- Email: [email protected]
Surgical Education and Training: How Are They Likely to Change?
Surgical Education and Training: How Are They Likely to Change? Thomas H Cogbill,
MD, FACS
I have two connections to Samuel Jason Mixter. His great grandson, Chip Mixter, did a rotation at the Denver General Hospital when I was a second-year resident at the University of Colorado. He was a resident at the Mayo Clinic and wanted to get some trauma experience, so he rotated at Colorado and we became good friends. Chip Mixter is currently a plastic surgeon in Milwaukee, Wisconsin. I spoke with him before this talk because I wanted to know more about his family, and he sent me a photograph taken in 1907. The picture shows scrub nurse, Ms Curly on the left and William J Mixter and Charles G. Mixter standing on each side of their father, Samuel Jason Mixter, for whom this talk is named (Fig. 1). William J Mixter became the first Department Chair of Neurosurgery at Massachusetts General Hospital and Charles G Mixter was the head of General Surgery at Beth Israel Hospital. The family has a long history of excellence in surgery. The other connection I have is to the Mixter clamps. The baby Mixter is my favorite clamp and the one I frequently use to take autonomy away from my residents (Fig. 2). Here are my disclosures. I absolutely love general surgery. I would do it again in whatever smallest subdivision of a second there is. These opinions are mine and mine alone. They clearly reflect my experience of 8 years on the American Board of Surgery (ABS). The last disclosure is that I am not a seer; I cannot predict the future. The rationale for this talk is that I was the program director of a small surgery residency for 20 years and that was the activity that I enjoyed most about my practice. Teaching is the closest thing we have to surgical immortality. It goes on beyond us. We teach somebody, they take care of patients. We teach many trainees, they take care of many patients, and maybe they go on to teach other surgeons, and so on. Surgical education is currently at a crossroads and I am worried; who is going to take care of my family and me, and who are we going to leave behind? 30th Annual Samuel Jason Mixter Lecture. Presented at the 95th Annual Meeting of the New England Surgical Society, Stowe, VT, September 2014. Received October 10, 2014; Accepted November 13, 2014. From the Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI. Correspondence address: Thomas H Cogbill, MD, FACS, Department of General and Vascular Surgery, Gundersen Health System, 1900 South Ave C05-001, La Crosse, WI 54601. email: [email protected]
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
CURRENT STATE OF SURGICAL EDUCATION Surgery residency today has de facto been shortened by about 1 year if you consider the difference in hours.1 Knowledge has really exploded, it has not contracted, and the number of procedures that a resident needs to learn is greater, not fewer. Recent studies of resident operative experience demonstrate stable total operations, increased laparoscopic procedures, a considerable decrease in total open operations, a substantial decrease in the number of emergency operations and cases in which the resident serves as an assistant, including as a teaching assistant. Mark Malangoni and colleagues2 at the ABS reported that the frequency of operations performed a mean of >10 times during residency remains at about 20 cases. Of the essential or common operations listed in the Surgical Council on Resident Education curriculum, 34% were performed a median of <5 times and 4 had a median of 0. Residents experience less independence during residency training due to changes in our society, regulatory changes, medicalelegal concerns, and a few highly publicized cases of health care finance enforcement. It is obvious that more resident graduates today are not confident about going into practice and their ability to independently perform a number of common procedures.3 This concern was shared by fellowship program directors and by fellows of the American College of Surgeons (ACS) in two recent surveys.4,5 However, a recent survey of graduating chief residents refutes these concerns, finding this group confident in their skills.6 The ABS examination results through 2012 demonstrate that the first-time fail rate on the qualifying examination has at least been stable and perhaps decreased during the past 8 to 10 years. The certifying examination has had a different trend, with a steady increase in the first-time fail rate until 2013. Finally, you cannot have a talk about surgical training if you do not know anything about surgical workforce predictions. There is a huge mismatch. The greatest need in the United States is for general surgeons. The two areas of greatest need for general surgeons are in rural areas and in the inner city. The mismatch is that 80% of our graduates pursue fellowships that make it less likely that they will practice general surgery.
1032
http://dx.doi.org/10.1016/j.jamcollsurg.2014.11.019 ISSN 1072-7515/14
Vol. 220, No. 6, June 2015
Cogbill
WHAT IS NOT LIKELY TO CHANGE There are a few trends in current surgical education that we must accept as immutable. First, the ABS is still going to give examinations. The pathway to certification will continue to involve a written examination followed by an oral examination. Maintenance of certification is here to stay, although there is some controversy at the American Board of Medical Specialties as to exactly what this is going to look like. I think that the ABS has tried really hard to not make maintenance of certification too burdensome for its diplomates. Second, are we really going to abolish the ACGME duty-hour regulations? No. Society has changed, our residents are of a different generation and I am proud of them. The good old days really were not that great if you think about it, and if we cannot educate residents in an 80-hour work week, we really have to change how we teach. We are not going to go back to loosely supervised surgery. Society has changed. Our patients have different expectations and our trainees have different expectations. Was it really okay for me to do my first craniotomy on a patient when I was 6 weeks out of medical school and I had seen my first one that morning and my attending was 45 minutes from the hospital? We are not going to observe an increase in the number of open cases. We have got to stop worrying about this. Minimally invasive surgery is well established. There are going to be minimally invasive and endovascular solutions for the complicated cases for which we currently rely on infrequent open operations. We just need to innovate. Many conditions (eg, peptic ulcer disease and solid organ injury) no longer require surgery, and more conditions (perhaps appendicitis and colonic diverticulitis) are not going to require surgery or often might not. Can we mandate fewer fellowships? No. The market is much more likely to affect change in the specialties selected by our graduates. However, any time that we meddle with training, we need to understand that there will be potential effects on other parts of training, and we should design something that does not harm general surgery, as that is where there is the greatest need. WHAT IS LIKELY TO CHANGE? I am going to focus on just the first 3 stages of training today: preresidency, residency, and immediately postresidency or the transition to practice. What about preresidency preparation is likely to change? Many medical schools currently offer a surgical “boot camp” to teach basic surgical skills to students who are planning to enter surgical residency. Some residencies have put a basic surgical skill module at the beginning of residency. This needs to be a requirement and needs to happen before residency so residents can come to residency already having knowledge of
Changes in Surgical Education and Training
1033
Figure 1. Photograph taken at Massachusetts General Hospital in 1907 of scrub nurse Ms Curly, William J Mixter, Samuel Jason Mixter, and Charles G Mixter (left to right).
