Looking forward – August 2018

David B. Hoyt

David B. Hoyt, MD, FACS

For several years, the August issue of the Bulletin has centered on a theme that the Resident and Associate Society of the American College of Surgeons (RAS-ACS) has selected, and members of the RAS-ACS write feature stories focused on that topic. This year, the RAS-ACS has chosen to address autonomy in surgical practice. The articles that follow offer recommendations on how surgical training can be restructured to ensure that graduating residents are able to confidently enter independent practice and still adhere to duty-hour limitations and other modern-day constraints on residents’ ability to actively participate in delivering surgical patient care.

The ACS has been grappling with these questions for a number of years, starting with efforts to “Fix the Five” and the development of the Transition to Practice Program in General Surgery, which has now evolved into the ACS Mastery in General Surgery Program (see the July issue of the Bulletin for details).* Most recently, May 23–24, the College hosted the third Annual ACS Summit on Surgical Training, which stakeholders from surgical specialties, educational societies, and accrediting bodies attended. A key issue addressed at the meeting, led by ACS Past-President J. David Richardson, MD, FACS, and the ACS Division of Education, was autonomy.

Ongoing challenges

Summit attendees discussed how a number of challenges in today’s health care environment affect autonomy. These issues are well documented in the articles that the RAS-ACS members have written and have been discussed in multiple forums. A brief summary of these concerns is as follows:

  • Centers for Medicare & Medicaid Services reimbursement policies that incentivize attendings to perform more procedures and spend less time teaching
  • Accreditation Council for Graduate Medical Education (ACGME) guidelines, which pose time challenges, do not always account for the learner’s skill level, and define required supervision
  • A disconnect between certification and accreditation requirements
  • Insurance mandates that threaten resident involvement in complex cases to decrease complications or improve efficiency
  • Public misperceptions about how residents are trained and contribute to the surgical team
  • Medical liability concerns
  • Inconsistent preparedness for residency among incoming trainees
  • Faculty-to-resident ratios


Summit attendees discussed the effects of these challenges on resident training in their specialties and offered a range of solutions to these problems.

Graduated autonomy

A key concept proposed by one of the speakers at the meeting, Jeffrey B. Matthews, MD, FACS, chair, department of surgery, University of Chicago, IL, was providing residents with conditional independence. Using this paradigm, residents would be expected to meet graduated duty-hour requirements and achieve sequential certification for procedures. Under this scenario, certification would be competence-based rather than time-based.

At present, no national rules, guidelines, or mandates state that teaching hospitals cannot offer opportunities for residents to experience appropriate autonomy, as long as those practices are nondiscriminatory, the patient gives informed consent, liability risk is minimized, and resident involvement in a procedure is correctly documented. As the group noted, it may be easier to provide residents in some specialties, such as urology and vascular surgery, with greater autonomy because advances in technology leave less room for error, whereas specialties that involve high-risk cases and have a more narrow margin for error require fellowships or additional training.

We noted that surgical education involves more than the acquisition of technical skills, however. It includes the development of clinical judgment, communication and interpersonal skills, and practice management strategies. Proposed methods to address these competencies include providing residents with entrustable professional activities (EPAs)—a model that has been developed by the Association of American Medical Colleges (AAMC). The EPA concept is similar to the idea of conditional independence, allowing faculty to make competency-based decisions regarding the level of supervision a trainee requires. Competency-based education targets standardized levels of ability to guarantee that all learners have sufficient proficiency at the completion of training.

Measurement tools

Attendees concluded that surgical educators need better and more readily accessible data on resident performance and outcomes to support the arguments for graduated responsibility and to help validate the possibility of moving board certification one year earlier to allow greater independence in the last year of training. The group also called for a greater focus on the learning environment, maximizing the educational experience to ensure competency and emphasizing the importance of quality and patient safety in training environments.

We also discussed the tools that are available to faculty to help evaluate residents’ ability to provide patient care, including 360 plus action plans, SIMPL (also known as the System for Improving and Measuring Procedural Learning), and other on-demand evaluations. Using the 360 plus action plan, resident performance is evaluated to determine how the trainee might benefit from coaching or mentoring. SIMPL is a novel smartphone-based evaluation tool that uses the four-level Zwisch scale to assess the level of autonomy achieved by residents in performing a surgical procedure.

Changing public perception

In addition, the attendees noted that public perception is vitally important to ensuring that residents can get the experience they need to practice independently. Surgeons need to do a better job of communicating the role of teaching hospitals in producing the next generation of surgical health care professionals and how residents build on their capabilities as they advance through the training process. We also must clearly articulate that surgery is team-based and that all players, including residents, contribute to the outcome. Indeed, communicating how surgical care teams work together and how we become certified to perform specific procedures—not just during residency but in practice as well—may be our greatest challenge.

A commitment to our patients

The Annual ACS Summit on Surgical Training provided a wonderful opportunity to achieve consensus on many of the issues facing graduate medical education, particularly ongoing concerns regarding the ability of graduating residents to enter independent practice. The ACS will continue to collaborate with the specialty societies, the AAMC, the ACGME, the boards, and other stakeholders to ensure that all trainees and practicing surgeons have opportunities to engage in the lifelong learning needed to independently deliver high-quality care to surgical patients.

The College has been dedicated to this objective since its inception. The rules may have changed, but our mission is everlasting.

If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at lookingforward@facs.org.

*Richardson JD, Buckley BM, Shabahang MM, Giles WH, Sachdeva AK, Burns RP. From Transition to Practice to Mastery in General Surgery. Bull Am Coll Surg. 2018;103(8):10-16.


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