- Email: [email protected]
A Colorectal Curriculum for General Surgery Residents: Are We Ready for Needs Assessment?
2007 APDS SPRING MEETING
A Colorectal Curriculum for General Surgery Residents: Are We Ready for Needs Assessment? Sara H. Javid, MD, Stanley Ashley, MD, and Elizabeth Breen, MD Department of Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts OBJECTIVE: The traditional scope of general surgery (GS) has been broadly encompassing. Although it is generally accepted that we need a more defined curriculum for GS training, the criteria for limiting its scope remain controversial. One approach is to perform a needs assessment, defined based on an analysis of current GS practice. The purpose of this study was to use such a needs assessment to model a subset of the GS curriculum in colon and rectal surgery. DESIGN: The numbers of colon and anorectal procedures
performed in the prior 24 months by 982 GS taking the 2004 ABS Recertification Examination in Surgery were examined to determine the mean number of procedures per surgeon along with the percentage of surgeons who had performed at least 1 of the identified procedures. The impact of using these numbers to define a general surgical curriculum was then examined. RESULTS: Procedures performed frequently and by ⬎60% GS included appendectomies, colostomies, colectomies, hemorrhoidectomies, and anorectal abscess procedures. Procedures performed infrequently, yet performed by ⬎30% of surgeons at least once, included subtotal colectomies, abdominoperineal resections, transanal excisions, sphincterotomies, and anorectal fistulotomies. The procedures performed rarely included ileoanal pouch anastomoses and procedures for incontinence and rectal prolapse. CONCLUSIONS: Based on this analysis, a colorectal surgical
curriculum would include the treatment of diseases that led to commonly performed operations such as colon cancer, diverticular disease, lower gastrointestinal bleeding, mesenteric ischemia, inflammatory bowel disease (IBD), hemorrhoids, and anorectal diseases. The management of low rectal cancer, complex IBD, rectal prolapse, and fecal incontinence might not be essential content. A curriculum based on needs assessment would deemphasize or even eliminate some areas traditionally considered within the realm of GS. Although this might approCorrespondence: Inquiries to Elizabeth Breen, MD, Department of Surgery, Brigham and Women’s Hospital, 75 Francis Street, ASB-3, Boston, Massachusetts 02115; fax: (617) 739-1728; e-mail: [email protected]
324
priately serve as a basis for defining the scope of GS, the indirect consequences will need to be defined. (J Surg 64:324-327. © 2007 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: curriculum, colorectal, general surgery, resi-
dency COMPETENCY: Patient Care, Medical Knowledge, Practice Based Learning and Improvement
INTRODUCTION Traditionally, the practice of general surgery has been heterogeneous, varying by type of practice and geographic region.1 As a result, the scope of general surgery training has not been clearly delineated. In fact, almost by definition, the well-trained general surgeon has been expected to be capable of managing the preoperative, operative, and postoperative care of virtually any surgical problem, including many that are today managed primarily by the surgical subspecialties. For a host of reasons, this paradigm may no longer be appropriate and now reasonably general agreement exists, at a national level, that the best way to address this is through the development of a focused curriculum in general surgery. This effort has recently developed increasing momentum with the formation of the Surgical Council on Resident Education (SCORE), which represents the major stakeholders in graduate medical education.2 SCORE has used an expert-consensus method to determine which procedures should be taught during surgical residency, although it has not yet made a final recommendation regarding the level of competency expected for the various procedures at the end of training. The Association of Program Directors in Surgery (APDS), a member of SCORE, working through the APDS Curriculum Committee headed by Dr John Potts, has offered to create educational content for the curriculum. The American College of Surgeons (ACS), also a SCORE member, is working with the APDS to define a skills curriculum to support the teaching of general surgery operations, which is a project headed by Dr. Gary Dunnington.
Journal of Surgical Education • © 2007 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/07/$30.00 doi:10.1016/j.jsurg.2007.04.008
performed in the prior 24 months by 982 general surgeons (GS) taking the Recertification Exam was examined. Data for major abdominal operations performed by those surgeons are reported as the mean, median, and the percentage of GS who had performed at least 1 of those procedures in the previous 24 months (% one) (Table 2). Similarly, these values for 67 colorectal specialists (CRS) also taking the 2004 ABS Recertification Examination in Surgery (Table 2) were also examined. Then the mean, median, and %1 of anorectal procedures performed by GS and CRS (Table 3) were examined. Using this data, a colorectal curriculum for general surgery residents was modeled based on the current practice patterns.
