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Opinions of practicing general surgeons on surgical education
Opinions of Practicing General Surgeons on Surgical Education John Weigelt, MD, Karen Brasel, MD, MPH, Christine Olson, MD, MPH, St. Paul, Minnesota, Erwin Thal, MD, Dallas, Texas
BACKGROUND: Collective opinions of practicing general surgeons on the current state of general surgical resident education are unknown. METHODS: A 26-item survey was mailed to practicing general surgeons in Minnesota and Texas. Average scores on 17 Likert-formatted questions and opinions on multiple-choice questions were compared by geographic area and academic affiliation. RESULTS: Overall response was 954 of 1,745 (55%). All surgeons felt changes were needed in surgical education. There was agreement by geographic area and academic affiliation that the current system of resident education allows chief residents to graduate with significant gaps in their education, and that the responsibility for correcting these gaps lies with the residency program. CONCLUSIONS: Opinions of general surgeons in two geographic areas and of differing academic affiliation regarding surgical education showed marked similarity. These data suggest change in the process of surgical education is the responsibility of the residency program and should be a priority for the profession. Am J Surg. 1998;176: 481– 485. © 1998 by Excerpta Medica, Inc.
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edical education continues to face pressure to re-engineer itself. These pressures include decreasing GME and IME reimbursement, decreasing patient populations at academic medical centers, competing care systems, correlating student output with marketplace needs, identifying the best way to train physicians, and the best site for training.1– 8 Solutions are not self-evident. Our purpose in performing this survey of practicing surgeons was to allow the products of our surgical educational system to assess its current state. Three specific areas were explored via a questionnaire: problems within the current
From the University of Minnesota, St. Paul, Minnesota, and University of Texas Southwestern Medical Center, Dallas, Texas. Presented in part as a poster presentation at the meeting of the Association for Surgical Education, Philadelphia, Pennsylvania, April 1997. Requests for reprints should be addressed to John A. Weigelt, MD, Professor and Vice-Chairman, Department of Surgery, University of Minnesota, Regions Hospital, 640 Jackson Street, St. Paul, Minnesota 55101. Manuscript submitted June 3, 1998 and accepted in revised form August 17, 1998.
© 1998 by Excerpta Medica, Inc. All rights reserved.
educational system, how education should best be accomplished, and who should be educating surgical trainees.
METHODS Survey questions were developed covering three aspects of surgical education: problems within the current educational system, how education should best be accomplished, and who is primarily responsible for the educational process. The majority of these questions were asked on a 4-point Likert scale. Demographic questions were also asked about the training, current practice, and length of practice of the responding surgeon. Respondents were asked to classify themselves as university surgeons, community surgeons with university affiliation, and community surgeons without university affiliation. The survey was pilot tested on a group of surgeons not part of the target population. All surgeons practicing in a metropolitan area (Minneapolis/St. Paul, Minnesota) were identified by obtaining lists of all surgeons with operating privileges at any hospital in the area. Surgeons in Texas were identified by the state continuing medical education list for surgeons. The final survey was mailed to all general, pediatric, vascular, cardiothoracic, colorectal, and transplant surgeons in both areas. Surgeons who did not return the survey within 4 weeks were sent a follow-up letter and second survey. University surgeons were referred to as full-time academic surgeons and the remaining groups were grouped as community surgeons, regardless of academic affiliation. Means of all Likert-scored questions were compared between geographic area and by academic affiliation using Student’s t test. Mean scores greater than 2.5 indicated agreement; less than 2.5, disagreement.
