Residency training in surgery in the 21st century: A new paradigm

Special section: Surgical residency redesign Residency training in surgery in the 21st century: A new paradigm Carlos A. Pellegrini, MD, FACS, Andrew L. Warshaw, MD, FACS, and Haile T. Debas, MD, FACS, Seattle, Wash; Cambridge, Mass; and San Francisco, Calif

From the Department of Surgery, University of Washington School of Medicine, Seattle, Wash; the Department of Surgery, Harvard University, Cambridge, Mass; and the Global Health Sciences, University of California, San Francisco, Calif

THE CURRENT STRUCTURE OF RESIDENCY TRAINING is little changed from when it was conceived originally by Halsted in the early part of last century. The idea then was to have a system that, through apprenticeship, would allow a new graduate from medical school to acquire the knowledge and skills necessary to manage safely the patients who required surgical treatment. Many changes have occurred since the structure was conceived. For example, the patterns of practice have been affected dramatically by the development of specialties and subspecialties. Advances in technology have brought new educational tools and methods, and the expectations of patients, trainees, and society at large are radically different. In 2002 the American Surgical Association, the American Board of Surgery (ABS), and the American College of Surgeons (ACS) created a Blue Ribbon Committee to examine surgical training indepth and to discuss what changes might be needed to better respond to the current needs of our society. The Committee’s work was completed in April 2004, and a summary of its deliberations and recommendations will be published in the near future. During its deliberations, the committee agreed that some of the proposals presented before it, but which did not reach universal agreement (such as this one, presented July 15, 2003), could and should be published separately. Accepted for publication September 9, 2004. Reprint requests: Carlos A. Pellegrini, MD, FACS, Henry N. Harkins Professor and Chairman, University of Washington Department of Surgery, 1959 NE Pacific Street, Box 3565410, Seattle, WA 98195-6410. Surgery 2004;136:953-65. 0039-6060/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.surg.2004.09.001

With this action, the committee intended to stimulate further and broader discussions, by all the constituencies, of issues for which a unanimous consensus could not be reached. This proposal describes and proposes a new structure, one that we believe may be more able to produce the new surgeon needed for the 21st century. To achieve this goal, we assume we are designing the educational system from the start, matching the tools available today with the needs of trainees, to produce in the shortest possible time surgeons who are able to serve the varying needs of patients, communities, and academic centers. We recognize that these changes will need to be implemented progressively and that changes to the current system---one that has served us well for many years---will need to be digested, accepted, and implemented by the relevant boards, residency review committees (RRCs), and training programs. Furthermore, we fully acknowledge that the ideas presented in this paper have not been tested, and therefore it is important that they receive broad discussion and, if judged worthwhile by the appropriate constituencies, be implemented in a slow and measured way. To that end, we have made every effort in fashioning our proposal to produce the least disruption to the system, using what appears to work well and recommending stepwise changes. This is a crucial time of change in surgical education; it is our responsibility to seize this opportunity to conceive and direct the process of change. BACKGROUND The development of surgical specialties and their impact in general surgery training. In the past, training in general surgery provided a comprehensive platform that allowed graduates from SURGERY 953

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medical school to apply surgical management to the treatment of disease. The product was a relatively undifferentiated, theoretically pluripotential individual who could perform ‘‘operations.’’ As some surgical specialties became more developed over the years, three patterns of specialized surgical training emerged. First, as is the case with obstetrics and gynecology, medical students enter the training track directly from medical school and receive their entire training in that discipline. Second, as is the case with many programs in orthopedics, urology, and otolaryngology, residents are trained in general surgery for 1 or 2 years and then for 3 or more additional years within the specialty. These specialties are currently considering shortening the period of training required from general surgery. Third, as is the case with pediatric surgery, vascular surgery, cardiothoracic surgery, surgical oncology, transplantation, and until recently plastic surgery, trainees are required to complete the full 5 years of general surgical residency, obtain certification in ‘‘surgery,’’ and then move on to advanced specialty training. As these subspecialties have reexamined their curricular needs, it has become apparent that their trainees need to spend more time in subspecialty training to keep up with the expansion of relevant knowledge and technologic advances. This need has led to a surge of interest in shortening the duration of time invested in general surgery training. In other words, the perceived need is for a more comprehensive, focused education directed at the area of future practice. In addition to the impact that these three patterns have had on general surgery, general surgery itself has evolved and has been spinning off areas of special interest and expertise that have been integral to the traditional practice. Indeed, many studies have now demonstrated clearly the advantages of concentrating the care of complex patients within groups of surgeons and hospitals possessing the experience, support systems, volumes, and outcomes necessary to provide superior care.1-3 Many trainees are now seeking postresidency fellowships in these specialized areas. Although currently not formally recognized or certified by the ABS or by an independent board, these disciplines are attracting more and more graduates who wish to acquire focused knowledge in those areas.4 Examples include endocrinology, foregut surgery, hepato-biliary-pancreatic surgery, bariatric surgery, intestinal surgery (with special focus on inflammatory bowel disease), breast surgery, critical care (with or without trauma surgery), burns, minimally invasive surgery, transplantation,

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and others (colorectal surgery currently has its own independent board, recognized by the American Board of Medical Specialties, or ABMS). As these areas of focused training have developed, nearly 75% of graduating residents now seek additional fellowship training after completing a general surgery residency. It is also important to note that examination of the practice patterns among surgeons taking the recertification examination of the ABS shows that despite general training, most surgeons practicing in urban areas in fact tend to limit their practice to relatively narrow fields over time.5 These observations must make us reexamine the future role of the general surgeon. There is no question that general surgeons are still very much needed: not only is their presence essential in rural areas, but they are essential for the delivery of care in many urban hospitals, not to mention in an uncertain world fraught with global terrorism.6 Factors that impact residency training. Several factors in addition to the evolution of surgical subspecialties have the potential for substantial impact on the current conduct of our residency training programs. a. Limitation on resident work hours : As of July 2003, the American Council for Graduate Medical Education (ACGME) imposed a limit on the number and duration of hours that residents can spend in the hospital. Serious penalties, including closure of the program (and all other ACGME programs within an institution), are in force for programs that are out of compliance. These guidelines defining acceptable work hours have an impact on the number of hours that trainees spend ‘‘on the job’’ and thus limit how much opportunity and exposure trainees have under an apprenticeship paradigm.7,8 b. Development and growth of simulation technology : During the last decade, devices that use simulation technology to teach hand-eye coordination and performance of simple and complex tasks have proliferated. Such systems have several potential advantages.9-11 Safety is increased because learners acquire basic skills before they apply them to patients. The learning environment is much friendlier and more controlled, and the individuals can take as long as needed to perfect the tasks. Objective evaluation of the ultimate result is possible, including evaluation of the learning process itself. Several studies have shown that individuals trained with simulators have a measurable improvement in their operating room efficiency, speed, and number of errors when compared with those who have learned in traditional, patientcentered models.12-15 Although such systems

