SCORE provides residents with Web-based curriculum for developing key competencies

Established in 2004, the Surgical Council on Resident Education (SCORE) is a consortium of seven U.S.-based surgical organizations: the American Board of Surgery (ABS), American College of Surgeons (ACS), American Surgical Association (ASA), Association of Program Directors in Surgery (APDS), Association for Surgical Education (ASE), Accreditation Council for Graduate Medical Education (ACGME), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). In an effort led by the ABS, six founding members of the group initially met in November of that year (with SAGES joining later) and agreed to work toward two goals:

  1. Develop a standardized, competency-based curriculum for general surgery residency training that addresses the six competency areas as defined by the Accreditation Council for Graduate Medical Education (ACGME).
  2. Develop a Web portal to deliver this content to general surgery residents in training. The first official meeting of the entire group convened in November 2006. Richard Bell, MD, FACS, who was hired by the ABS to oversee the initial development of the curriculum and Web portal, chaired this conference.1

Over the next two years, an initial curriculum outline was developed covering the competency of patient care and operative skills. This curriculum was developed through an iterative process that involved SCORE council representatives and program directors in surgery. The operative case experience of surgery residents was examined and classified by program directors in surgery, and input was obtained from other stakeholders.2 This curriculum outline was the basis for development of the early content that was delivered on the SCORE Web portal, which was piloted to 33 selected residency programs in 2008.3 This curriculum outline has since been expanded to include the competencies of medical knowledge, systems-based practice, professionalism, and interpersonal skills and communication. The curriculum outline is dynamic and is reviewed and updated annually according to recommendations made by various stakeholder groups, as coordinated by the ABS. It is publicly available on the SCORE Web portal, as well as in a print version.

SCORE Web portal

In 2009, the Web portal was made available to all residency programs free of charge. In the 2010–2011 academic year, the portal became a subscription-only resource, and by 2012, 96 percent of general surgery residency programs subscribed to the SCORE Web portal to support education. Participation in the Web portal has expanded to include surgery residencies in Canada and other nations throughout the world, as well as more than half of all osteopathic surgery training programs.

The patient care competency is organized in 28 categories and presented in individual content areas, termed “modules.” These modules are divided into two overarching areas: diseases/conditions and operations/procedures. Each area is subdivided according to the level of proficiency a residency graduate is expected to possess. These designations serve to focus the learning experience during training. For diseases/conditions, modules are defined as either “broad” or “focused.” A graduate should be able to provide comprehensive management for all aspects of diseases classified as broad. For focused diseases, a graduate should be able to make a diagnosis and provide initial management and stabilization but should not be expected to provide comprehensive care. Operations/procedures topics are classified into one of three areas: essential-common, essential-uncommon, and complex.

Essential-common operations are defined as “frequently performed operations in general surgery; specific procedure competence is required by the end of training.” 4 Essential-uncommon operations are “uncommon, often urgent operations seen in general surgical practice but not typically done in significant numbers by residents; specific procedure competency required by end of training (but may not be obtained by case volume alone).” 4 Complex operations are “not consistently performed by general surgeons in training or not typically performed in general surgery practice.”4 It is expected that residents will obtain generic experience in complex procedures but not competence in individual procedures and that some residency programs may provide sufficient experience for competency by their graduates. These classifications are reviewed annually to determine their continuing relevance to a given category. We anticipate that the curriculum will be dynamic and that some topics will change over time as technology and disease management evolve.5

Organizational structure and outreach

SCORE, as a consortium, curriculum, and Web portal, has a defined and complementary organizational structure (see boxed item). The daily operation of the Web portal is overseen by a leadership group, which is also responsible for implementing new features on the portal as well as overseeing overall direction and business operations of the portal and curriculum. The SCORE council (composed of representatives from each of the seven member organizations) helps set the strategy and meets at least once a year. An editorial board, composed of residency program directors and other surgical educators, oversees the development of all content for the Web portal, and works to ensure that all content is relevant, timely, and up-to-date. Lastly, a resident advisory group, populated with residents representing a variety of program types, locations, and sizes, advises on the delivery and type of content that best suits trainees’ learning needs and preferences. This combination of stakeholders, users, and education experts helps to ensure that the SCORE curriculum and Web portal remain relevant, useful, and engaging.