RESULTS Demographics Overall response rate was 55% (954 of 1,754). Response rate was higher in Minnesota (173 of 264) than in Texas (781 of 1,490). No statistical differences in surgeon demographics existed between the two states. There were 807 community surgeons (84%) and 106 academic surgeons (11%) who responded. Surgeons had been in practice an average of 17.4 years (range 1 to 55). In all, 562 surgeons classified themselves as general surgeons and 334 as other specialists (29 nonclassified and 29 with a combined practice); 497 surgeons obtained some type of fellowship training after completing a general surgery residency. Survey questions are listed in Figure 1. There was remarkable similarity in the responses of surgeons grouped by academic affiliation, length of practice, and geographic area. 0002-9610/98/$19.00 PII S0002-9610(98)00237-2
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GENERAL SURGEONS’ OPINIONS OF SURGICAL EDUCATION/WEIGELT ET AL
SURVEY QUESTIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
All surgeons with resident training responsibilities should have specific training in education. On-the-job training in educational techniques is adequate for surgeons responsible for training residents. Didactic material can be effectively taught by surgeons without specific training in surgical education. Clinical material can be effectively taught by surgeons without specific training in surgical education. All aspects of surgical training should be limited to individuals with specific training in surgical education. It is possible to be an effective teacher without regularly scheduled contact with the primary training institution. There should be a physician coordinator responsible for the educational program in a surgical residency. I would be willing to attend CME on surgical education. I believe changes are necessary in surgical education. It is necessary to have contact with residents in the operating room, on ward rounds and through formal didactic lectures in order to be an effective teacher. Perioperative care can be taught separately from operative care. Technical skills can be taught separately from perioperative care. Teaching skills can be learned and improved through specific training in educational techniques. Didactic material and clinical material can be taught independently. The current system of training residents allows chief residents to graduate with significant gaps in their education. The responsibility for correcting deficits in a resident’s education lies with the resident. The responsibility for correcting deficits in a resident’s education lies with the residency program. The responsibility for surgical education should ideally fall primarily to (check one box only): ❏ university faculty ❏ clinically affiliated faculty ❏ community surgeons without University affiliation ❏ should be balanced among groups ❏ does not matter—any combination of the above
19. The minimum amount of resident contact necessary for an individual surgeon to be an effective teacher is (check one box only): ❏ daily ❏ 23/week ❏ weekly ❏ monthly ❏ 1–2 months/year
20. The biggest deficit in graduating chief residents is (check one box only): ❏ technical skill ❏ basic science knowledge ❏ clinical knowledge ❏ patient care
21. The best approaches to correcting educational deficits would be (check 2 boxes): ❏ more didactic teaching time ❏ more preceptor (one-on-one) time ❏ more clinical teaching time ❏ increasing the length of general surgery residency ❏ specific coursework designed by surgical educators 22. In what type of residency program did you train? ❏ hospital-sponsored community hospital ❏ university-sponsored community hospital ❏ university-based academic 23. How long have you been in practice? 24. Did you obtain additional fellowship training after your general surgery residency? If yes, what type? 25. Which phrase describes you current practice? ❏ general surgery ❏ surgical specialty 26. Which phrase describes your current practice? ❏ full-time academic surgeon ❏ community surgeon with academic affiliation ❏ community surgeon without academic affiliation Figure 1. Survey questions. Questions 1 through 17 were answered on a 4-point Likert scale: 1, strongly disagree; 2, disagree; 3, agree; 4, strongly agree.
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TABLE I Deficits Identified in Graduating Chief Residents by Respondent Geographic Area and Academic Affiliation Number of Respondents Deficit
MN
TX
AS
CS
Technical skill Basic science knowledge Clinical knowledge Patient care
53 9 50 24
191 143 153 209
19 35 33 5
218 110 161 218
There were 1,754 total survey respondents: 173 MN and 781 TX; 807 CS and 106 AS. Not all respondents answered each question. MN 5 Minnesota metropolitan surgeons; TX 5 Texas state surgeons; AS 5 full-time academic surgeon; CS 5 community surgeon with or without academic affiliation.
TABLE II Approaches Identified to Correct Educational Deficits of Chief Residents by Respondent Geographic Area and Academic Affiliation
Figure 2. Distribution of responses to question 17; “The responsibility for correcting deficits in a resident’s education lies with the residency program.” An overwhelming number of respondents agreed with this statement.
TABLE III Groups Ideally Responsible for Surgical Education by Respondent Geographic Area and Academic Affiliation
Number of Respondents Approach to Correct Deficit
MN
TX
AS
CS
More didactic teaching time More preceptor (one-on-one) time More clinical teaching time Increasing length of residency Specific coursework for educators
19 78 90 4 47
107 449 357 49 240
20 32 40 11 43
90 479 383 39 236
Respondents were asked to identify best two approaches. There were 1,754 total survey respondents: 173 MN and 781 TX; 807 CS and 106 AS. Not all respondents answered each question. MN 5 Minnesota metropolitan surgeons; TX 5 Texas state surgeons; AS 5 full-time academic surgeon; CS 5 community surgeon with or without academic affiliation.
Problems within the Current Educational System The majority of surgeons feel changes are necessary in surgical education (question 9). Slightly fewer agreed that the current system allows chief residents to graduate with significant gaps in their education (question 15). The major deficit identified in graduating chief residents by the Minnesota group was technical skill, and in Texas it was patient care. Community surgeons identified these deficits as technical skill and patient care, whereas academic surgeons selected basic science knowledge (question 20, Table I). How to Accomplish Surgical Education Minnesota surgeons felt the best way to correct educational deficits was to increase clinical teaching time and Texas surgeons chose increasing preceptor (one-on-one) time (question 21, Table II). There was strong agreement that a physician coordinator should be responsible for surgical education (question 7), and physicians in both groups were willing to attend CME on surgical education (question 8). Both geographic groups disagreed that surgical instruction should be limited to individuals with specific educational training (question 5). The Texas group felt that surgeons with resident training responsibilities should receive educational training (question 1); this was
Number of Respondents Group Responsible for Education
MN
TX
AS
CS
Academic faculty Clinically affiliated faculty Community surgeons without academic affiliation Should be balanced among groups Any combination of above
47 9
173 53
39 3
174 55
1 106 10
3 486 63
0 57 8
4 516 56
There were 1,754 total survey respondents; 173 MN and 781 TX; 807 CS and 106 AS. Not all respondents answered each question. MN 5 Minnesota metropolitan surgeons; TX 5 Texas state surgeons; AS 5 full-time academic surgeon; CS 5 community surgeon with or without academic affiliation.