TABLE 1. Mean Number of Annual Procedures Performed by General Surgeons Taking the ABS Recertification Examination from 1995 to 2001 Procedure Category Abdomen Alimentary Tract Breast Endoscopy Miscellaneous
Mean
Percentage
110 67 57 57 53
25.5 15.6 13.3 13.2 12.4
Principles of adult education would suggest that curricula be based on a needs assessment of the learners.3,4 There are several ways to perform such a needs assessment; for general surgery; 1 approach is to examine practice patterns, basing the scope of training on the current range of activities of general surgeons. In the context of current curricular development activities, the purpose of this study was to perform such an analysis, using this exercise to determine the wider implications of such an approach. Specifically, the operative log reports were examined in colorectal surgery submitted to the American Board of Surgery by recertifying general surgeons. This content area was chosen because it is an area traditionally within the realm of general surgery but also increasingly focused in the hands of subspecialists. For this exercise, excluding operations performed infrequently by general surgeons from the curriculum is proposed. It is hypothesized that the resulting curriculum might be very different than what is currently considered within the scope of general surgery training.
RESULTS General surgeons taking the ABS recertification examination between 1995 and 2001 on average performed a total of 429 procedures per year. Of these, the majority were abdominal and alimentary tract procedures (Table 1). Tables 2 and 3 show the mean, median, and %1 of major abdominal and anorectal procedures, respectively, performed by GS and CRS. Procedures performed either frequently or by a large percentage of GS included appendectomies, colostomies, partial colectomies, hemorrhoidectomies, and anorectal abscess procedures (mean/ year ⫽ 19, 2.2,13, 5, and 2.8, respectively). Over 60% had performed at least 1 each of these procedures during the 24 months prior. In addition, endoscopy was performed with great frequency (mean 57 procedures/year) and comprised 13% of GS operative procedures, nearly the same percentage occupied by breast surgeries. With regard to major abdominal operations, CRS performed all procedures, with the exception of appendectomies, more frequently than GS. The percentage of CRS who had performed at least 1 (%1) of each of these procedures also exceeded that of GS. This disparity was greatest for ileoanal pouch anal anastomoses (IPAAs), abdominoperineal resections (APRs), and transanal excision of tumors. Procedures performed infrequently, yet performed by ⬎30% of GS at least once during the 2 years included subtotal colectomies, APRs, transanal excisions, sphincterotomies, and anorectal fistulotomies. The procedures performed rarely included IPAAs,
METHODS Data from the 1995–2001 and 2004 American Board of Surgery (ABS) Recertification Examination in Surgery were employed. Recertifying surgeons were asked to submit an operative experience report for the previous 12 and 24 months, respectively. The numbers of overall procedures performed during the previous 12 months by recertifying general surgeons in 19952001 were examined. General procedures were categorized as abdomen, alimentary tract, breast, endoscopy, or miscellaneous (Table 1). Then the number of colon and anorectal procedures
TABLE 2. Mean, Median, and % one (% surgeons who had performed at least 1 of those procedures) of Major Abdominal Operations Performed in the Previous 24 Months by Surgeons Taking the ABS Recertification Examination in General Surgery in 2004 General Surgeons (GS) Major Abdominal Operations Appendectomy Colectomy Subtotal/total colectomy IPAA Colostomy APR Laparoscopic colectomy Transanal excision tumors
Colorectal Surgeons (CRS)
Mean
Med
%1
Mean
Med
%1
19 13 1 0 2.2 0.6 1.6 0.7
10 9 0 0 1 0 0 0
83 88 31 2.6 63 31 29 30
12 43 4 2 3.7 4 6.8 7.4
6 31 2 0 2 3 3 5
60 97 82 42 77 78 66 90
Journal of Surgical Education • Volume 64/Number 6 • November/December 2007
325
TABLE 3. Mean, Median, and %1 of Anorectal Procedures Performed in the Previous 24 Months by Surgeons Taking the ABS Recertification Examination in General Surgery in 2004 General Surgeons (GS)
Colorectal Surgeons (CRS)
Anorectal Operations
Mean
Med
%1
Mean
Med
%1
Hemorrhoidectomy Sphincterotomy Drainage of anorectal abscess Repair anorectal fistula Anorectal incontinence Repair rectal prolapse
5 1.4 2.8 1.5 0.02 0.2
3 0 2 0 0 0
70 42 66 47 0.9 9.2
33.6 16 11.5 15 2.1 4.5
26 12 7 15 0 3
100 95 91 100 45 79
laparoscopic colectomies, and procedures for incontinence and rectal prolapse.
