore, MD.² Prior to that time, all individuals with medical degrees were considered “physicians and surgeons.” Ophthalmologists, otolaryngologists, gynecologists, orthopaedists, and genito-urinary surgeons comprised 43 percent of the first class of Fellows of the American College of Surgeons (ACS) in 1913. However, the term “general surgery” was not a category in the ACS directory until 1965.³ Since then, the practice of surgery has become increasingly specialized, so that orthopaedic surgeons often practice on only one particular joint, general surgeons on a particular organ, or neurosurgeons on a particular disease.

The course of study to become subspecialized traditionally proceeded through medical school, internship, general surgery residency, and often into a subspecialty of general surgery. Trainees and educators have asked whether all those years of background training are required for residents who plan to practice a single subspecialty, and there has been a move toward earlier subspecialization. One advantage of shorter training is that physicians can repay their educational debt earlier. Several subspecialties have already developed well-formed paradigms for training programs independent of general surgery residency programs. These programs are the focus of this article.

Vascular surgery

Over the last 50 years, the training of vascular surgeons has gone from apprenticeships in the early 1960s to the development of fellowships certified by the ABS. In this century, a new training model for vascular surgeons has emerged and more changes are likely on the horizon.

During the 1960s and 1970s the norm was a five-year general surgery residency followed by one year of specialization with pioneers in vascular surgery. As time passed, the need for more formalized vascular fellowships became apparent. Edwin J. Wiley, MD, was one of the key contributors to the development and promotion of training in vascular surgery.⁴ The Society for Vascular Surgery (SVS) and the North American Chapter of the International Society of Cardiovascular Surgery spearheaded these efforts under the leadership of Dr. Wiley and other pioneers in the field. The collaboration between both societies continued with the development of the Joint Council (JC) in the early 1970s. Over the next decade, the governing bodies for graduate medical education agreed on guidelines for essentials in the training of vascular surgeons. By 1982, the JC had credentialed 52 programs in vascular training; 1982 also marked the inception of a certificate of special qualifications in vascular surgery by the ABS.⁵

In these early years, vascular training consisted of a one-year fellowship after a five-year general surgery residency. The requirement for ABS special certification consisted of a written examination in 1983 and subsequently incorporated an oral examination in 1986. As the requirements of certification changed, so did the training, with expansion into a two-year fellowship program. The second year was initially tailored to bolster research efforts; however, a more clinical component was incorporated in 1995 as the endovascular aspect of vascular surgery began to flourish. From 1982 through 2007, the ABS certified 2,676 diplomats.⁶ The key turning point took place on July 1, 2006, when the ABS converted the subspecialty certificate of special qualifications in vascular surgery to a primary specialty certificate. This move allowed for the creation and development of new training paradigms to prepare competent future leaders in vascular surgery.

The training pathways may be divided into two categories: independent and integrated. The independent category consists of the following pathways: 5+2, 4+2, and 3+3 (see Table 1). The integrated program, also known as the 0+5 pathway, consists of two years of core surgical education followed by three years of concentrated vascular surgery. This new training paradigm allows residents to participate in a variety of rotations related to vascular surgery that are difficult to incorporate in the traditional 5+2 model.

Table 1. Vascular surgery training pathways

Pathway	Years of training	Board certification
5+2 (traditional)	7	General surgery and vascular surgery
4+2	6	General surgery and vascular surgery
3+3	6	Vascular surgery
0+5 (integrated)	5	Vascular surgery

In 2007, the inaugural year of the integrated (0+5) pathway, three institutions participated in this model. Since then, the number of individuals training in vascular surgery has increased rapidly, and 40 integrated programs are now in place nationwide. The paradigm shift is probably a multi-factorial response related to: (1) the technological advancement within the specialty, such as the rapid expansion of endovascular surgery; (2) the increase in overall trainee debt; (3) residents’ desire to curtail length of training; and (4) the societal obligation to provide well-rounded competent vascular surgical care.⁷ Although a number of different training pathways still exist, the integrated pathway is gaining the greatest momentum.

