The five-year general surgery residency: Reform or revolution?

Editor’s note: The subject of this article, the future of the general surgery residency, will be debated at this year’s Resident and Associate Society of the American College of Surgeons (RAS-ACS) Symposium on Sunday, October 26, at the 2014 Clinical Congress in San Francisco, CA. The symposium and this article are sponsored by the Advocacy and Issues Committee of the RAS-ACS.

In 1904, William Halsted, MD, presented his revolutionary concepts on the “training of the surgeon.”¹ By replacing an unstructured apprenticeship model with a rigorous, formal curriculum based on basic science and bedside training, he introduced the principles that continue to guide modern surgical residency training in the U.S.^2,3

The field of medicine and the practice of surgery have seen tremendous advances in the last few decades, but surgical educators and other stakeholders have expressed concern that our current training system may be lagging behind modern demands, which raises the question, “Does the traditional five-year general surgery residency structure still prepare graduates optimally for their role as practicing surgeons?”

This apprehension has transcended our “inner circle” as medical professionals and moved into the public media. Last year, a column in the New York Times asked, “Are today’s new surgeons unprepared?”⁴ Furthermore, whereas the state of surgical training and its future challenges have always been topics of speeches at surgical conferences, in editorials, and of scientific inquiry, the last decade has seen an alarming increase in studies demonstrating a lack of confidence and skill of graduating surgical trainees.^5-8 In other words, today, surgical training is again at a crossroads.

A look back at surgical training in the U.S.

When Dr. Halsted announced his new tenets of surgery resident training at the turn of the 20th century, his ideas were mostly influenced by the authoritarian and hierarchical German system of surgical instruction. An intense and comprehensive training experience in a pyramidal system emphasized a close and dependent relationship between the surgical mentor and the trainee. Despite training that could last for many years, graduation was uncertain. Although this system did produce remarkable individual master surgeons, it did not ensure that all surgical trainees had a generalizable and standardized educational experience. It was Edward Churchill, MD, FACS, of Massachusetts General Hospital, Boston, who led the effort to replace the pyramidal structure with a ‘‘rectangular’’ training system to deliver comprehensive training for all residents in a program and provide a steady supply of well-trained surgeons.^2,3

The inception of credentialing and accrediting organizations, such as the American Board of Surgery (ABS), the Residency Review Committee, and the Accreditation Council for Graduate Medical Education, provided supervision and structure to residency training and surgeon certification.

For decades, it was accepted that the rigorous five-year training program encompassing more than 100 hours per week of bedside and operative experience would adequately prepare surgical residents for independent practice and ensure a consistent stream of highly qualified surgeons. The exceptionally high standards and demanding training, however, took their toll on surgical residents, and many medical school graduates began to lose interest in surgery in the 1990s, culminating in unfilled surgery slots in the national resident matching program in the early 2000s.^2,3,9 While this trend has reversed, concerns about the attractiveness of a surgical career remain and a high attrition rate among general surgery residents continues to plague our training system.¹⁰

Are young surgeons unprepared?

With the introduction of work-hour restrictions, substantial limitations in resident autonomy, and the decline in the number of traditional, open surgical procedures, the adequacy of the five-year residency model has come into question.

When Mattar and colleagues surveyed fellowship program directors in 2012 about their experience with recent graduates from surgical residencies, a total of 91 responded and the results were dismal.⁵ Many fellows could not operate for 30 unsupervised minutes in a major procedure, were unprepared for the operation, or demonstrated reluctance to take full responsibility for a case. Furthermore, the failure rate on the ABS certifying exam has increased by more than 50 percent over the last 10 years, and 80 percent of graduating residents now pursue fellowships after residency, presumably a result of trainees feeling inadequately prepared for independent practice after completion of residency.^7,11

However, in other studies, most surgery residents appear to be satisfied with their training experience (n=3,686; 85.2%), and the majority of senior residents report choosing their fellowship based on real interest, not lack of skill.12,13 In addition, 77 percent (n=229) of chief residents surveyed by Friedell and colleagues had performed more than 950 operations during their residency and felt comfortable with their operative skills and the prospect of taking call in a trauma center.¹³

Of course, the results of voluntary surveys must be taken with a grain of salt. Response rates are often low and may introduce bias—frequently toward residents in university programs and those individuals with either excellent or very poor experiences. Moreover, participating residents may be either overconfident or unwilling to admit to deficits in their training or to feelings of anxiety.