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would be appealing for use in residency training, there is no specific placeholder within the current residency program model that allows for the systematic and efficient incorporation of simulators in the training framework. c. Rapid development of information technology : Just as much as simulators can play an essential role in the acquisition of manual dexterity, the rapid growth of information technology and the web has allowed for the creation of many interactive programs that facilitate learning of patient management. The creation of interactive case management, in which the learner is presented with a patient and is asked to obtain diagnostic tests and to manage treatment, has the ability to provide immediate feedback and to identify areas of knowledge that need improvement. Thus, case management under computer-simulated scenarios has the potential to become a rich educational tool. However, it also does not have a defined placeholder (other than at night and on weekends) in the curriculum of the majority of training programs. d. Societal evolution toward lower tolerance for receiving care from individuals in training : Apprenticeship as the core of residency training was appropriate and socially acceptable during the first part of the 20th century, when patients who had no ability to pay were grateful for the care provided by individuals who were learning. After the establishment in 1965 of Medicare, which gave all Americans over the age of 65 the right to access medical care in a more or less private setting, and the consequent abolition of ward or city-county charity services, society became much more concerned about the use of unsupervised trainees to provide medical care. As principles of ethics evolved in medicine, many have started to question the very essence of providing care while training.16 A new structure for residency training must take this change into consideration. e. The need for efficient utilization of expensive resources : During the last decade, as reimbursement for services provided by hospitals and physicians has declined and as technologic advances have provided more sophisticated (and expensive) ways to provide care, hospitals have become more concerned about their cost structure and the inefficiencies that result from the learning curve associated with the apprenticeship model.17-19 Hospitals have, so far, been willing and largely able to absorb this cost, which is in part mitigated by the Indirect Medical Education (IME) portion of Medicare reimbursement. Medicare, however, is only a portion of hospital reimbursement, and

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the IME has been targeted for reexamination and potential reduction. Surgical training, or at least a part of it, will have to take place outside the operating room. f. Increased complexity in basic science research: Many residencies incorporate a research experience in their curriculum. Residents who want to develop ‘‘laboratory skills,’’ those who intend to pursue academic practices, and many who want to go into specialty fields like cardiothoracic surgery, pediatric surgery, and vascular surgery usually choose to spend 1 or more years during their general surgery training in a laboratory setting. In the last decade, it has become apparent that with the increased complexity of the techniques needed to pursue almost any form of basic science research, at least 2 and probably 3 years are required. Secondly, with the ongoing rapid evolution of research tools, the best time for residents to acquire laboratory skills that will be useful in their future careers needs reexamination as well. In the past, ‘‘surgical research’’ could readily be conducted in surgery departments, often with minimally adequate supervision by faculty much more focused on clinical care. Today, except for a small percentage of laboratories run by true surgeon-scientists, this model can no longer provide the quality educational experience that young trainees need. Surgeons seeking adequate research training will more likely find focused basic science in other laboratories. Furthermore, there is a need to develop appropriate research opportunities for surgeons interested in technology development (eg, minimally invasive surgery), the ‘‘softer’’ sciences (quality-measurement, outcomes, and public health), and health care and business administration (eg, master of business administration, master of public health). Therefore, the timing, opportunities, and character of the research experience need to be reexamined as has recently been proposed by R. Scott Jones.20 g. Oversight of residents’ research experience : The RRC oversees all aspects of clinical training in general surgery. Surprisingly, the research aspects of residency training have not received much attention. Indeed, programs are free to develop this experience in whichever manner suits their interest and resources. With increased restrictions in resident work hours, with decreased resources available to pay for the years of research experience, and with the current lack of consistency across residencies with regard to the research experience, this issue demands serious consideration and strategies for resolution. Appropriate organization of residents’ time in research is

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needed, along with appropriate monitoring of programs with research opportunities by the RRC or by the ACS Committee on Research and Optimal Patient Care; appropriate decisions with regard to funding this time are all in need of revision if we are going to incorporate research seriously into the residency program as a valuable educational piece. h. Increased scrutiny by credentialing bodies : Residency training has, until now, been carried out with the idea that, at the end, one has the opportunity to sit for board examination and to obtain a certificate that will provide a conduit for surgeons’ credentialing by hospitals. It has been argued that providing certificates of ‘‘special training’’ in more areas than are currently available would lead inexorably to the loss of credentials by those who do not have them. In reality, formal credentialing bodies have evolved substantially. Although there certainly is a place for a Boardissued ‘‘certificate,’’ demonstration of actual training, description of the training system itself, operative logs during training, and, in the not too distant future, demonstration of proficiency in all 6 areas of competence agreed on by the ABMS and ACGME will play an increasingly more important role in the initial credentialing process. Furthermore, once the individual starts practicing, training becomes a historical component of the credentialing process, with experience and outcomes becoming a more important determinant of ongoing assessment of competence. i. Advances in surgical education : Over the past decade, major advances in surgical education have resulted from cutting-edge educational research. Innovative approaches have been developed to apply principles of adult learning and experiential learning to contemporary surgical education. Learner-centered education modules have been designed that include methods to assess knowledge and skills. Major emphasis is being placed on competency-based education and verification of competence. Advances in understanding concepts and methodology for teaching, learning, and assessment of clinical and technical skills have been especially noteworthy. Faculty development has also been emphasized to enhance the skills of surgeon educators and to implement cutting-edge methods of education and to facilitate training of the faculty to serve as effective preceptors and mentors. Results of cutting-edge surgical education research have been presented in national forums and published in prestigious, peerreviewed journals.19,21-23 Faculty development courses have been conducted by national organ-