Plastic and reconstructive surgery

Plastic and reconstructive surgery training in the U.S. has become quite competitive. Medical student applications to plastic surgery residency programs increased 34 percent from 2002 to 2005.⁸ An online survey of 49 programs found that only 4.7 percent had a residency spot go unfilled in the last 10 years.⁹ Nonetheless, 10 programs (23.3 percent) were less than satisfied with the selection process.⁹

The American Society of Plastic Surgeons (ASPS) was founded in 1931 and is the largest plastic surgery organization in the world.¹⁰ The American Board of Plastic Surgery (ABPS) began in 1938 as a subsidiary of the ABS and achieved status as a major specialty board in May 1941.¹¹ In 1958, S. Milton Dupertuis, MD, president of the ASPS, noted that there were 36 residency programs in plastic surgery with an additional 28 preceptorships that provided training for 140 plastic surgeons.¹¹ Dr. Dupertuis recommended a gradual conversion from preceptorships to residency programs, noting that “all other surgical specialty boards have either discontinued preceptorships or now permit preceptor training only to supplement approved residencies.”¹¹ Since then, plastic surgery training programs have continued to evolve.

The plastic surgery program at Columbia-Presbyterian Medical Center, New York, NY, is considered the oldest continuously running plastic surgery training program in the nation.¹² Shortly after the formation of the ABPS, a certified two-year residency program was established at Columbia, one of the first of its kind, with Dr. Dupertuis as the first plastic surgery resident in 1938.¹² In 1958, the ABPS officially increased the requirement of approved residency training in “basic surgery” from two to three years effective in 1960.¹¹ In 1994, the Association of Academic Chairmen of Plastic Surgery reported that approximately 4,300 fully trained plastic surgeons were actively practicing in the U.S.¹³ As a result, the ratio of plastic surgeons to population was 1:59,302, with 200 plastic surgery trainees per year.¹³ Furthermore, the report suggested lengthening all two-year plastic surgery programs to three years and reducing prerequisite training to three years.¹³

Plastic surgery trainees now follow one of three pathways, as summarized in Table 2.¹⁴

Table 2. Plastic surgery training pathways

Pathway	Years of training	Board certification	Created	Other
Independent/ traditional/ fellowship	7–10 (complete surgical residency followed by fellowship)	General surgery and plastic surgery	1938—Columbia12	Model through which most practicing plastic surgeons received their training
Combined/ coordinated/ transition	5–6 (3 years general surgery, 2-3 years plastic surgery)	Plastic surgery	1989 via meeting of Association of Program Directors in Surgery and AACPS15-16	First three years trainees are considered general surgery residents and are under the general surgery program director’s purview
Integrated	5–7	Plastic surgery	1992—Loma Linda, first ACGME-accredited;Early 1960s—Stanford	Trainees are always considered plastic surgery residents and are always under the plastic surgery program director’s purview

Both the combined and integrated models are recognized by the ABPS, but the integrated model is also recognized by the Accreditation Council for Graduate Medical Education (ACGME), whereas the ACGME does not recognize the combined model.¹⁴ Roughly half of all plastic surgery training programs have adopted the integrated model, which accounts for approximately 50 percent of all training spots.^17-18 However, four programs stopped taking residents through the integrated model within the last 10 years, and nearly half of the integrated and combined programs surveyed also take residents via the traditional pathway.⁹

A recent 40-question survey looking at 130 graduates of the integrated program at Stanford University School of Medicine, CA, graduates from 1966 to 2009 found that career outcomes between integrated and traditional plastic surgery graduates appear to be similar.¹⁴ Of the integrated Stanford graduates, 86 percent were in clinical practice.¹⁴ All of the graduates were either board certified (82 percent), board-eligible (recent graduates, 9 percent), or retired.¹⁴ Although most of these plastic surgeons were in private practice, at least 82 percent had been academically productive, whether through contributing to peer-reviewed publications and book chapters, or serving as program directors.¹⁴

Plastic surgery training has evolved over the last century. The rise of the three models of training has raised the question about which one is best, which begs the larger question of the pros and cons of early surgical subspecialization. Although an argument may be made in favor of each model, and each model produces successful graduates, only time will tell which pathway becomes preferred.