the only Likert-formatted question with a statistical difference in average response by geographic area. Community surgeons felt increasing preceptor time was the best way to correct educational deficits, whereas academic surgeons felt specific course work was the best option (question 21, Table II). Who Is Responsible for Education The program, rather than the resident, was identified as primarily responsible for correcting educational gaps (question 16 and 17, Figure 2). Grouped by geographic area or academic affiliation, surgeons felt that the responsibility for surgical education should be balanced among affiliated groups (question 18, Table III). The majority agreed that regularly scheduled contact with the primary institution was not necessary for effective teaching (question 6).
COMMENTS
Surgical education is unique.9 It has its underpinnings in an apprentice system that was critically adjusted after the Flexner report in 1910.10 This report established standards for the medical educational process. That system and those standards are facing some difficult problems as a result of changes in our care delivery system.
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Our survey was directed at two populations of surgeons. The metropolitan area surveyed in Minnesota is heavily penetrated by managed care, whereas penetration in Texas is much less. Despite the statewide difference in managed care penetration, surgeon perceptions regarding surgical education were not significantly different. Although managed care penetration may affect patient flow into an academic medical center,5 concerns regarding methods of surgical education were not affected. How Education Is Accomplished The quantity and quality of surgical education is identified as one of the foremost concerns of surgical residents, ranking third of 23 potential problems surveyed by Gabram et al.11 Our survey showed that practicing surgeons support this same concern. Regardless of geographic location, academic affiliation, or length of time in practice, the majority of queried surgeons felt that graduating surgical residents have major gaps in their training. Technical skill and patient care were the two most commonly identified deficits. Minnesota surgeons thought basic science knowledge was less of a problem than clinical knowledge. This perception may be a result of the strong heritage in the Minnesota program for a basic science research component.12 Responding surgeons suggest the educational system needs to change. Alternatives for surgical residency training have been described.13–16 Barnes13 suggests lengthening the training period for most surgical specialties, an option not favored by our respondents. Alternatively, Pories et al6,14 have called for surgical education to become shorter and more effective. He and others advocate the elimination of 5 years of general surgery for many residents destined for surgical subspecialities.6,14,15 In an era of fewer cases, this would leave the most complex general surgical cases for those residents who would ultimately be performing them in practice. Since few of these suggestions have been implemented, it is clear that we are still searching for the correct solution. How surgical educators accomplish better information transfer was not apparent from our survey. Surgeons had no strong preference for separating didactic and clinical teaching. Teaching perioperative and operative care were linked more strongly than teaching technical skills with perioperative information. Separation of technical and didactic information may offer an opportunity to refocus some of the operative training in surgical education. Skills laboratories, teaching videotapes, and virtual reality are potential examples that we may have to make better use of in the future.17,18 Allowing initial operative skills to be acquired in a computerized simulator may improve learning and clinical efficiency while decreasing the number of operative cases required for resident training by accrediting agencies. Virtual training may further remove some faculty mentors from technical teaching. However, simulation training may provide a better opportunity for objective skills assessment, an often overlooked component of teaching technical skills.19 Two educational methods that have used assessment techniques successfully are videotaping residents with faculty review and the Objective Structured Clinical Examination.20 Specific course work and curricula have been tried at484
tempting to address the perceived deficit in basic science knowledge. The Surgical Resident Curriculum has been developed by the Association of Program Directors and has undergone pilot testing. Implementation of a scientific curriculum at the University of Connecticut raised scores on monthly examinations but did not change scores significantly on ABSITE or mock oral examinations.21 Rhodes and others22 have used the ABSITE to identify areas of curricular weakness within a program by grouping resident responses. Who Is Providing Education Griffen23 has said that those responsible for surgical education “must know something about education.” Our respondents indicated a willingness to attend surgical education CME. The American College of Surgeons sponsors a course designed to provide surgeons with knowledge and skills about surgical education curriculum, teaching strategies, administration, and performance evaluation. The course is highly rated by participants and has produced changes in many residency programs.24 Despite this willingness to attend a CME course, surgeons were equally split