DISCUSSION As summarized recently by Dr. Richard Bell of the American Board of Surgery, the current effort to develop a focused curriculum in generally surgery was initiated in 2002 when Dr. Haile Debas, as President of the American Surgical Association (ASA), established a Blue Ribbon Committee to examine the many forces for change in surgical education and to formulate a response.5 The Committee published its analysis in 2005, and among its central recommendations was the development of such a curriculum.6 Subsequently, the ABS convened a meeting in November 2004 with representatives from the ABS, ASA, ACS, APDS, Association for Surgical Education (ASE), and the Residency Review Committee for Surgery (RRC-S). This group proposed to join forces to work on a standardized national curriculum. In addition, the ABS agreed to fund, with the other attending organizations contributing, a new position devoting full-time attention to surgery graduate medical education. Dr. Bell was chosen for this position; one of his first projects was to reconvene the multiorganization task force that met in 2004, adopting the name Surgical Council on Resident Education (SCORE). Among the initiatives this group again agreed to pursue was the development of a defined curriculum.2 The ABS has provided administrative support for this project, establishing a Web site with a learning content management system. The content of this site will be provided by members of the APDS, working through the APDS Curriculum Committee headed by Dr John Potts. The only previous effort to develop such a curriculum was the Surgical Resident Curriculum of the APDS initiated by Dr. Walter Pories.7 Although useful, reasonable consensus exists that this curriculum is too broad, and that a more focused approach is necessary. Efforts to determine the scope of a new GS curriculum are already underway. This discussion undoubtedly represents the critical step in the process and has already generated considerable discussion. The concept that educational curricula should be based on a needs assessment is well established; the real issue is how to define these needs.3,4 The complexity of issues facing surgical education today has been summarized elsewhere; the 326
extent to which a new curriculum could or should be used to address these issues remains the subject of debate. Confronting the choices about which of these needs should be considered will undoubtedly have a major impact on the future of the specialty as well as on the nature and quality of surgical care. In this context, perhaps the simplest approach would be that described here, basing a general surgical curriculum on current practice patterns. We proposed that it might be useful to analyze the impact of such an approach in 1 content area of general surgery, colorectal surgery. Colon and rectal surgery has always been at the core of general surgery training and practice. However, today, at least in many urban areas, colorectal surgeon specialists are referred to a disproportionately large number of patients with the more complex colorectal diseases. Hyman had previously used ABS Recertification data to analyze the colorectal practice patterns of general surgeons and found that the mean number of yearly anorectal cases for general surgeons was only 9.3 in 1997.8 The current data suggest that this experience may be decreasing further. Based on this analysis, a colorectal surgical curriculum for general surgery would focus heavily on those procedures most frequently performed by GS, yet include content related to procedures performed infrequently by a significant percentage of general surgeons at least once every 24 months. The curriculum would not emphasize content related to procedures performed more rarely by GS. It was found, not unexpectedly, that several procedures, including APRs, transanal excisions, IPAAs, and rectal prolapse operations, such as the Altmeier and Delorme procedures, were performed infrequently if at all by practicing GS. Tailoring the colorectal content for GS based on this, we would exclude many of these procedures previously owned by general surgery from the defined curriculum. Extrapolating to disease entities represented by these procedures, a colorectal curriculum for GS residents would focus on colon and rectal cancer, diverticular disease, lower gastrointestinal bleeding, volvulus, mesenteric ischemia, uncomplicated IBD, hemorrhoids, and anorectal abscesses/fistulae. Given the rising percentages of colectomies being performed laparoscopically by both GS and CRS, it would be premature to exclude these techniques from the curriculum. Based on those procedures performed rarely by GS, the management of complex IBD, rectal prolapse, low rectal cancers, and fecal incontinence