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izations such as the ACS. However, adoption of contemporary teaching, learning, and assessment methods by surgical residency programs has been slow. Most residency programs continue to use outmoded, century-old, apprentice-based educational methods and techniques. j. Blurring of traditional specialty boundaries : Although traditionally specialties were divided along clear lines between those that were essentially ‘‘cognitive’’ and ‘‘diagnostic’’ (the medical specialties) and those that were ‘‘procedure oriented’’ (the surgical specialties), the boundaries have disappeared substantially during the past 25 years. Thus, gastroenterologists perform interventions through endoscopes, cardiologists have developed many forms of treatment for ischemic heart disease based on the utilization of catheters, ‘‘surgical’’ dermatologists ablate skin lesions by new interventions, and so on. This blurring of the traditional barriers has taken place primarily at the expense of surgery as more of the so-called cognitive sciences became procedure oriented. Simultaneously, surgeons have expanded their domains into the cognitive, diagnostic, and disease-based conceptual frameworks that form the context of the procedures they perform. There is yet an opportunity that remains largely untapped: that of surgeons moving ‘‘closer to the patients’’ by increasing their participation in the diagnostic and medical treatment of patients. In this scenario, the surgeon becomes an ‘‘interventional biologist’’ whose influence on the strategic management of the patient can balance that of physicians whose initial training was in the medical specialties and whose subsequent training led them to practice interventions. This concept has to be embedded in the training of residents, an approach the current structure of training is ill prepared to accommodate. The potential benefits of an early and intense exposure of trainees to specialty fields must emphasize the growing importance of interdisciplinary teams and collaborations that have the durable potential to improve the quality, efficiency, and continuity of care. k. Recruiting women to surgery : Surgery has traditionally fallen short in attracting women to surgical careers. Even today, women represent only about 20% of the total resident workforce. If one considers that women comprise about 50% of the medical school graduating class and well over 50% of college graduates, surgery is obviously missing the opportunity to attract needed talent to its ranks. Female medical students cite as one consideration in their choice of career training the duration and inflexibility of surgical training.

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Reducing the years of training and creating alternative accommodations in the structure of training should, therefore, enlarge the pool of quality applicants to surgery.24 Thus, the current system is no longer reflective of the practice of surgery, the new educational opportunities, the needs of society, or the needs of the trainees. A NEW PARADIGM The specific goal of this proposal is to transform surgical training in the United States to: 1. Serve the country’s needs across surgical specialties in both community-based and academic environments and in urban and rural settings. 2. Reduce the duration of training not needed for or relevant to the ultimate goals of the trainee. 3. Utilize advances in technology to develop and implement competence-based education with objective assessment of performance. 4. Enable disease-focused approaches in which surgeons can play leading roles within teams of experts. 5. Improve the quality of life of trainees.

I. Principles. We propose the following principles as those that should guide the development of a new structure for the training of residents: 1. A basic core of knowledge : The trainee should be given a basic core of knowledge of biology and pathobiology of diseases related to surgical disciplines. We believe there is a common, basic core of knowledge and experience needed to practice surgical interventions of all kinds (eg, knowledge of wound healing, nutrition, infection, immunology, hemodynamics). Thus, the structure should identify a block of time and define a curriculum that will address this need. In addition to the care of actual patients, this curriculum should make full use of information technology and simulation. This curriculum should also incorporate clinical experiences that provide the trainee with the basics for further specialization. 2. Early specialization : To the extent that is possible and practical, early specialization would begin the exposure of the trainees to their area of future specialty sooner, thus providing longer and deeper training in more limited areas without extending the duration of training. Expansion and increased complexity of knowledge, skills, systems, and devices require extensive training in focused areas. Some form of tracking or early entry into the specialty (as plastic surgery has implemented) is assumed.

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3. Best use of training resources : A new structure should make better use of limited clinical resources. Early tracking or an early move into a focused area would allow the concentration of uncommon pathologies in the hands of trainees who will be working in that field. On the other hand, this new structure should also provide opportunities for surgeons to train in more than one domain if they wish to practice in more than one narrow area. The creation of modules of focused training would provide the platform for this principle. 4. Maintaining a disease focus : A new structure should, to the extent possible, provide a diseasefocused approach to surgical care. We recognize that this concept may not always be possible to implement with purity as there are many areas of overlap in surgical specialization (surgical gastroenterology and surgical oncology, for example). Nevertheless, we recognize that when the focus is a disease, surgeons tend to cluster with physicians, scientists, and other health care professionals who possess skills in that particular area. Cross-fertilization of ideas in these teams leads to new knowledge, the development of new diagnostic and treatment algorithms, and ultimately to better patient outcomes. Furthermore, surgeons will have the opportunity to exercise leadership of the multidisciplinary process. By contrast, when the focus is on technique (eg, catheter, endoscopic, and robotic-based techniques), the practitioners tend to cluster with other practitioners who use the same tools. Such funneling limits the potential for growth in the field to the identification of new techniques (with old tools) or the creation of new tools. In that sense, surgery falls into the trap of becoming purely application rather than creation of new knowledge and skill. Under these circumstances, the surgeon will perforce become a follower (ie, of orders from others who claim to know what is needed for the patient) rather than a leader. On a larger scale, such developments threaten the continued existence of surgery as a learned and scientific profession. 5. Enhancing general surgery : The new structure should recognize that the general surgeon in the broadest sense of the word is still very much needed despite the proliferation of subspecialties and the development of areas of special interest. True general surgical practice serves a vital function in many communities, but current training programs and requirements may be inadequately preparing surgeons for that role. An appropriate curriculum should be developed with the aim of training individuals who are going to be doing the common surgical procedures across a broader