Cardiothoracic surgery

Cardiothoracic surgery training first began at the University of Michigan, Ann Arbor, in 1928, mainly for surgical treatment of empyema and tuberculosis. It subsequently developed more formally after World War II, propelled by the invention of the cardiopulmonary bypass machine. Finally, in 1971, the American Board of Thoracic Surgery (ABTS) was established.¹⁹ Despite the high rate of general surgery graduates pursuing fellowship, the number of candidates for traditional cardiothoracic surgery fellowship has been declining. From 1994 to 2003 the candidate pool decreased at a rate of 4 to 5 percent per year but then dropped precipitously thereafter, leading to unfilled positions every year since 2004.^20-21 In 2012, 24 percent of fellowship positions remained unfilled, despite an approximate 20 percent reduction in available positions over the last five years.²²

Decreasing interest in cardiothoracic fellowships was thought to be due to the decreased exposure to the specialty, especially since these rotations are no longer a mandatory requirement for general surgery board certification. Only an estimated 70 percent of general surgery residents have a cardiothoracic surgery rotation as a required part of their curriculum, and this training may be on the general thoracic service only.²⁰ Cited drawbacks of specializing in cardiothoracic surgery include the work schedule and length of training.^19-20 Therefore, the aim became to pique interest in students earlier in the career path and to decrease the onerous length of training.

To alleviate the impending shortage of cardiothoracic surgeons, in 2003, the ABTS revised the available pathways for cardiothoracic surgery board certification by retracting the mandate of general surgery board certification. See Table 3 for the three currently available pathways to ABTS certification.

Table 3. Cardiothoracic surgery training pathways

Pathway	Years of training	Board certification
Traditional	7 or 8 (5 general surgery + 2 or 3 cardiothoracic)	General surgery and cardiothoracic surgery
Joint	7 (4 general surgery + 3 cardiothoracic)	General surgery and cardiothoracic surgery
Integrated/I-6	6 (all cardiothoracic)	Cardiothoracic surgery

Thus, integrated six-year (I-6) programs began development at institutions with an existing cardiothoracic residency program in place. They first entered the National Resident Matching Program in 2007, and the first graduate completed training two years ago, in 2011.²³ Based on the most recent match data from 2012, 13 I-6 programs are in place, with 20 positions filled by graduating medical students.²⁴ The same year, 72 programs and 102 positions were available for the traditional cardiothoracic fellowship offered after completion of general surgery residency.²² Ratios of candidates to available positions were 27:1 and 131:1 for traditional and integrated programs respectively, and like other subspecialties, candidates for the integrated programs have higher United States Medical Licensing Examination (USMLE) scores than candidates for traditional programs.²³ It is hard to say whether the field is attracting high-quality applicants due in part to the highly competitive nature of this newly formed track with only 20 positions available, and if this trend would persist with an increase of available I-6 positions.

The future of cardiothoracic training is still variable, especially considering the rapidly diverging tracks of thoracic and cardiac surgery and the unique requirements for board certification in both branches of the specialty.

Discussion

Surgical training has been rapidly changing and developing over the past 30 years, especially within certain subspecialties as described in this article. The optimal training paradigm for each remains the source of ongoing debate. The integrated and combined pathways are shorter (and thus cheaper) and have increased training time spent focused in each specialty, but some argue that more general surgery training is necessary to fulfill patient needs. Independent pathway trainees may be at a more mature point in life with more subspecialty experience when they make their career choice than the typical medical student. The counterpoint is that integrated programs lock in quality candidates early.

Overall, it appears that applicants for integrated programs may have stronger applications. A study by Guo and colleagues examining the plastic surgery training program at Harvard University School of Medicine, Boston, MA, showed that when comparing integrated to independent programs, trainees applying to integrated residencies graduated from more highly ranked medical schools, had higher USMLE step 1 scores (mean 235, versus 220 p = 0.015), had higher pre-residency publication scores, and included more MD/PhDs (33 percent versus 4 percent).²⁵ Researchers at the Medical College of Wisconsin, Milwaukee, compared the demographics and applications of cardiothoracic candidates from their traditional program and their newly formed I-6 training program. They found a much higher candidate-to-position ratio after developing the I-6 program and that applicants had higher USMLE Step 1 and 2 scores, had contributed to more publications, and had more advanced degrees compared with the traditional group.²¹ Researchers at Mount Sinai Medical Center in New York, NY, also found that cardiothoracic integrated applicants had higher USMLE scores but found no difference in research activity. Given that candidates with advanced degrees have spent a substantial amount of time in training already, many are looking for a shorter path to board certification.

It may be that no one paradigm fits every specialty, and by providing multiple pathways, all qualified candidates may enter the field of their choice. The current shift appears to be back in the direction of allowing early specialization and less general training.

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References

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