on the need for specific educational training for surgeons involved with teaching. Being a clinical teacher is not an easy task.25 The overall effectiveness of a physician as a teacher depends on allocation of time specific for instruction, ability to create a climate of trust and concern, and the ability to establish clinical credibility. Other skills needed include conducting entrance and exit evaluations, use of ward teaching rounds, and delegation of teaching responsibility. Communication skills training can improve teaching effectiveness.26 The best learning environment has a balance between full-time and clinically affiliated faculty. Teaching success was not equated with sponsoring institution contact, nor should it be limited to individuals with specific educational training. In a previous survey, private practice surgeons in Minnesota were almost unanimous in individual support of resident teaching. More than three quarters felt an obligation to teaching hospital residency programs.8 Elliot describes use of a voluntary faculty that has produced teaching success. These faculty efforts occur in a voluntary independent hospital and not a community hospital, but are in danger from hours restrictions, increasing costs, and decreasing Medicare support. He believes this type of teaching structure can support our educational system, but that teaching at academic medical centers can not be eliminated.7 Our respondents believe combining didactic and clinical teaching provides the best learning experience. This is consistent with the time commitment identified by Mattern et al.25 One-on-one teaching was favored by respondents. Although this method favors improved continuity of care, it may not provide broad-based learning.27 Incorporating teaching activities into a financial plan has been modeled in Oregon. Unfortunately this report does not comment on the quality of teaching.28 The residency program was identified as being responsible for improving the training experience. The unanimity of these data across geographic area and academic affiliation suggests resident education is of significant concern and
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working on improvements should be a priority for our profession. Recommendations for Improvement Faculty development. The full-time faculty model may need to be seriously rethought. Teaching requirements for full-time faculty should be established. Career development should involve an assessment of teaching abilities and offer opportunities to improve teaching skills. Using part-time faculty to supplement the full-time faculty might make more sense than a continual increase in full-time faculty. Funding for full-time or part-time faculty is needed since high-quality teaching activities require adequate salary support.29 Part-time faculty. Proper incentives and systems to support part-time faculty must be designed. It is doubtful that the same teaching standards will apply to part-time faculty, but some type of limited educational training may be necessary. This could be structured as a CME course within the local community, possibly designed by one of the professional or scientific surgical organizations. Faculty assessment. Evaluations of full-time faculty emphasize structure and feedback as essential components of improving teaching skills. Feedback can be used to improve teaching effectiveness. It is disappointing that, as Cohen et al30 showed, once academic surgeons gain tenure their teaching effectiveness drops. Educational methods. Continuity of exposure between teacher and student is desirable. Making the contact time productive may require us to reexamine Wangensteen’s31 Teachers Oath: “We . . . instill in . . . teachers a fervent desire to become spirited and effective preceptors of all our student progeny.” Teaching teams composed of full- and part-time faculty with a set of assigned students and residents that are not tied to a hospital but rotate among many sites where assigned faculty see patients may accomplish this goal. This arrangement would require changes in the site of learning, the people involved, the reimbursement process, and the minds of surgeons. Curriculum development. The training program will need to reassess how the trainees spend their time. Rotations providing only a service function should be deleted from the curriculum. Defining objectives for each rotation helps set expectations and goals for learning outcomes that can be measured. As new training technology becomes available, proper investigations should be performed to evaluate its worth in an educational program.
ACKNOWLEDGMENT The authors would like to thank Diane Wynne for her diligence in helping complete this survey and collating the data.
REFERENCES 1. Mason GR. Health care reform: residency training and medical education. Am J Surg. 1995;169:561–563. 2. Andreopoulos S. The folly of teaching-hospital mergers. NEJM. 1997;336:61– 64. 3. Ritchie WP. Graduate surgical education in the era of managed care: a statement from the American Board of Surgery. J Am Coll Surg. 1997;184:311–312. 4. Fox PD, Wasserman J. Academic medical centers and managed care: uneasy partners. Health Affairs. 1993;12:85–93.