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range. The content of terminal training in general surgery would comprise elements not currently included but would not contain advanced elements that would be directed toward other subspecialty programs. As a result, fewer individuals will be using the limited training resources because those who have chosen other fields of specialization will have branched out earlier and thus will not be expected to practice what is currently under the umbrella of general surgery. With this new concept, a general surgeon is trained as a specialist in surgery, similar to other subspecialties of surgery. 6. Transferability of skills and knowledge is limited : As surgery has evolved and as techniques and devices have become more complex, transferability of skills, both technical and cognitive, has become more limited. Performing a liver resection does not equate to performing a coronary artery bypass or an esophagectomy. Each one of these operations requires specific skills. Although experience performing any complex procedure will add to the general technical skill of the surgeon, the knowledge (eg, pathophysiology, genetics, epidemiology, outcomes) required to be a leader in any field demands specific education and expertise in that field. 7. Creation of new fields of work : The new structure should be accessible to change and evolution as new areas of specialization appropriate for diseasefocused surgeons emerge. 8. Identification of research as an important element of training : It is critically important that we incorporate into this new system a placeholder for research opportunities that is realistic, consistent across the residencies, and defined clearly. Individuals seeking a career in academic surgery specifically may require additional time and more rigorous research training. 9. Demonstration of competence : Our current training system is based on time (yearly promotion to the next level, 5 years total) rather than on the demonstration of competence at any given milepost. Instead, the newer concepts stress the potential value of competency-based advancement based on contemporary educational principles and stateof-the-art technology. The importance of assessment of competence at the completion of each block of training and periodically throughout training is compelling.21,25,26 Although we recognize from the outset that the current measures of competency are relatively crude, we should join in the efforts to develop appropriate methodology. We should strive to reach the goal that advancement to the next level of training should not occur unless the achievement of competence has been demonstrated satisfactorily.

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10. Progressive incorporation of the new structure into the current system : It is crucial that the new structure be developed in a progressive manner and that it is flexible enough so as not to destroy the current training system even as it is replacing it. 11. Administrative oversight of training in all current areas of surgery by the American Boards of Surgery and RRCs : It is assumed that the ultimate product, its administration, and its oversight will be the responsibility of the Boards, RRCs, and training program directors (with appropriate input from the relevant surgical societies). II. The Modular System. With the above principles in mind, a modular approach to surgical education may best address the desired educational goals. In this new paradigm, a basic module for all future practitioners of surgery would be followed by subsequent modules of focused training. After completing the basic module, the resident has the option of taking one or more subspecialty modules (Figure). Each of the modules would have its own (a) admission requirements, (b) curriculum, and (c) completion requirements. For example, under this scenario, a surgeon who has completed the basic module could proceed to a cardiothoracic training module. Upon completion of the cardiothoracic curriculum, the surgeon could apply for further specialization in congenital heart surgery. The prerequisite for entry into the congenital heart surgery module would be completion and demonstration of cardiothoracic competence. The offering of subspecialty modules would depend on the resources of a given institution and its desire to implement the program. The duration of each module and its curriculum will require careful planning and would vary depending on the specialty. Since certain specialty modules would probably be offered in only a limited number of institutions, it is assumed that trainees may have to move to the appropriate locale for the next phase of training. The modular system recognizes that some individuals may wish to practice in more than one domain (eg, vascular surgery and general surgery) and provides for those individuals the opportunity to be fully trained and credentialed in more than one subspecialty. 1. The basic module : The basic module might have a duration of 2 to 4 years. It is considered desirable, working with the Association of American Medical Colleges and other relevant bodies, to integrate some of the basic module requirements into the fourth year of medical school for students who have identified surgery as their field of choice

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Figure. Proposed schema for restructured surgical residency training.

early on. By obtaining ‘‘credits’’ during medical school, particularly during the fourth year, students may better utilize the fourth year of medical school and shorten the time required for postgraduate training without unduly affecting the medical school requirements for the final year. The end result will be a more efficient training program. The key is to develop a curriculum that uses competencybased educational approaches and includes effective use of information technology, interactive systems, simulation, and other innovations. Clear educational goals and learning objectives need to be developed and appropriate end-points established with identification of valid systems of measurement. The increasing use of simulation will allow for procedures to be repeated as many times as needed to achieve the end points that are measured easily and rapidly.11-13 Such a curriculum of surgical training is currently under investigation and development by committees of the ACS and the ABS. It is imperative that the elements taught in the basic module, including regular upgrades to conform to new knowledge and practice, be uniform throughout the country to make it possible for residents to be able to integrate seamlessly into the next module at any institution. It is not desirable or realistic that there be a certification process that would allow for the independent practice of surgery upon completion of the basic module. Instead, an attestation of completion of the basic surgery core could be issued

to allow the trainee to graduate to the advanced modules (Figure). 2. Research module : For residencies that wish to offer a research opportunity and for residents who wish to avail themselves of this opportunity, a module of not less than 2 years should be developed. Such modules must have the necessary resources, expertise, and mentoring to be accredited. National standards for research training in surgery and an oversight mechanism need to be developed. Similarly, a national registry of research opportunities and funding mechanisms should be created. This module would be available to trainees who have completed the basic module and for those who have completed a specialty module. Although the research module can theoretically be inserted at several levels (Figure), some see advantages in placing it at the completion of the clinical training so that the tools and techniques learned can be put into action immediately as the new faculty members starts their academic career. Also, the period of clinical training is not broken up, which may facilitate the development of competence through a continuum of progressively complex clinical experiences. 3. Specialty modules : Central to the modular system is the definition of subspecialty areas within surgery. This concept is very important to develop training modules with well-defined admission requirements, curricula, and completion standards.