Representatives of SCORE have participated in a number of national presentations related to the SCORE curriculum and Web portal use, including a presentation describing the best methods to incorporate the many features of the portal into the defined curriculum that drives an individual program’s learning and teaching.6 This topic has been the subject of workshops during Surgical Education Week (the combined meetings of the APDS and ASE) for the past five years and has been part of panel discussions during the ACS Clinical Congress on several occasions. These efforts, combined with frequent, free webinars, have helped program directors and residents better understand the content available on the SCORE Web portal and how to best use it to optimize resident teaching and learning.

Status of the SCORE portal

The content on the SCORE Web portal is categorized into several areas, including modules, textbooks, videos, self-assessment questions, and supplemental resources. This structure is intended to provide an integrated, comprehensive site for both program-directed and self-directed learning.

Modules. A module defines a specific disease/condition or operation/procedure in the curriculum outline. Each module is an originally authored subject that follows a specific outline, ensuring consistency in the learner experience. Within each module are defined learning objectives to focus the residents’ learning and mastery of the material, open-ended questions that residents may use to assess their knowledge of the material or that faculty may use to facilitate a didactic conference, links to chapters from the major surgical texts, and relevant videos. Currently, approximately 650 modules on patient care, medical knowledge, and systems-based practice competency are posted on the SCORE portal, and approximately 150 additional modules are in production. Once these remaining modules are posted, which is expected to occur by the end of 2013, the current curriculum outline will be complete.

Textbooks with chapters available on SCORE

ACS Surgery: Principles and Practice, 6th edition
Editorial Board: Stanley W. Ashley, MD, FACS, Editorial Vice-Chair; Philip S. Barie, MD, FACS; William G. Cance, MD, FACS; Gregory J. Jurkovich, MD, FACS; Larry R. Kaiser, MD, FACS; William H. Pearce, MD, FACS; John H. Pemberton, MD, FACS; and Nathaniel J. Soper, MD, FACS

Ethical Issues in Clinical Surgery
Editors: Mary H. McGrath, MD, MPH, FACS; Donald A. Risucci, PhD; Abraham Schwab, PhD
Fischer’s Mastery of Surgery, 6th edition
Editors: Josef E. Fischer, MD, FACS; Daniel B. Jones, MD, FACS; Frank B. Pomposelli, MD, FACS; Gilbert R. Upchurch, Jr., MD, FACS

Greenfield’s Surgery: Scientific Principles and Practice, 5th edition
Editors: Michael W. Mullholland, MD, FACS; Keith D. Lillemoe, MD, FACS; Gerard M. Doherty, MD, FACS; Ronald V. Maier, MD, FACS; Diane M. Simeone, MD, FACS; Gilbert R. Upchurch, Jr., MD, FACS

Surgery: Basic Science and Clinical Evidence, 2nd edition
Editors: Jeffrey A. Norton, MD, FACS; Phillip S. Barie, MD, FACS; R. Randal Bollinger, MD, FACS; Alfred E. Chang, MD, FACS; Stephen Lowry, MD, FACS; Harvey I. Pass, MD, FACS; Robert W. Thompson, MD, FACS

Surgical Palliative Care: A Resident’s Guide
Editors: Geoffrey P. Dunn, MD, FACS; Robert Martensen, MD, PhD; David Weissman, MD, FACP

Surgical Pitfalls: Prevention and Management
Editor: Stephen R.T. Evans, MD, FACS

The ASCRS Textbook of Colon and Rectal Surgery
Editors: Bruce G. Wolff, MD, FACS; James W. Fleshman, MD, FACS; David E. Beck, MD, FACS; John H. Pemberton,MD, FACS; Stephen D. Wexner, MD, FACS

The SAGES Manual: Fundamentals of Laparoscopy, Thoracoscopy, and GI Endoscopy, 2nd edition
Editors: Carol E.H. Scott-Conner, MD, FACS
The Physiologic Basis of Surgery, 4th edition
Editors: J. Patrick O’Leary, MD, FACS; Arnold Tabuenca, MD, FACS

Textbooks. With the permission of their publishers, the Web portal features chapters from a number of major surgical textbooks to supplement the learning experience. Chapters are linked to specific learning modules. The list of available textbooks is shown in the sidebar . Most of the textbooks support the patient care and medical knowledge competency areas, but two recent additions, Ethical Issues in Clinical Surgery and Surgical Palliative Care: A Resident’s Guide, support professionalism and interpersonal and communication skills. Additional content is under development for these general competency areas.