Journal of Surgical Education • Volume 64/Number 6 • November/December 2007
might not be essential content within a general surgical resident curriculum. The first question raised by this analysis is whether the ABS data are an accurate reflection of current practice. Although the data excluded recertifying surgeons with a primary certificate in another area (colorectal, vascular, cardiothoracic, pediatric surgery, plastic surgery), it includes subspecialists in surgical oncology, transplant, bariatrics, minimally invasive surgery, and critical care, where no primary certificate is offered. In addition, in response to referral patterns in many urban areas, many general surgeons are effectively subspecialized, managing primarily breast disease or hernias, for example. Both of these trends undoubtedly dilute the pool, making the means of procedures artificially low. Even if we could exclude these surgeons, the numbers for some procedures, such as IPAAs, would still be expected to be exceedingly low, even though undoubtedly some surgeons in community practice are performing such operations in significant numbers. It is suggested that, as this general surgical curriculum is developed, a decision will need to be made about whether to tailor the scope based on the means or to focus on the outliers. Similarly, considering the potential impact of such a change, clearly both positives and negatives will need to be weighed. For example, if a needs assessment-based curriculum was applied across content areas, it would significantly focus the learning of surgical residents, permitting them to increase their efforts in areas that they will eventually use in practice. As the discussion moves from time-based to competency-based training, this might permit a significant reduction in the length of training. For the 70% of residents currently seeking additional specialty training, this might be a significant benefit (ABS, personal communication). On the other hand, the impact might not be so positive for general surgery itself— essentially the complex cases would be removed that are often the most appealing, in effect truncating the specialty at a time when most projections suggest that a shortage of surgeons will continue to increase over the next decade.9 One alternative approach, proposed by the Blue Ribbon Committee, would be to preserve areas that really have been at the core of general surgery but to permit the specialists themselves to branch off at an earlier juncture.6 Varying levels of proficiency within general surgery might be another approach to curriculum development. For example, the resident completing general surgery residency might be expected to be competent in the management of colon cancer but only familiar with that of rectal prolapse. A host of indirect consequences also needs to be considered. For example, if the ABS and RRC-S were to endorse such a tailored curriculum, essentially removing some operations from the content of general surgery, these organizations would potentially assume a considerably greater role in credentialing. Likewise, for colorectal surgery training itself, this change might significantly strengthen training, concentrating the most complex cases with trainees who will eventually be doing the surger-
ies. On the other hand, it has been suggested that the exposure of training general surgeons to these complex procedures is what attracts them to the specialty. The effect of such a change on quality of care is also unclear, although the accumulating evidence for a volume-outcome relationship for such complex procedures would support their concentration in a group of specialists, the impact on access is difficult to predict and may outweigh the volume consideration.10 In summary, although the needs analysis principle seems a reasonable starting point for the development of a general surgery curriculum, there are clearly needs other than those reflected in current practice patterns. Although these numbers should be considered in the development of a new curriculum, they should represent only 1 factor in the equation. In fact, rather than tailoring the curriculum to fit the current scope of practice, the opportunity now exists to establish a new and potentially very exciting identity for the specialty of general surgery.