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Currently, the ABMS delegates the responsibility for these functions to the member boards. Unless this concept is changed, the specialty modules must originate and be regulated by a recognized board, perhaps with the input of the appropriate specialty society. Some surgical specialties affected by this new paradigm already have their own boards, namely colon and rectal surgery, thoracic surgery (which includes cardiac and general thoracic surgery), and plastic surgery. Other surgical specialties, primarily those that evolved from within traditional general surgery (breast surgery, endocrine surgery, hepatobiliary surgery, trauma and critical care, transplantation, and others) and do not have a separate board, pose a particular challenge to the creation of a paradigm based on the recognition of the need for independent, focused training in ‘‘new’’ specialty areas. Under current ABMS rules, the ABS would have to assume responsibility and administrative oversight for the training modules in these fields. Although there are unregulated fellowships available currently in a variety of surgical subspecialties, the quality and uniformity vary greatly, in part dependent on the vigor with which specialty societies (eg, the Society for Surgical Oncology) have exercised authority. There is substantial opportunity to improve the educational benefits of the currently unregulated fellowships. Certification of both the primary specialty and any subspecialty will remain the province of the relevant board. Ideally, individuals will practice strictly within the defined scope of their training. This may imply that those who have chosen a subspecialty should no longer practice the entire scope of general surgery, since they are not trained or do not remain qualified to do so. For example, the certified vascular surgeon who has not completed the general surgery advanced module would be limited to vascular surgery practice. Those individuals who wish to practice both general and vascular surgery will have to obtain training in both areas. The principle we are espousing is that certification, to have real merit, must be related directly to the training received. With that in mind, we believe that specialty modules as defined in this paper fall into three general categories: (a) those specialties that have an independent board (ie, cardiothoracic surgery, colon and rectal surgery, and plastic and reconstructive surgery), (b) those specialties that are recognized by the ABS and for which the Board currently offers certification (ie, vascular surgery, critical care, hand surgery, and pediatric surgery), and (c) all other specialties that have emerged from general surgery, do not have independent

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boards, and are currently not formally recognized by the ABS but have representative societies and identifiable practices (eg, surgical oncology, transplantation, hepatobiliary surgery, breast surgery, endocrine surgery, bariatric surgery). The modules should be recognized formally as component programs within the ABS. It is time to recognize that there are many domains of surgery that are practiced as specialties and for which patients seek the care of a surgical specialist. Providing appropriate modules for the training of these individuals and providing methods to determine their competency should be a priority from which we cannot shrink. A. SPECIALTIES WITH THEIR OWN INDEPENDENT BOARDS. d

Cardiothoracic surgery: Candidates for a residency in cardiothoracic surgery would enter this specialty training module at the completion of the basic module, with or without the addition of a research module. Duration, curriculum, and competency standards for the cardiothoracic module would be determined by the American Board ot Thoracic Surgery (ABTS). A transition to this new structure can be accomplished easily without major disruption of current training. The ABTS may choose to implement this program in a few centers and, based on the experience, broaden its application over time. It is possible that the ABTS may also wish to keep the current Early Specialization Program (ESP) (4 years total of general surgery), which in the new paradigm would mean completion of the basic module and completion of at least 1 year of a general surgery program to receive ABS certification in general surgery as well. However, we believe it is preferable to evolve to the new paradigm of focused training, in which each endpoint, including general surgery, receives equivalent valuation based on completion of the full curriculum. This means that the only path to general surgery certification would (and should) be the completion of full training in general surgery (3 years plus at least 2 years of special training). The proposed new path for cardiothoracic surgery would allow either for a shortened combined residency (3 years plus 2 years vs 4 or 5 years plus 2 years) or for use of the saved time to expand the cardiothoracic training to accommodate the growth of the knowledge base (3 years plus 3 years).

In addition, working with the ABTS, it may be desirable to explore the separation of cardiac and general thoracic (noncardiac) modules. It is clear that the diseases, techniques, and diagnostic methods used by cardiac surgeons differ radically from those used by general thoracic surgeons. Although

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the former concentrate on the treatment of valvular, coronary, and myocardial diseases, the latter concentrate on the lungs, esophagus, and chest wall, primarily related to cancer. Although the former rely on extracorporeal circulation, the latter use techniques much more akin to those used by the general surgeon. This relatively radical concept, already debated for more than a decade, is aligned conceptually with the proposed structure of surgical training focused on the intended endpoint of practice. d

d

d

Plastic surgery: The American Board of Plastic Surgery has already developed and implemented a 3-year curriculum to follow a ‘‘basic’’ module of 3 years in general surgery. This new integrated program now includes many, perhaps most, of the new trainees in plastic surgery. The basic module proposed in this paper would provide an enhancement by upgrading the base 3-year core. Some programs in plastic surgery still require preliminary completion of a 5 years of general surgery, an example of the coexistence of parallel training pathways, which are likely to continue for some period of experimentation, trial, and evolution. Colon and rectal surgery: This specialty module would be developed by the American Board of Colorectal Surgery and its RRC. A new pathway, however, might consider entry into the specialty after completion of the basic 3-year module with or without research. In the 2 years of subspecialty training, there would be increased opportunity to teach and learn the new tools of colorectal surgery such as laparoscopic, robotic, and endoscopic techniques. There would be time to expand exposure to multidisciplinary, disease-focused groups related to inflammatory bowel disease, pelvic floor physiology, and others.

B. SPECIALTIES

UNDER THE

ABS

THAT ARE WELL

DEVELOPED. d

General surgery module: The prerequisite for this module would be demonstration of competence in the basic module. The general surgery module would consist of 2 to 3 years of training with maximum emphasis on clinical training in a manner similar to the current fourth and fifth residency years but with more emphasis on the demands on the general surgeon in the community. This approach implies both a broader exposure to common surgical conditions and less emphasis on tertiary surgical problems except for the ability to manage urgent situations and recognize the ultimate needs of the patient. There might also be curricular additions such as practice management, contracting, and HMO relations. A good portion of the training in general surgery ideally should take place