Videos. As a digital interface for learning, the SCORE portal is ideal for incorporating multimedia instructional channels. The video library available on SCORE covers a broad range of topics, from minimally invasive operations, to operative exposures for trauma, to endoscopy. SAGES has contributed a number of excellent videos to SCORE, including the SAGES Top 21 Videos. The ACS has contributed videos from the Advanced Surgical Skills for Exposure in Trauma (ASSET) and Advanced Trauma Life Support® (ATLS®) courses, the University of Texas-Southwestern has contributed a number of trauma operative videos, and a number of individuals have provided important videos of other procedures to round out the catalog. SCORE continues to seek additional videos for use as adjuncts to instruction.

Self-assessment questions. A feature on the Web portal that has been popular with resident users is the self-assessment area, which features more than 2,000 multiple-choice questions, covering all of the content areas on the curriculum outline. These questions allow trainees to assess their knowledge and focus their learning, as each question is accompanied by a detailed explanation of the correct and incorrect answers. In the future, these questions will be linked directly to modules for an improved navigation experience.

Supplemental resources

The supplemental resources area of the Web portal comprises several important adjuncts to the learning experience. For example, StatDx is an online decision support system primarily intended for radiologists. This extensive resource provides a written overview of a vast range of topics with differential diagnoses as well as anatomic drawings and radiologic images, including plain films, ultrasound, and computed tomography scan and magnetic resonance imaging examples representing a broad spectrum of radiologic diagnoses and findings.

Educational tools include the ACS Surgery Weekly Curriculum, which is drawn from ACS Surgery: Principles & Practice and features a short, multiple-choice quiz on a selected topic each week that is indexed to the SCORE curriculum outline. Residents often use this additional resource for self-assessment of knowledge, whereas residency program directors use the weekly schedule of topics as a method for developing an annual outline for their own program-based didactic conference schedule.

The American Society of Transplant Surgeons Academic Universe is a collection of information that provides in-depth exposure to selected topics in solid organ transplantation. The Academic Universe is intended to support the resident learning experience during his or her transplant surgery rotations and for residents who are interested in learning more about these transplantations.

Journal Club (an evidence-based, critical appraisal of the literature) is an important part of the resident learning experience. This resource is supported on the SCORE portal via links to the ACS Evidence-Based Reviews in Surgery (EBRS) and the Annals of Surgery Journal Club. The EBRS comprises an extensive catalog of topics, divided by either research methodology or clinical category, that teaches critical appraisal skills in the context of current articles from the surgical literature. Methodological and clinical reviews of the articles are included for each topic and can easily be used to provide residents with the tools to learn important skills essential to lifelong learning. The Annals of Surgery Journal Club is an interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in the journal. A guest expert selects an article for discussion each month, summarizes it, and poses questions to the residents, who may respond using an interactive, online forum.

The Comprehensive Online Archived Care Heuristic (COACH) operated by the Columbia University Medical Center, New York, NY, is an online multimedia educational resource based on pretraining. It provides users with training videos, articles, and simulations that are intended for resident review prior to exposure to real-life situations. COACH delivers rich, multimedia content including operative videos, 3-D animations, lectures, illustrations, and text that are ideal for both in-depth study and just-in-time learning. Popular items in this extensive learning resource include “case cards” that residents may view for the pragmatic aspects of preparing for an operative case, as well as extensively annotated 3-D animations of surgical anatomy.

The future of SCORE

The SCORE curriculum outline has become widely accepted as an essential resource for resident education. The ABS has started to use the curriculum outline to construct questions for its examinations and to set expectations for evaluation. The SCORE Web portal, in particular, has enjoyed early success for delivery of educational content. Perhaps as an acknowledgement of this accomplishment, educators in other specialty areas including anesthesia, orthopaedics, otolaryngology, and neurosurgery have all made inquiries regarding the feasibility of developing a similar system to support training in these fields. Pediatric surgery, vascular surgery, surgical oncology, and surgical critical care have all begun efforts to develop and deliver curricular content to support the learning of trainees in these fields using the existing Web platform. Through partnerships with other specialty boards and societies, SCORE is working to develop specific curricula for each of these disciplines.

The Web portal continues to evolve and improve with input from our organizational structure and from users. New features planned for the portal include improved navigation to self-assessment content, more robust reporting and tracking features, and expanded content to support all six of the competency areas.