REFERENCES 1. 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;230:533-542, discussion 542-543. 2. Surgical Council on Resident Education. A new organiza-
tion devoted to graduate surgical education. JACS. 2007; 204:341-346. 3. Ornstein AC, Hunkins FP. Curriculum Foundations,
Principles, and Issues. 3rd ed. Needham Heights, MA: Allyn and Bacon; 1988. 4. Prideaux D. ABC’s of learning and teaching in medicine:
curriculum design. BMJ. 2003;326:268-270. 5. Debas HT. Surgery: a noble profession in a changing
world. Ann Surg. 2002;236:263-269. 6. Debas HT, Bass BL, Brennan MF, et al. American surgical
association blue ribbon committee report on surgical education: 2004. Ann Surg. 2005;241:1-8. 7. Cox SS, Pofahl WEII, Pories WJ, eds. Surgical Resident
Curriculum. 4th ed. Arlington, VA: The Association of Program Directors in Surgery; 2002. 8. Hyman N. How much colorectal surgery do general sur-
geons do? JACS. 2002;194:37-39. 9. Cooper RA, Getzen TE, Mckee HJ, Laud P. Economic
and demographic trends signal an impending physician shortage. Health Affairs. 2002;21:140-154. 10. Birkmeyer JD, Dimick JB. Staiger DO. Operative mor-
tality and procedure volume as predictors of subsequent hospital performance. Ann Surg. 2006;243:411-417.
Journal of Surgical Education • Volume 64/Number 6 • November/December 2007
327
A Colorectal Curriculum for General Surgery Residents: Are We Ready for Needs Assessment? Sara H. Javid, MD, Stanley Ashley, MD, and Elizabeth Breen, MD Department of Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts OBJECTIVE: The traditional scope of general surgery (GS) has been broadly encompassing. Although it is generally accepted that we need a more defined curriculum for GS training, the criteria for limiting its scope remain controversial. One approach is to perform a needs assessment, defined based on an analysis of current GS practice. The purpose of this study was to use such a needs assessment to model a subset of the GS curriculum in colon and rectal surgery. DESIGN: The numbers of colon and anorectal procedures
performed in the prior 24 months by 982 GS taking the 2004 ABS Recertification Examination in Surgery were examined to determine the mean number of procedures per surgeon along with the percentage of surgeons who had performed at least 1 of the identified procedures. The impact of using these numbers to define a general surgical curriculum was then examined. RESULTS: Procedures performed frequently and by ⬎60% GS included appendectomies, colostomies, colectomies, hemorrhoidectomies, and anorectal abscess procedures. Procedures performed infrequently, yet performed by ⬎30% of surgeons at least once, included subtotal colectomies, abdominoperineal resections, transanal excisions, sphincterotomies, and anorectal fistulotomies. The procedures performed rarely included ileoanal pouch anastomoses and procedures for incontinence and rectal prolapse. CONCLUSIONS: Based on this analysis, a colorectal surgical
curriculum would include the treatment of diseases that led to commonly performed operations such as colon cancer, diverticular disease, lower gastrointestinal bleeding, mesenteric ischemia, inflammatory bowel disease (IBD), hemorrhoids, and anorectal diseases. The management of low rectal cancer, complex IBD, rectal prolapse, and fecal incontinence might not be essential content. A curriculum based on needs assessment would deemphasize or even eliminate some areas traditionally considered within the realm of GS. Although this might approCorrespondence: Inquiries to Elizabeth Breen, MD, Department of Surgery, Brigham and Women’s Hospital, 75 Francis Street, ASB-3, Boston, Massachusetts 02115; fax: (617) 739-1728; e-mail: [email protected]
324
priately serve as a basis for defining the scope of GS, the indirect consequences will need to be defined. (J Surg 64:324-327. © 2007 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: curriculum, colorectal, general surgery, resi-
dency COMPETENCY: Patient Care, Medical Knowledge, Practice Based Learning and Improvement
INTRODUCTION Traditionally, the practice of general surgery has been heterogeneous, varying by type of practice and geographic region.1 As a result, the scope of general surgery training has not been clearly delineated. In fact, almost by definition, the well-trained general surgeon has been expected to be capable of managing the preoperative, operative, and postoperative care of virtually any surgical problem, including many that are today managed primarily by the surgical subspecialties. For a host of reasons, this paradigm may no longer be appropriate and now reasonably general agreement exists, at a national level, that the best way to address this is through the development of a focused curriculum in general surgery. This effort has recently developed increasing momentum with the formation of the Surgical Council on Resident Education (SCORE), which represents the major stakeholders in graduate medical education.2 SCORE has used an expert-consensus method to determine which procedures should be taught during surgical residency, although it has not yet made a final recommendation regarding the level of competency expected for the various procedures at the end of training. The Association of Program Directors in Surgery (APDS), a member of SCORE, working through the APDS Curriculum Committee headed by Dr John Potts, has offered to create educational content for the curriculum. The American College of Surgeons (ACS), also a SCORE member, is working with the APDS to define a skills curriculum to support the teaching of general surgery operations, which is a project headed by Dr. Gary Dunnington.