5. Flint L, Flint CB. Academic surgical group practices at the dawn of health reform. Ann Surg. 1994;220:374 –381. 6. Pories WJ, Smout JC, Morris A, Lewkow VE. U.S. health care reform: will it change postgraduate surgical education? World J Surg. 1994;18:745–752. 7. Elliot DW. Presidential address: outsiders in surgical education—are the voluntary faculty worth more than they are paid? Surgery. 1988;104:585–591. 8. Ward HB, Macauley MK, Foker JE. The ivory tower from outside and in: a survey of Minnesota surgeons. Surgery. 1993;114: 436 – 441. 9. Walt AJ. The uniqueness of American surgical education and its presentation. ACS Bulletin. 1994;79:9 –20. 10. Flexner A. Medical Education in the United States and Canada. New York: Carnegie Foundation; 1910. 11. Gabram SGA, Allen LW, Deckers PJ. Surgical residents in the 1990s: issues and concerns for men and women. Arch Surg. 1995; 130:24 –28. 12. Wangensteen OH. Glimpses of the University of Minnesota’s surgery department: old and new, pedagogic and philosophic. Journal-Lancet. 1963:161–176. 13. Barnes RW. Surgical handicraft: teaching and learning surgical skills. Am J Surg. 1987;153:422– 427. 14. Pories WJ, Aslakson HM. The surgical residency: the job description does not fit the job. Arch Surg. 1990;125:147–149. 15. Barnes RW. The next generation of surgical residencies: what are the challenges and the opportunities? Arch Surg. 1990;125:433– 436. 16. Folse JR. Presidential address: surgical education—addressing the challenges of change. Surgery. 1996;120:575–579. 17. Bevin PG. Craft workshops in surgery. Br J Surg. 1986;73:7– 8. 18. Ota D, Loftin B, Saito T, Lea R, Keller J. Virtual reality in surgical education. Comput Biol Med. 1995;25:127–137. 19. Reznick RK. Teaching and testing technical skills. Am J Surg. 1993;165:358 –361. 20. Sloan DA, Donnelly MB, Johnson SB, et al. Use of an objective structured clinical examination (OSCE) to measure improvement in clinical competence during the surgical internship. Surgery. 1993;114:343–351. 21. Safran DB, Crombie HD, Allen L, Ruby ST, Deckers PJ. Preliminary assessment of a scientific curriculum in a surgical residency program. Arch Surg. 1992;127:529 –535. 22. Rhodes RS, Wile MZ, Persons ML, Shuck JM. Cognitive learning during surgical residency: a model for curriculum evaluation. Ann Surg. 1987;205:208 –212. 23. Griffen WO. Surgical residency: on the job training or education? Am J Surg. 1980;140:720 –723. 24. DaRosa DA, Folse JR, Reznick RK, et al. Description and evaluation of the Surgeons as Educators course. J Am Coll Surg. 1996;183:499 –505. 25. Mattern WD, Weinholtz D, Friedman CP. The attending physician as teacher. NEJM. 1983;308:1129 –1132. 26. Barth RJ, Rowland-Morin PA, Mott LA, Burchard KW. Communication effectiveness training improves surgical resident teaching ability. J Am Coll Surg. 1987;185:516 –519. 27. Chung RS, Verghese J, Diaz J, Eisenstat M. One-on-one mentor-resident rotation for improving continuity of care in a surgical training program. J Surg Res. 1997;69:359 –361. 28. O’Hollaren MT, Romm CL, Cooney TG, et al. A model for faculty practice teaching clinics developed at the Oregon Health Sciences University. Acad Med. 1992;67:51–53. 29. Kassirer JP. Tribulations and rewards of academic medicine— where does teaching fit? NEJM. 1996;334:184 –185. 30. Cohen R, MacRae H, Jamieson C. Teaching effectiveness of surgeons. Am Surg. 1996;171:612– 614. 31. Wangensteen OH. Teacher’s oath. J Med Educ. 1978;53:524. Letter.
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BACKGROUND: Collective opinions of practicing general surgeons on the current state of general surgical resident education are unknown. METHODS: A 26-item survey was mailed to practicing general surgeons in Minnesota and Texas. Average scores on 17 Likert-formatted questions and opinions on multiple-choice questions were compared by geographic area and academic affiliation. RESULTS: Overall response was 954 of 1,745 (55%). All surgeons felt changes were needed in surgical education. There was agreement by geographic area and academic affiliation that the current system of resident education allows chief residents to graduate with significant gaps in their education, and that the responsibility for correcting these gaps lies with the residency program. CONCLUSIONS: Opinions of general surgeons in two geographic areas and of differing academic affiliation regarding surgical education showed marked similarity. These data suggest change in the process of surgical education is the responsibility of the residency program and should be a priority for the profession. Am J Surg. 1998;176: 481– 485. © 1998 by Excerpta Medica, Inc.
M
edical education continues to face pressure to re-engineer itself. These pressures include decreasing GME and IME reimbursement, decreasing patient populations at academic medical centers, competing care systems, correlating student output with marketplace needs, identifying the best way to train physicians, and the best site for training.1– 8 Solutions are not self-evident. Our purpose in performing this survey of practicing surgeons was to allow the products of our surgical educational system to assess its current state. Three specific areas were explored via a questionnaire: problems within the current
From the University of Minnesota, St. Paul, Minnesota, and University of Texas Southwestern Medical Center, Dallas, Texas. Presented in part as a poster presentation at the meeting of the Association for Surgical Education, Philadelphia, Pennsylvania, April 1997. Requests for reprints should be addressed to John A. Weigelt, MD, Professor and Vice-Chairman, Department of Surgery, University of Minnesota, Regions Hospital, 640 Jackson Street, St. Paul, Minnesota 55101. Manuscript submitted June 3, 1998 and accepted in revised form August 17, 1998.
© 1998 by Excerpta Medica, Inc. All rights reserved.
educational system, how education should best be accomplished, and who should be educating surgical trainees.