d

in community hospitals or in institutions with a large volume of moderately complex cases. Extensive exposure to transplantation, burn surgery, complex hepatic resections, and more than basic vascular and thoracic procedures may be limited or unnecessary. On the other hand, more training in endoscopy, gynecology, and trauma, including basic fracture management, would be of value to the surgeon in some communities. It is expected that these individuals would, upon completion, become ‘‘specialists in surgery.’’ Surgical oncology: Management of patients with cancer has become a highly developed subspecialty. These fellowships are currently taught in a few training centers with a curriculum crafted primarily by the Society of Surgical Oncology and to students who have completed 5 years of general surgery residency. Although we recognize that a solid foundation in general surgery (ie, full training in the specialty) may yet be advantageous before training in surgical oncology, it is clear that some elements of current surgical training are less important to the surgical oncologist. Rotations in cardiac and vascular surgery are possible examples. Conversely, the existing excellent surgical oncology fellowships provide very relevant education in medical oncology, radiation oncology, biostatistics, clinical trial design, cancer biology, genetics, and epidemiology. The modular design allows for possible redirection in training time and expansion of exposure to the most relevant aspects of the discipline. Although the general curriculum should be developed by the ABS in cooperation with the Society of Surgical Oncology, the specific strengths of each institution may determine variation of emphasis on areas or diseases within surgical oncology and consequently direct trainees with special interest to one or another training site. Completion of a 2-year to 3-year training module in surgical oncology may be particularly attractive to surgeons desiring to pursue an academic career or to find a stepping-stone to an even narrower focus, such as breast, sarcoma, or melanoma surgery. Pediatric surgery: This area is a specialty for which currently the ABS provides a certificate of special competence. Pediatric surgery fellowships already have a functional curriculum that has been approved by the ABS and the RRC. Given that pediatric surgery comprises a very broad spectrum of disorders encompassing most of the child’s body, it may be appropriate to continue to require general surgery training as a prerequisite. In fact, the Association of Program Directors in Pediatric Surgery recently decided not to avail itself of the shorter ESP 4-year program in general surgery; in contrast, it reaffirmed that full training in general pediatric surgery should follow full training in general surgery. However, it may be useful to consider development of an expanded pediatric

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surgery training module that can follow completion of the basic module. New educational materials could incorporate advanced training in minimally invasive technologies, genetics, developmental biology, neonatology, and oncology. Vascular surgery: At present, vascular surgery is certified by the ABS on completion of a fellowship that follows a full general surgery residency. The option of an early specialization program offered by the ABS, in which the fellowship may be entered after only 4 years of training, has not met with the enthusiasm of the vascular surgery program directors. Training in vascular surgery has been revolutionized with the introduction of catheterbased techniques for the treatment of vascular disease. This new field has allowed vascular surgeons to reclaim a large area that was being taken away by radiologists who had no significant clinical experience and limited knowledge of vascular disease. The combination of training in catheter-based techniques and increased use of noninvasive functional laboratories to diagnose vascular disease and to measure the outcomes of operations has resulted in the recent prolongation of the vascular fellowship to 2 years.

Although vascular surgery residencies might have the option of continuing as is, in the modular system, individuals aspiring to a career in vascular surgery would complete the basic 3-year module and then specialize for 2 to 3 years in vascular surgery. After completion of their training, they would limit their practice to vascular surgery. Currently in the United States, approximately two thirds of vascular surgeons limit their practice to vascular surgery, and the remaining third continue to practice vascular and general surgery. Indeed, the ABS decided at its 2004 retreat to put forth an application to the ABMS requesting authority to issue a new primary certificate in vascular surgery. Those vascular surgeons wishing to practice general surgery in addition to vascular surgery would need to obtain the requisite training by taking the general surgery module. Another difference from the current system is that training in general surgery could occur before or after training in vascular surgery. d

Transplantation: The American Association of Transplant Surgeons has developed an excellent, detailed curriculum for the transplantation fellowship. The ABS is working currently on the establishment of transplantation as a specialty within surgery. Transplantation as a discipline requires, in addition to excellent technical surgical skills, a unique set of abilities that include an intimate knowledge of immunology and the long-term management of immunosuppressed patients, special relations with medical specialties that focus on the management of end-stage organ diseases, knowledge

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and application of ethics to a greater degree than other surgical disciplines, and knowledge and expertise in the development of systems of practice that are less dependent on the individual surgeon and that rely to a greater extent on systems-based practices. Furthermore, transplant surgeons generally limit their practice to that of transplantation. Early admission into the specialty after completing a basic module might be ideal in this specialty, but might need the addition of vascular and possibly cardiothoracic training to the current transplantation curriculum, since these are at present taught during the fourth and fifth years. One could conceive of the transplantation module as a 2-year to 3year curriculum by itself, after the basic module or in conjunction with another module (e.g., hepatobiliary, cardiac, or general thoracic).

C. SUBSPECIALTIES

UNDER THE

ABS

THAT ARE CUR-

RENTLY LESS DEVELOPED.

There are a number of subspecialties recognized by their societies and promoted as such but for which there is less agreement among surgeons broadly (and within the ABS) regarding the need for extra training and (even more controversial) specific certification. Training in these areas is currently irregular and essentially without supervision. Opportunities for this training are less well known and generally based on word of mouth or personal contacts. More important is that these training programs are not under any form of administrative oversight, and quality control of their educational outcomes is exercised primarily by the programs themselves. We feel it is important that these training programs adopt the format, curriculum, and competency-based requirements consistent with other residency fellowship programs and that there be administrative oversight by the ABS and the RRC-Surgery. Defining appropriate training possibilities, developing appropriate curricula, and holding training centers responsible will open new opportunities for our trainees in surgery. Modifications in the training to incorporate into these areas the newer diagnostic capabilities and surgical techniques (including the use of minimally invasive, catheterbased, and robotic techniques) would have a very positive effect on the development of these areas as independent specialties and might improve the access of patients to surgeons by removing the middlemen. In most of these areas, we envision a continuing requirement for completion of a 5-year residency training. The concept of a ‘‘specialty module’’ to be taken directly after the completion of a basic residency training module is probably not