Journal of Surgical Education • © 2007 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/07/$30.00 doi:10.1016/j.jsurg.2007.04.008
performed in the prior 24 months by 982 general surgeons (GS) taking the Recertification Exam was examined. Data for major abdominal operations performed by those surgeons are reported as the mean, median, and the percentage of GS who had performed at least 1 of those procedures in the previous 24 months (% one) (Table 2). Similarly, these values for 67 colorectal specialists (CRS) also taking the 2004 ABS Recertification Examination in Surgery (Table 2) were also examined. Then the mean, median, and %1 of anorectal procedures performed by GS and CRS (Table 3) were examined. Using this data, a colorectal curriculum for general surgery residents was modeled based on the current practice patterns.
TABLE 1. Mean Number of Annual Procedures Performed by General Surgeons Taking the ABS Recertification Examination from 1995 to 2001 Procedure Category Abdomen Alimentary Tract Breast Endoscopy Miscellaneous
Mean
Percentage
110 67 57 57 53
25.5 15.6 13.3 13.2 12.4
Principles of adult education would suggest that curricula be based on a needs assessment of the learners.3,4 There are several ways to perform such a needs assessment; for general surgery; 1 approach is to examine practice patterns, basing the scope of training on the current range of activities of general surgeons. In the context of current curricular development activities, the purpose of this study was to perform such an analysis, using this exercise to determine the wider implications of such an approach. Specifically, the operative log reports were examined in colorectal surgery submitted to the American Board of Surgery by recertifying general surgeons. This content area was chosen because it is an area traditionally within the realm of general surgery but also increasingly focused in the hands of subspecialists. For this exercise, excluding operations performed infrequently by general surgeons from the curriculum is proposed. It is hypothesized that the resulting curriculum might be very different than what is currently considered within the scope of general surgery training.
RESULTS General surgeons taking the ABS recertification examination between 1995 and 2001 on average performed a total of 429 procedures per year. Of these, the majority were abdominal and alimentary tract procedures (Table 1). Tables 2 and 3 show the mean, median, and %1 of major abdominal and anorectal procedures, respectively, performed by GS and CRS. Procedures performed either frequently or by a large percentage of GS included appendectomies, colostomies, partial colectomies, hemorrhoidectomies, and anorectal abscess procedures (mean/ year ⫽ 19, 2.2,13, 5, and 2.8, respectively). Over 60% had performed at least 1 each of these procedures during the 24 months prior. In addition, endoscopy was performed with great frequency (mean 57 procedures/year) and comprised 13% of GS operative procedures, nearly the same percentage occupied by breast surgeries. With regard to major abdominal operations, CRS performed all procedures, with the exception of appendectomies, more frequently than GS. The percentage of CRS who had performed at least 1 (%1) of each of these procedures also exceeded that of GS. This disparity was greatest for ileoanal pouch anal anastomoses (IPAAs), abdominoperineal resections (APRs), and transanal excision of tumors. Procedures performed infrequently, yet performed by ⬎30% of GS at least once during the 2 years included subtotal colectomies, APRs, transanal excisions, sphincterotomies, and anorectal fistulotomies. The procedures performed rarely included IPAAs,
METHODS Data from the 1995–2001 and 2004 American Board of Surgery (ABS) Recertification Examination in Surgery were employed. Recertifying surgeons were asked to submit an operative experience report for the previous 12 and 24 months, respectively. The numbers of overall procedures performed during the previous 12 months by recertifying general surgeons in 19952001 were examined. General procedures were categorized as abdomen, alimentary tract, breast, endoscopy, or miscellaneous (Table 1). Then the number of colon and anorectal procedures
TABLE 2. Mean, Median, and % one (% surgeons who had performed at least 1 of those procedures) of Major Abdominal Operations Performed in the Previous 24 Months by Surgeons Taking the ABS Recertification Examination in General Surgery in 2004 General Surgeons (GS) Major Abdominal Operations Appendectomy Colectomy Subtotal/total colectomy IPAA Colostomy APR Laparoscopic colectomy Transanal excision tumors
Colorectal Surgeons (CRS)
Mean
Med
%1
Mean
Med
%1
19 13 1 0 2.2 0.6 1.6 0.7
10 9 0 0 1 0 0 0
83 88 31 2.6 63 31 29 30
12 43 4 2 3.7 4 6.8 7.4
6 31 2 0 2 3 3 5
60 97 82 42 77 78 66 90
Journal of Surgical Education • Volume 64/Number 6 • November/December 2007