METHODS Survey questions were developed covering three aspects of surgical education: problems within the current educational system, how education should best be accomplished, and who is primarily responsible for the educational process. The majority of these questions were asked on a 4-point Likert scale. Demographic questions were also asked about the training, current practice, and length of practice of the responding surgeon. Respondents were asked to classify themselves as university surgeons, community surgeons with university affiliation, and community surgeons without university affiliation. The survey was pilot tested on a group of surgeons not part of the target population. All surgeons practicing in a metropolitan area (Minneapolis/St. Paul, Minnesota) were identified by obtaining lists of all surgeons with operating privileges at any hospital in the area. Surgeons in Texas were identified by the state continuing medical education list for surgeons. The final survey was mailed to all general, pediatric, vascular, cardiothoracic, colorectal, and transplant surgeons in both areas. Surgeons who did not return the survey within 4 weeks were sent a follow-up letter and second survey. University surgeons were referred to as full-time academic surgeons and the remaining groups were grouped as community surgeons, regardless of academic affiliation. Means of all Likert-scored questions were compared between geographic area and by academic affiliation using Student’s t test. Mean scores greater than 2.5 indicated agreement; less than 2.5, disagreement.
RESULTS Demographics Overall response rate was 55% (954 of 1,754). Response rate was higher in Minnesota (173 of 264) than in Texas (781 of 1,490). No statistical differences in surgeon demographics existed between the two states. There were 807 community surgeons (84%) and 106 academic surgeons (11%) who responded. Surgeons had been in practice an average of 17.4 years (range 1 to 55). In all, 562 surgeons classified themselves as general surgeons and 334 as other specialists (29 nonclassified and 29 with a combined practice); 497 surgeons obtained some type of fellowship training after completing a general surgery residency. Survey questions are listed in Figure 1. There was remarkable similarity in the responses of surgeons grouped by academic affiliation, length of practice, and geographic area. 0002-9610/98/$19.00 PII S0002-9610(98)00237-2
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SURVEY QUESTIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
All surgeons with resident training responsibilities should have specific training in education. On-the-job training in educational techniques is adequate for surgeons responsible for training residents. Didactic material can be effectively taught by surgeons without specific training in surgical education. Clinical material can be effectively taught by surgeons without specific training in surgical education. All aspects of surgical training should be limited to individuals with specific training in surgical education. It is possible to be an effective teacher without regularly scheduled contact with the primary training institution. There should be a physician coordinator responsible for the educational program in a surgical residency. I would be willing to attend CME on surgical education. I believe changes are necessary in surgical education. It is necessary to have contact with residents in the operating room, on ward rounds and through formal didactic lectures in order to be an effective teacher. Perioperative care can be taught separately from operative care. Technical skills can be taught separately from perioperative care. Teaching skills can be learned and improved through specific training in educational techniques. Didactic material and clinical material can be taught independently. The current system of training residents allows chief residents to graduate with significant gaps in their education. The responsibility for correcting deficits in a resident’s education lies with the resident. The responsibility for correcting deficits in a resident’s education lies with the residency program. The responsibility for surgical education should ideally fall primarily to (check one box only): ❏ university faculty ❏ clinically affiliated faculty ❏ community surgeons without University affiliation ❏ should be balanced among groups ❏ does not matter—any combination of the above
19. The minimum amount of resident contact necessary for an individual surgeon to be an effective teacher is (check one box only): ❏ daily ❏ 23/week ❏ weekly ❏ monthly ❏ 1–2 months/year
20. The biggest deficit in graduating chief residents is (check one box only): ❏ technical skill ❏ basic science knowledge ❏ clinical knowledge ❏ patient care
21. The best approaches to correcting educational deficits would be (check 2 boxes): ❏ more didactic teaching time ❏ more preceptor (one-on-one) time ❏ more clinical teaching time ❏ increasing the length of general surgery residency ❏ specific coursework designed by surgical educators 22. In what type of residency program did you train? ❏ hospital-sponsored community hospital ❏ university-sponsored community hospital ❏ university-based academic 23. How long have you been in practice? 24. Did you obtain additional fellowship training after your general surgery residency? If yes, what type? 25. Which phrase describes you current practice? ❏ general surgery ❏ surgical specialty 26. Which phrase describes your current practice? ❏ full-time academic surgeon ❏ community surgeon with academic affiliation ❏ community surgeon without academic affiliation Figure 1. Survey questions. Questions 1 through 17 were answered on a 4-point Likert scale: 1, strongly disagree; 2, disagree; 3, agree; 4, strongly agree.
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TABLE I Deficits Identified in Graduating Chief Residents by Respondent Geographic Area and Academic Affiliation Number of Respondents Deficit
MN
TX
AS
CS
Technical skill Basic science knowledge Clinical knowledge Patient care
53 9 50 24
191 143 153 209
19 35 33 5
218 110 161 218
There were 1,754 total survey respondents: 173 MN and 781 TX; 807 CS and 106 AS. Not all respondents answered each question. MN 5 Minnesota metropolitan surgeons; TX 5 Texas state surgeons; AS 5 full-time academic surgeon; CS 5 community surgeon with or without academic affiliation.
TABLE II Approaches Identified to Correct Educational Deficits of Chief Residents by Respondent Geographic Area and Academic Affiliation
Figure 2. Distribution of responses to question 17; “The responsibility for correcting deficits in a resident’s education lies with the residency program.” An overwhelming number of respondents agreed with this statement.