Controlling financial costs remains a priority for the SCORE council. To date the ABS has invested several million dollars in the SCORE curriculum project and Web portal, with the ACS, ASA, and APDS also contributing to their development. SCORE was developed to help provide more equity in curricular resources available to support residency learning, and keeping subscription costs low has been a guiding principle. Training programs are charged a $500 enrollment fee in addition to $125 per resident per year. With significant stewardship of resources, it is anticipated that the SCORE Web portal will become self-sustaining within the next two years. The SCORE council will be performing a needs assessment to determine the feasibility of expanding subscriptions to the Web portal to other users.

The SCORE Web portal has been widely accepted in surgical training programs and has provided a resource that affords the vast majority of residents a rich, multimedia resource to support both their didactic learning as well as patient care activities. This collaborative effort of major surgical organizations, including the College, has resulted in a comprehensive and user-friendly Web portal that has become a valuable adjunct to resident learning and patient care.

SCORE Organization

SCORE leadership team

Mary E. Klingensmith, MD, FACS
Chair, SCORE Council
Mary Culver Distinguished Professor of Surgery, vice-chair for education
Washington University, St. Louis, MO

Mark A. Malangoni, MD, FACS
Associate executive director
American Board of Surgery

Mark J. Hickey
Chief operating officer

Kerry B. Barrett
Content management specialist

SCORE editorial board

Cameron Akbari, MD, FACS
Assistant professor of surgery, division of vascular surgery
Georgetown University School of Medicine, Washington, DC

Michael Awad, MD, PhD, FACS
Program director, general surgery;
director, surgical skills laboratory;
assistant professor of surgery
Washington University, St. Louis, MO

Mary E. Klingensmith, MD, FACS
Mary Culver Distinguished Professor of Surgery
Washington University, St. Louis, MO

Monica E. Lopez, MD, FACS, FAAP
Assistant professor of surgery and pediatrics
Baylor College of Medicine, Houston, TX

Douglas S. Smink, MD, MPH, FACS
Program director, general surgery residency; associate medical director, STRATUS Center for Medical Simulation,
Brigham and Women’s Hospital;
assistant professor of surgery;
Harvard Medical School, Boston, MA

Eric G. Van Eaton, MD, FACS
Assistant medical director for surgical critical care;
service director, surgical intensive care unit;
assistant professor of surgery, Division of Harborview Trauma and Burns;
Adjunct assistant professor of biomedical informatics and medical education, division of biomedical and health informatics;
University of Washington, Seattle, WA

Daniel Vargo, MD, FACS
Program director, general surgery residency;
associate professor of surgery;
University of Utah School of Medicine, Salt Lake City, UT

Tina W.F. Yen, MD, MS, FACS
Associate professor of surgery,
division of surgical oncology,
Medical College of Wisconsin, Milwaukee, WI

SCORE resident advisory group

Jenny Guido, MD
University of South Florida
Tampa, FL

Grace Hsiung, MD
University of Texas-San Antonio
San Antonio, TX

Ray King, MD
Georgia Health Sciences University
Augusta, GA

Richard Miskimins, MD
University of New Mexico
Santa Fe, NM

Danielle Pigneri, MD
Robert Packer Hospital/Guthrie Clinic
Sayre, PA

Lin Riccio, MD
University of Virginia
Charlottesville, VA

Anna Royer, MD
University of Tennessee-Chattanooga
Chattanooga, TN


  1. Bell RH. Surgical council on resident education: A new organization devoted to graduate surgical education. J Am Coll Surg. 2007;204(3):341-346.
  2. Bell RH Jr, Biester TW, Tabuenca A, Rhodes RS, Cofer JB, Britt LD, Lewis FR Jr. Operative experience of residents in U.S. general surgery programs. Ann Surg. 2009;249(5):719-724.
  3. Schmidt CC, Risucci D, Plass J, Jones A, Darosa DA. Preimplementation predictors of website use: Preliminary findings from the SCORE portal pilot study. Am J Surg. 2011;201(1):7-15.
  4. Surgical Council on Resident Education. SCORE curriculum outline. Available at: Accessed August 12, 2013.
  5. Lewis FR, Klingensmith ME. Issues in general surgery training—2012. Ann Surg. 2012;256(4):553-557.
  6. Moalem J, Edhayan E, DaRosa DA, Valentine RJ, Szlabick RE, Klingensmith ME, Bell RH Jr. Incorporating the SCORE curriculum and web site into your residency. J Surg Educ. 2011;68(4):294-297.

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