In a study conducted by the ACS Board of Governors and the Young Fellows Association, Lena M. Napolitano, MD, FACS, FCCP, FCCM, and colleagues posed the following question: “Are general surgery residents ready to practice?” After analyzing the results, a large gap was found between the impression of “young surgeons” (n=282) and “older surgeons” (n=978).⁶ While most young surgeons felt that they had received adequate training and preparation for their transition into the attending role, only half of older surgeons agreed with that impression. The two groups also differed significantly in what they considered important aspects of the training for young surgeons.

More detailed information about trainees’ operative experience was collected by Bell and colleagues, who surveyed 115 general surgery program directors to determine 121 “essential” procedures, such as laparoscopic cholecystectomies and colectomies. On average, general surgery residents reported completing only nine of these operations more than 20 times, and that they had performed 83 of these essential procedures fewer than five times.8 Those are barely the numbers required to achieve competence and may be part of the reason up to one-quarter of senior surgery residents are worried their operative skills are inadequate.¹¹

Revolution versus reform

Fortunately, the surgical community has been actively investigating these concerns and seeking strategies to tackle the challenges facing the surgical training system. Suggested solutions range from reform, or fixing the current system, to revolution, or replacing the five-year training structure as we know it.

The RAS-ACS will contribute to this important discussion during this year’s debate at the resident symposium at the 2014 ACS Clinical Congress. We anticipate a lively discussion among residents and faculty in response to the question, The Five-Year General Surgery Residency: Reform or Revolution?

A Blue Ribbon Committee Report on Surgical Education issued in 2005 suggested changing the five-year surgical training paradigm to a “3+3” model, with two- or three-year core training in general surgery followed by early specialization.¹⁴ This concept was never directly adopted, but it has been embraced in the form of the popular “integrated residencies” in plastic, cardiothoracic, and vascular surgery. Additionally, this model gave rise to initiatives, such as the ABS-approved “flexibility in surgical training” (FIST) model and projects such as “early tracking” available at selected institutions. These programs allow for a more customized residency experience.¹⁵

Early specialization seems to have support among a majority of surgery residents and to have multiple advantages.⁷ Financially, integrated pathways allow for shorter overall training duration and earlier opportunities for higher income and higher reimbursement as a specialist. Better income opportunities are also driven by patient demand for a surgical specialist rather than a “generalist.” Additionally, the increasing complexity of surgical care delivery—including the use of advanced technology in areas such as minimally invasive and endovascular surgery—often requires highly specialized training. Integrated training pathways allow for extra time and focus in these areas, while minimizing the exposure to skills and knowledge deemed unnecessary for certain subspecialties.

However, early specialization comes at the expense of a broader training and is fraught with potential problems. Integrated residencies and early specialization limit the exposure of medical students or junior residents to the full scope of surgery and require these individuals to decide early on in their education what direction their career will take. It is also unclear if the integrated residents’ overall clinical and operative abilities are as good as the “battle-tested” management and operative skills of the general surgery residents entering a fellowship program. An analysis of practice patterns of general surgeons and their fellowship-trained colleagues demonstrated that many general surgery operations are performed by surgical specialists, making a strong argument for a basis in general surgery, even for trainees who intend to subspecialize.16 Furthermore, splitting up general surgery may exacerbate the already critical shortage of general surgeons in rural areas and create organizational problems for residency programs, particularly those in community settings.¹⁷

The ACS recently introduced an alternative to a radical restructuring of surgical residency training through its Transition to Practice program (TTP). An increasing number of institutions across the nation are offering this opportunity to surgeons after completion of their five-year training. While surgeons in the TTP practice as board-eligible/certified attending surgeons, they enjoy close mentorship and individually tailored, graded responsibilities as well as additional training in the areas of leadership and practice management. Whether this “5+1” model represents a viable and successful strategy to encourage more graduates to enter general surgery practice and improve their confidence and skill set has yet to be determined. Conceivably, the TTP could be added onto a completed surgical residency shortened to four years, replacing the current chief year of residency, and thus emulating the chief year of previous decades.

Additionally, many other adjustments and improvements, such as a higher number of operative cases and endoscopy requirements for residents, as well as the introduction of milestone-based resident advancement, are promising steps toward reform of our current training system.

Conclusion

The debate continues over whether surgical training is in need of reform or revolution. Restoring the confidence of patients, surgeons, and trainees in the excellence of our education system is of utmost importance. The proactive role that surgeon leaders have assumed in this process is commendable and will prove invaluable to successfully addressing the challenges in surgical residency training. After all, despite the concerns addressed in this article, the quality of care provided by surgeons in this country remains exceptional, and the U.S. remains one of the most attractive and highly sought-after locations for residency and fellowship training among medical school graduates and physicians worldwide.¹⁸

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References

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