TABLE III Groups Ideally Responsible for Surgical Education by Respondent Geographic Area and Academic Affiliation
Number of Respondents Approach to Correct Deficit
MN
TX
AS
CS
More didactic teaching time More preceptor (one-on-one) time More clinical teaching time Increasing length of residency Specific coursework for educators
19 78 90 4 47
107 449 357 49 240
20 32 40 11 43
90 479 383 39 236
Respondents were asked to identify best two approaches. There were 1,754 total survey respondents: 173 MN and 781 TX; 807 CS and 106 AS. Not all respondents answered each question. MN 5 Minnesota metropolitan surgeons; TX 5 Texas state surgeons; AS 5 full-time academic surgeon; CS 5 community surgeon with or without academic affiliation.
Problems within the Current Educational System The majority of surgeons feel changes are necessary in surgical education (question 9). Slightly fewer agreed that the current system allows chief residents to graduate with significant gaps in their education (question 15). The major deficit identified in graduating chief residents by the Minnesota group was technical skill, and in Texas it was patient care. Community surgeons identified these deficits as technical skill and patient care, whereas academic surgeons selected basic science knowledge (question 20, Table I). How to Accomplish Surgical Education Minnesota surgeons felt the best way to correct educational deficits was to increase clinical teaching time and Texas surgeons chose increasing preceptor (one-on-one) time (question 21, Table II). There was strong agreement that a physician coordinator should be responsible for surgical education (question 7), and physicians in both groups were willing to attend CME on surgical education (question 8). Both geographic groups disagreed that surgical instruction should be limited to individuals with specific educational training (question 5). The Texas group felt that surgeons with resident training responsibilities should receive educational training (question 1); this was
Number of Respondents Group Responsible for Education
MN
TX
AS
CS
Academic faculty Clinically affiliated faculty Community surgeons without academic affiliation Should be balanced among groups Any combination of above
47 9
173 53
39 3
174 55
1 106 10
3 486 63
0 57 8
4 516 56
There were 1,754 total survey respondents; 173 MN and 781 TX; 807 CS and 106 AS. Not all respondents answered each question. MN 5 Minnesota metropolitan surgeons; TX 5 Texas state surgeons; AS 5 full-time academic surgeon; CS 5 community surgeon with or without academic affiliation.
the only Likert-formatted question with a statistical difference in average response by geographic area. Community surgeons felt increasing preceptor time was the best way to correct educational deficits, whereas academic surgeons felt specific course work was the best option (question 21, Table II). Who Is Responsible for Education The program, rather than the resident, was identified as primarily responsible for correcting educational gaps (question 16 and 17, Figure 2). Grouped by geographic area or academic affiliation, surgeons felt that the responsibility for surgical education should be balanced among affiliated groups (question 18, Table III). The majority agreed that regularly scheduled contact with the primary institution was not necessary for effective teaching (question 6).
COMMENTS
Surgical education is unique.9 It has its underpinnings in an apprentice system that was critically adjusted after the Flexner report in 1910.10 This report established standards for the medical educational process. That system and those standards are facing some difficult problems as a result of changes in our care delivery system.
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Our survey was directed at two populations of surgeons. The metropolitan area surveyed in Minnesota is heavily penetrated by managed care, whereas penetration in Texas is much less. Despite the statewide difference in managed care penetration, surgeon perceptions regarding surgical education were not significantly different. Although managed care penetration may affect patient flow into an academic medical center,5 concerns regarding methods of surgical education were not affected. How Education Is Accomplished The quantity and quality of surgical education is identified as one of the foremost concerns of surgical residents, ranking third of 23 potential problems surveyed by Gabram et al.11 Our survey showed that practicing surgeons support this same concern. Regardless of geographic location, academic affiliation, or length of time in practice, the majority of queried surgeons felt that graduating surgical residents have major gaps in their training. Technical skill and patient care were the two most commonly identified deficits. Minnesota surgeons thought basic science knowledge was less of a problem than clinical knowledge. This perception may be a result of the strong heritage in the Minnesota program for a basic science research component.12 Responding surgeons suggest the educational system needs to change. Alternatives for surgical residency training have been described.13–16 Barnes13 suggests lengthening the training period for most surgical specialties, an option not favored by our respondents. Alternatively, Pories et al6,14 have called for surgical education to become shorter and more effective. He and others advocate the elimination of 5 years of general surgery for many residents destined for surgical subspecialities.6,14,15 In an era of fewer cases, this would leave the most complex general surgical cases for those residents who would ultimately be performing them in practice. Since few of these suggestions have been implemented, it is clear that we are still searching for the correct solution. How surgical educators accomplish better information transfer was not apparent from our survey. Surgeons had no strong preference for separating didactic and clinical teaching. Teaching perioperative and operative care were linked more strongly than teaching technical skills with perioperative information. Separation of technical and didactic information may offer an opportunity to refocus some of the operative training in surgical education. Skills laboratories, teaching videotapes, and virtual reality are potential examples that we may have to make better use of in the future.17,18 Allowing initial operative skills to be acquired in a computerized simulator may improve learning and clinical efficiency while decreasing the number of operative cases required for resident training by accrediting agencies. Virtual training may further remove some faculty mentors from technical teaching. However, simulation training may provide a better opportunity for objective skills assessment, an often overlooked component of teaching technical skills.19 Two educational methods that have used assessment techniques successfully are videotaping residents with faculty review and the Objective Structured Clinical Examination.20 Specific course work and curricula have been tried at484