325
TABLE 3. Mean, Median, and %1 of Anorectal Procedures Performed in the Previous 24 Months by Surgeons Taking the ABS Recertification Examination in General Surgery in 2004 General Surgeons (GS)
Colorectal Surgeons (CRS)
Anorectal Operations
Mean
Med
%1
Mean
Med
%1
Hemorrhoidectomy Sphincterotomy Drainage of anorectal abscess Repair anorectal fistula Anorectal incontinence Repair rectal prolapse
5 1.4 2.8 1.5 0.02 0.2
3 0 2 0 0 0
70 42 66 47 0.9 9.2
33.6 16 11.5 15 2.1 4.5
26 12 7 15 0 3
100 95 91 100 45 79
laparoscopic colectomies, and procedures for incontinence and rectal prolapse.
DISCUSSION As summarized recently by Dr. Richard Bell of the American Board of Surgery, the current effort to develop a focused curriculum in generally surgery was initiated in 2002 when Dr. Haile Debas, as President of the American Surgical Association (ASA), established a Blue Ribbon Committee to examine the many forces for change in surgical education and to formulate a response.5 The Committee published its analysis in 2005, and among its central recommendations was the development of such a curriculum.6 Subsequently, the ABS convened a meeting in November 2004 with representatives from the ABS, ASA, ACS, APDS, Association for Surgical Education (ASE), and the Residency Review Committee for Surgery (RRC-S). This group proposed to join forces to work on a standardized national curriculum. In addition, the ABS agreed to fund, with the other attending organizations contributing, a new position devoting full-time attention to surgery graduate medical education. Dr. Bell was chosen for this position; one of his first projects was to reconvene the multiorganization task force that met in 2004, adopting the name Surgical Council on Resident Education (SCORE). Among the initiatives this group again agreed to pursue was the development of a defined curriculum.2 The ABS has provided administrative support for this project, establishing a Web site with a learning content management system. The content of this site will be provided by members of the APDS, working through the APDS Curriculum Committee headed by Dr John Potts. The only previous effort to develop such a curriculum was the Surgical Resident Curriculum of the APDS initiated by Dr. Walter Pories.7 Although useful, reasonable consensus exists that this curriculum is too broad, and that a more focused approach is necessary. Efforts to determine the scope of a new GS curriculum are already underway. This discussion undoubtedly represents the critical step in the process and has already generated considerable discussion. The concept that educational curricula should be based on a needs assessment is well established; the real issue is how to define these needs.3,4 The complexity of issues facing surgical education today has been summarized elsewhere; the 326
extent to which a new curriculum could or should be used to address these issues remains the subject of debate. Confronting the choices about which of these needs should be considered will undoubtedly have a major impact on the future of the specialty as well as on the nature and quality of surgical care. In this context, perhaps the simplest approach would be that described here, basing a general surgical curriculum on current practice patterns. We proposed that it might be useful to analyze the impact of such an approach in 1 content area of general surgery, colorectal surgery. Colon and rectal surgery has always been at the core of general surgery training and practice. However, today, at least in many urban areas, colorectal surgeon specialists are referred to a disproportionately large number of patients with the more complex colorectal diseases. Hyman had previously used ABS Recertification data to analyze the colorectal practice patterns of general surgeons and found that the mean number of yearly anorectal cases for general surgeons was only 9.3 in 1997.8 The current data suggest that this experience may be decreasing further. Based on this analysis, a colorectal surgical curriculum for general surgery would focus heavily on those procedures most frequently performed by GS, yet include content related to procedures performed infrequently by a significant percentage of general surgeons at least once every 24 months. The curriculum would not emphasize content related to procedures performed more rarely by GS. It was found, not unexpectedly, that several procedures, including APRs, transanal excisions, IPAAs, and rectal prolapse operations, such as the Altmeier and Delorme procedures, were performed infrequently if at all by practicing GS. Tailoring the colorectal content for GS based on this, we would exclude many of these procedures previously owned by general surgery from the defined curriculum. Extrapolating to disease entities represented by these procedures, a colorectal curriculum for GS residents would focus on colon and rectal cancer, diverticular disease, lower gastrointestinal bleeding, volvulus, mesenteric ischemia, uncomplicated IBD, hemorrhoids, and anorectal abscesses/fistulae. Given the rising percentages of colectomies being performed laparoscopically by both GS and CRS, it would be premature to exclude these techniques from the curriculum. Based on those procedures performed rarely by GS, the management of complex IBD, rectal prolapse, low rectal cancers, and fecal incontinence