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desirable at this time. First, the specialty modules themselves are currently not developed completely, and the oversight previously discussed is missing. Second, departure of residents from their programs after the basic module to join these programs will have to be developed over a long period lest we accept the substantial disruption this would cause if implemented immediately. Some of these specialty modules are in different stages of formation now and include: d

d

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Foregut surgery: Training in foregut surgery is envisioned as a 1-year or 2-year module with heavy emphasis on the use of endoscopic techniques (transoral diagnostic and therapeutic endoscopy) as well as thoracoscopic and laparoscopic techniques. Training must include appropriate familiarization with the diagnostic evaluation of esophageal and gastric diseases with the full spectrum of devices available today. Surgeons have been leaders in this field, and in many institutions surgeons run the functional diagnostic laboratories. When endoscopic training is added, the surgeon has direct input to the initial evaluation of patients with moderate and severe esophagogastric diseases at an earlier stage of their evaluation. This is an example of surgery taking on nontraditional (diagnostic) roles and leadership in a defined field. Hepatobiliary and pancreatic surgery: As in foregut surgery, this is likely to be a 2-year module; however, certain modules (rural, general, oncologic surgery, and others) could potentially provide ‘‘credit’’ for up to 1 year, shortening this module to 1 year. Training in this module should include catheter-based techniques in radiology as well as skills in the use of transoral endoscopes for diagnostic and therapeutic procedures. Laparoscopy, ultrasonography, radiofrequency ablation, and other techniques applicable to the management of patients with diseases of the liver, biliary tract, and pancreas should be integral parts of this curriculum. The relationship to (and potentially an amalgamation with) liver transplantation should be explored in this area. After all, if one remains faithful to the diseasebased approach described previously, understanding hepatobiliary and pancreatic disease should include the understanding and management of end-stage organ disease. This is an instance in which the modular concept presented in this paper is clearly applicable. Some trainees may choose to take the transplantation module and add the hepato-biliary-pancreatic module either before or after. Others may wish to limit themselves to one of the two fields. Trauma surgery: Training is envisioned as a 1-year module after the completion of general surgery, and perhaps in the future as a 2-year to 3-year module after completion of a basic module. The curriculum would be

d

d

d

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laden heavily with appropriate access to epidemiology, health services, critical care, and emergency medicine and could be combined with a master of public health. Critical care: This is one of the areas for which the ABS currently offers special certification. It should perhaps be included among the ‘‘well-developed’’ specialties, but in practical terms, most surgeons who train in this area today use this as a subspecialty with trauma surgery. The curriculum used currently by the fellowship in critical care should serve as the basis for this module. With appropriate modifications of the existing curriculum, critical care would take 1 year of intensive study and practice in intensive care units. It should follow the basic curriculum and provide enough training for independent practice. However, it is envisioned that most individuals would take this 1-year module in combination with another 1-year module (trauma, general surgery, burns, or some other form of specialization more surgical in nature). Endocrine surgery: Training in endocrine surgery is envisioned as a 1-year curriculum similar to that used today in the fellowships available in this specialty. In his presidential address to the American Association of Endocrine Surgeons, Dr. Jay Harness spoke of the need to create more appropriate training opportunities in endocrine surgery, as has already been done outside the United States.26 This training may be a 2-year module after basic training or associated as a 1-year extension after an oncology or other related module. Endocrine surgery should expose trainees to the area of minimally invasive techniques for diseases of the endocrine pancreas as well as the thyroid, parathyroid, and adrenal glands. Breast surgery: The training for this module follows those concepts outlined above. These surgeons would take additional training in diagnostic techniques (radiology and pathology) and in aspects of medical oncology and medical genetics. It could follow formal training in oncology and general surgery, or be a separate ‘‘destination’’ module. Rural surgery: Although not currently recognized as a specialty by the ABS, we include rural surgery here because of its relationship to the specialty of general surgery. Few parts of the United States have more real need for the traditional general surgeon than do rural areas. Yet general surgery as currently taught falls short of the needs of individuals practicing in rural areas. A survey of graduates of the University of Washington determined that the training they received too heavily emphasized complex surgery and management of complex cases while totally omitting some areas required for the practice of rural medicine,28 most notably orthopedics and gynecology. These two, along with emphasis on emergency medicine, triage and stabilization of trauma victims, transportation of

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injured patients, and organ donation are areas needed for this curriculum. During a 3-year module after the basic surgery module or a 1-year module after the specialist-in-surgery training, these surgeons incorporate basic general surgery with orthopedics, gynecology, and urology. An initial effort in this regard has been established at Oregon Health Sciences University under the leadership of Donald Trunkey, Karen Deveney, and John Hunter. Initial results of this application are encouraging.29

Our description of these specialty modules is obviously both tentative and incomplete. Other potential areas of specialization or of focused interest have been omitted because they are in even earlier stages of development. One such area is bariatric surgery, for which there is substantial enthusiasm to create appropriate training. However, the development of such a program should preserve the broader aspects of a disease focus and should not merely be centered on the technique of gastric bypass. The program should promote the science of nutrition and surgical applications to nutritional problems. Similarly, we view laparoscopy as a technique, as one form of surgical access, to be applied as a tool within the context of a disease-focused discipline. Laparoscopy should be incorporated to a greater or lesser extent as appropriate in a number of specialty areas. For example, it would be basic to foregut surgery, although it may be much less important to critical care and trauma. It is also important to keep in mind that the descriptions above are intended as ‘‘proof of concept’’ and not necessarily as prescriptions for the curriculum of the various modules. Although we believe a modular system is the approach best suited to replace the current residency structure, we admit that such a system as a method of content organization has the risk of fragmenting knowledge. Adequate practice and integration of sequenced modular information will have to be crafted carefully to ameliorate this problem. Ultimately, there is no proof that this new paradigm will be superior to the current one. Our intention is to show that these concepts are not only possible, but that there is justification for their further development and for exploring the potential benefits that may accrue to patients, trainees, and surgery. The specifics with respect to the duration and content of each of these modules should be left to the boards in consultation with the relevant societies. We acknowledge that there are already well-developed, comprehensive, wellmonitored, society-approved training programs,