tempting to address the perceived deficit in basic science knowledge. The Surgical Resident Curriculum has been developed by the Association of Program Directors and has undergone pilot testing. Implementation of a scientific curriculum at the University of Connecticut raised scores on monthly examinations but did not change scores significantly on ABSITE or mock oral examinations.21 Rhodes and others22 have used the ABSITE to identify areas of curricular weakness within a program by grouping resident responses. Who Is Providing Education Griffen23 has said that those responsible for surgical education “must know something about education.” Our respondents indicated a willingness to attend surgical education CME. The American College of Surgeons sponsors a course designed to provide surgeons with knowledge and skills about surgical education curriculum, teaching strategies, administration, and performance evaluation. The course is highly rated by participants and has produced changes in many residency programs.24 Despite this willingness to attend a CME course, surgeons were equally split on the need for specific educational training for surgeons involved with teaching. Being a clinical teacher is not an easy task.25 The overall effectiveness of a physician as a teacher depends on allocation of time specific for instruction, ability to create a climate of trust and concern, and the ability to establish clinical credibility. Other skills needed include conducting entrance and exit evaluations, use of ward teaching rounds, and delegation of teaching responsibility. Communication skills training can improve teaching effectiveness.26 The best learning environment has a balance between full-time and clinically affiliated faculty. Teaching success was not equated with sponsoring institution contact, nor should it be limited to individuals with specific educational training. In a previous survey, private practice surgeons in Minnesota were almost unanimous in individual support of resident teaching. More than three quarters felt an obligation to teaching hospital residency programs.8 Elliot describes use of a voluntary faculty that has produced teaching success. These faculty efforts occur in a voluntary independent hospital and not a community hospital, but are in danger from hours restrictions, increasing costs, and decreasing Medicare support. He believes this type of teaching structure can support our educational system, but that teaching at academic medical centers can not be eliminated.7 Our respondents believe combining didactic and clinical teaching provides the best learning experience. This is consistent with the time commitment identified by Mattern et al.25 One-on-one teaching was favored by respondents. Although this method favors improved continuity of care, it may not provide broad-based learning.27 Incorporating teaching activities into a financial plan has been modeled in Oregon. Unfortunately this report does not comment on the quality of teaching.28 The residency program was identified as being responsible for improving the training experience. The unanimity of these data across geographic area and academic affiliation suggests resident education is of significant concern and
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working on improvements should be a priority for our profession. Recommendations for Improvement Faculty development. The full-time faculty model may need to be seriously rethought. Teaching requirements for full-time faculty should be established. Career development should involve an assessment of teaching abilities and offer opportunities to improve teaching skills. Using part-time faculty to supplement the full-time faculty might make more sense than a continual increase in full-time faculty. Funding for full-time or part-time faculty is needed since high-quality teaching activities require adequate salary support.29 Part-time faculty. Proper incentives and systems to support part-time faculty must be designed. It is doubtful that the same teaching standards will apply to part-time faculty, but some type of limited educational training may be necessary. This could be structured as a CME course within the local community, possibly designed by one of the professional or scientific surgical organizations. Faculty assessment. Evaluations of full-time faculty emphasize structure and feedback as essential components of improving teaching skills. Feedback can be used to improve teaching effectiveness. It is disappointing that, as Cohen et al30 showed, once academic surgeons gain tenure their teaching effectiveness drops. Educational methods. Continuity of exposure between teacher and student is desirable. Making the contact time productive may require us to reexamine Wangensteen’s31 Teachers Oath: “We . . . instill in . . . teachers a fervent desire to become spirited and effective preceptors of all our student progeny.” Teaching teams composed of full- and part-time faculty with a set of assigned students and residents that are not tied to a hospital but rotate among many sites where assigned faculty see patients may accomplish this goal. This arrangement would require changes in the site of learning, the people involved, the reimbursement process, and the minds of surgeons. Curriculum development. The training program will need to reassess how the trainees spend their time. Rotations providing only a service function should be deleted from the curriculum. Defining objectives for each rotation helps set expectations and goals for learning outcomes that can be measured. As new training technology becomes available, proper investigations should be performed to evaluate its worth in an educational program.
ACKNOWLEDGMENT The authors would like to thank Diane Wynne for her diligence in helping complete this survey and collating the data.
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