Journal of Surgical Education • Volume 64/Number 6 • November/December 2007
might not be essential content within a general surgical resident curriculum. The first question raised by this analysis is whether the ABS data are an accurate reflection of current practice. Although the data excluded recertifying surgeons with a primary certificate in another area (colorectal, vascular, cardiothoracic, pediatric surgery, plastic surgery), it includes subspecialists in surgical oncology, transplant, bariatrics, minimally invasive surgery, and critical care, where no primary certificate is offered. In addition, in response to referral patterns in many urban areas, many general surgeons are effectively subspecialized, managing primarily breast disease or hernias, for example. Both of these trends undoubtedly dilute the pool, making the means of procedures artificially low. Even if we could exclude these surgeons, the numbers for some procedures, such as IPAAs, would still be expected to be exceedingly low, even though undoubtedly some surgeons in community practice are performing such operations in significant numbers. It is suggested that, as this general surgical curriculum is developed, a decision will need to be made about whether to tailor the scope based on the means or to focus on the outliers. Similarly, considering the potential impact of such a change, clearly both positives and negatives will need to be weighed. For example, if a needs assessment-based curriculum was applied across content areas, it would significantly focus the learning of surgical residents, permitting them to increase their efforts in areas that they will eventually use in practice. As the discussion moves from time-based to competency-based training, this might permit a significant reduction in the length of training. For the 70% of residents currently seeking additional specialty training, this might be a significant benefit (ABS, personal communication). On the other hand, the impact might not be so positive for general surgery itself— essentially the complex cases would be removed that are often the most appealing, in effect truncating the specialty at a time when most projections suggest that a shortage of surgeons will continue to increase over the next decade.9 One alternative approach, proposed by the Blue Ribbon Committee, would be to preserve areas that really have been at the core of general surgery but to permit the specialists themselves to branch off at an earlier juncture.6 Varying levels of proficiency within general surgery might be another approach to curriculum development. For example, the resident completing general surgery residency might be expected to be competent in the management of colon cancer but only familiar with that of rectal prolapse. A host of indirect consequences also needs to be considered. For example, if the ABS and RRC-S were to endorse such a tailored curriculum, essentially removing some operations from the content of general surgery, these organizations would potentially assume a considerably greater role in credentialing. Likewise, for colorectal surgery training itself, this change might significantly strengthen training, concentrating the most complex cases with trainees who will eventually be doing the surger-
ies. On the other hand, it has been suggested that the exposure of training general surgeons to these complex procedures is what attracts them to the specialty. The effect of such a change on quality of care is also unclear, although the accumulating evidence for a volume-outcome relationship for such complex procedures would support their concentration in a group of specialists, the impact on access is difficult to predict and may outweigh the volume consideration.10 In summary, although the needs analysis principle seems a reasonable starting point for the development of a general surgery curriculum, there are clearly needs other than those reflected in current practice patterns. Although these numbers should be considered in the development of a new curriculum, they should represent only 1 factor in the equation. In fact, rather than tailoring the curriculum to fit the current scope of practice, the opportunity now exists to establish a new and potentially very exciting identity for the specialty of general surgery.
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