Surgery November 2004

such as surgical oncology and transplantation. These existing programs fit comfortably into our modular construct of surgical education. The modular approach has the additional flexibility of permitting inclusion of new modules in the future in specialty areas yet to be defined. As new training domains emerge in the future, the surgical training model can remain dynamic and responsive to the needs of learners and society.30 We acknowledge that the current system of residency has produced excellent surgeons for many years, has served society well, has played an important role in the provision of care in safety-net hospitals, and is regarded as the best system by much of the rest of the world. Nonetheless, we have tried to devise a new paradigm that might be introduced progressively into the training of surgeons while some of the unique aspects of our current system are preserved. Our objective has been to redesign the training process to serve the needs of patients, trainees, and society at large even better. We recognize that the re-examination can be disruptive and that there will be unanticipated and unintended consequences that may threaten the implementation of this proposal. For example, what will be the effects of this new training paradigm on the logistics of organizing a residency program with a series of branching alternatives? How will program directors be able to accommodate unpredictable alterations of career choice, which may leave some programs with holes and flood others? How will this influence both the educational and the service components provided by current residents? What will be the effects of this modular ‘‘early specialization’’ program on the composition and magnitude of the surgical workforce? We recognize that proposals for change almost always generate resistance. We feel it is essential that this proposal receive thorough discussion by the surgical boards (Surgery, Cardiothoracic, Colon and Rectal Surgery, Plastic Surgery), the ACGME, hospital organizations, the Association of Program Directors of Surgery, and other organizations impacted by it. The success of a program of this magnitude is possible only insofar as those organizations support it. There is precedent, however, for the successful implementation of substantial change. One need only look at the radical change brought about by the introduction of the 80-hour workweek. In relative contrast with our proposal, the 80-hour week was mandated with much less discussion, and its implementation was mandated in all 260+ programs in July 2003. Major changes were required, and the surgical community responded appropriately. Most believe today that this change

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was positive, and if nothing else, it showed that we can break with traditions when necessary and move forward. Modifications to a system of training that has served us well during so many years have to be implemented carefully, methodically, and progressively, but now is the right time to start the process. Indeed, we have noted a unique alignment of circumstances fueling the need for change, not the least of which is the immense progress made in information and systems technology. We need to seize this opportunity and lead in the process of change. Our patients, our trainees, and our society expect nothing less. REFERENCES 1. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349: 2117-27. 2. Kizer KW. The volume-outcome conundrum. N Engl J Med 2003;349:2159-61. 3. Goodney PP, Stukel TA, Lucas FL, Finlayson EV, Birkmeyer JD. Hospital volume, length of stay, and readmission rates in high-risk surgery. Ann Surg 2003;238:161-7. 4. Bland KI. Challenges to academic surgery: the impact of surgical fellowships on choice of an academic career. Bull Am Coll Surg 2000;85:17-23, 46. 5. Ritchie WP Jr, Rhodes RS, Biester TW. Work loads and practice patterns of general surgeons in the United States, 1995-1997: a report from the American Board of Surgery. Ann Surg 1999;230:533-42; discussion 542-3. 6. Sheldon GF. Great expectations: the 21st century health workforce. Am J Surg 2003;185:35-41. 7. DaRosa DA, Bell RH Jr, Dunnington GL. Residency program models, implications, and evaluation: results of a think tank consortium on resident work hours. Surgery 2003;133:13-23. 8. Whang EE, Mello MM, Ashley SW, Zinner MJ. Implementing resident work hour limitations: lessons from the New York State experience. Ann Surg 2003;237:449-55. 9. Peters JH, Fried GM, Swanstrom LL, Soper NJ, Sillin LF, Schirmer B, et al. Development and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surgery 2004;135:21-7. 10. Feldman LS, Sherman V, Fried GM. Using simulators to assess laparoscopic competence: ready for widespread use?(review). Surgery 2004;135:28-42. 11. Feldman LS, Hagarty SE, Ghitulescu G, Stanbridge D, Fried GM. Relationship between objective assessment of technical skills and subjective in-training evaluations in surgical residents. J Am Coll Surg 2004;198:105-10.

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12. Chang L, Satava RM, Pellegrini CA, Sinanan MN. Robotic surgery: identifying the learning curve through objective measurements of skill. Surg Endosc 2003;17:1744-8. 13. Villegas L, Schneider BE, Callery MP, Jones DB. Laparoscopic skills training. Surg Endosc 2003;17:1879-88. 14. Ritter EM, McClusky DA III, Lederman AB, Gallagher AG, Smith CD. Objective psychomotor skills assessment of experienced and novice flexible endoscopists with a virtual reality simulator. J Gastrointest Surg 2003;7:871-7; discussion 877-8. 15. Etchells E, O’Neill C, Bernstein M. Patient safety in surgery: error detection and prevention (review). World J Surg 2003; 27:936-41; discussion 941-2. 16. Dutta S, Dunnington G, Blanchard MC, Spielman B, DaRosa D, Joehl RJ. ‘‘And doctor, no residents please!’’. J Am Coll Surg 2003;197:1012-7. 17. Babineau TJ, Becker J, Gibbons G, Sentovich S, Hess D, Robertson S, et al. The ‘‘Cost’’ of operative training for surgical residents. Arch Surg 2004;139:366-9; discussion 369-70. 18. Bridges M, Diamond DL. The financial impact of teaching surgical residents in the operating room. Am J Surg 1999; 177:28-32. 19. Gold JP, Verrier ED, Mathisen DJ, Fullerton DA, Orringer MD. Successful implementation of a novel internet hybrid surgery curriculum: the early phase outcome of thoracic surgery prerequisite curriculum e-learning project. Ann Surg 2004;240:499-509. 20. Jones RS, Debas HT. Surgical education in the United States: portents for change. Ann Surg 2004;204:563-72. 21. Sachdeva AK. Acquisition and maintenance of surgical competence(review). Semin Vasc Surg 2002;15:182-90. 22. Sachdeva AK. Invited commentary: educational interventions to address the core competencies in surgery. Surgery 2004;135:43-7. 23. Velmahos GC, Toutouzas KG, Sillin LF, Chan L, Clark RE, Theodorou D, et al. Cognitive task analysis for teaching technical skills in an inanimate surgical skills laboratory. Am J Surg 2004;187:114-9. 24. Schroen AT, Brownstein MR, Sheldon GF. Women in academic general surgery. Acad Med 2004;79:310-8. 25. Patil NG, Cheng SW, Wong J. Surgical competence. World J Surg 2003;27:943-7. 26. Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg 2004;239:475-82. 27. Harness JK. Interdisciplinary care–the future of endocrine surgery. Surgery 2000;128:873-80. 28. Crittenden R, Schaad D, Coombs J. Surveying graduates of one school to determine regional workforce demand. Acad Med 2001;76:623-7. 29. Hunter JG, Deveney KE. Training the rural surgeon: a proposal. Bull Am Coll Surg 2003;88:13-7. 30. Brennan M, Debas HT. Research: a vital component of optimal patient care in the United States. Ann Surg 2004; 204:S73-7.