basic technical skills, how to preoperatively assess a patient, how to take care of common postoperative problems, and how to effectively communicate with each other and with other hospital personnel. A joint statement made by the ABS, ACS, the Association of Program Directors in Surgery, and the Association for Surgical Education supporting a requirement for a preresidency preparatory course will appear in the October issue of each of the 8 major surgery journals. What is likely to change during residency? We will see significant changes in curriculum, procedural training, and evaluation. The ABS has recently made several moves to redesign surgical residency. There have been some substantial core curriculum changes based on Surgical Council on Resident Education. The curriculum will continue to undergo redefinition to include those conditions and procedures that are central to general surgery practice and a de-emphasis on the remainder. It does not mean to
Figure 2. Photograph of baby Mixter or small right angle clamp.
1034
Cogbill
Changes in Surgical Education and Training
Figure 3. Photograph of Dartmouth surgeon Arthur Naitove, MD. (From: Geisel School of Medicine at Dartmouth, with permission.)
“dumb down” surgical training; it means concentrate on what is important. More modular curricula will be developed. As examples, the ABS already requires completion of Advanced Cardiovascular Life Support, ATLS, Fundamentals of Laparoscopic Surgery, and Fundamentals of Endoscopic Surgery. What is common to each of these modules is a defined curriculum, specific technical skills that a person must practice, and then assessment to assure that they have learned something. In an effort to assure that residents gain operative experience earlier in their training, the ABS, in concert with the Residency Review CommitteeeSurgery, has established that a minimum of 250 cases be completed by the end of the PGY2. A minimum of 25 teaching assistant cases was also established. There will be increased emphasis on minimally invasive surgical cases and endoscopy. Evaluation will include increased assessment of a resident’s operative skills with procedurespecific tools for analysis. Practice management skills do not get enough attention in our residencies today.7 This is another reason that our graduates might not be confident to go out into practice. We should teach them how to code and reimburse, how to run a busy clinic, how to protect themselves against a malpractice suit, how to read a contract, how to communicate with referral doctors, and how to actually do something with patient satisfaction that is meaningful. What is procedural training likely to look like? I believe that we must include more time for deliberate practice and reflection. These are adult educational methods. Adult education experts have said that simple repetition is not the greatest of all teachers. Without time for feedback or reflection on one’s performance, a trainee does not learn very much and continues to make the same mistakes over and over.8 Every time we come out of the operating room, we should ask the resident, “how do you think it went; what did you do well; what could you
J Am Coll Surg
have done better?” Then, “this is what I think you did well; this is where I think you need to practice.” There is going to be less reliance on case numbers. Numbers have been a surrogate for experience for too long. Competence is what we train to now. Maybe we should be training to proficiency. The PASS (procedural autonomy and supervision system) program or credentialing during residency clearly look like they are going to have a role in our future to allow residents more independence in decision making and assure patient safety.9 We are going to see more simulation training. Although simulation laboratories are currently required for all surgical residencies, a robust simulation curriculum with teaching modules and assessment needs to be implemented. We should observe significant improvements in methods of evaluation. The ACGME surgery milestones allow us to track resident’s performance in a number of different areas that relate to the 6 competencies along an expected trajectory.10 These are not actual activities in which a learner must demonstrate proficiency before they can advance. The milestones allow us to track performance against other residents of the same level. The future is going to be in competency-based advancement.11 This effort should begin with determining the entrustable professional activities (EPA) that define general surgery. An EPA is an essential task or responsibility of professional practice that will eventually be entrusted to the unsupervised performance by a trainee.12,13 In other words, what are the activities that are absolutely essential for a general surgeon to know and be able to do? As part of assessment during residency, we will sign off on EPAs as all of the key steps are achieved by our trainees. This will allow the competency committee to credential during residency, which might be the answer to offering an autonomous experience during residency, because if a resident can be credentialed to do a procedure, then the level of supervision can be lessened. Advancement occurs whenever all of the level-specific EPAs are achieved. Currently, a variety of postgraduate fellowships are providing structured autonomy and a transition to practice for 80% of residency graduates. The ACS Transition to Practice programs were developed as a possible parallel pathway for graduates anticipating general surgery practice. It is unknown whether Transition to Practice programs will really catch on or become the required pathway for general surgery. Personally, I believe that an additional year is not necessary for most graduates. However, we need to help those who are going into practice to develop some onboarding recommendations so we can help them ease into practice with mentorship. The basic principles of the ACS Transition to Practice programs include an intake assessment to catalog the resident graduate’s previous experience,
Vol. 220, No. 6, June 2015
Cogbill
outline their goals for their intended future career, and try to map out their first year to meet those needs. Flexibility is inherent in the design of the curriculum. There is an autonomous experience in the operating room and in the clinic, on call, and with practice management. Outcomes are tracked, discussed, and an assessment is made. Finally, this year, the ABS has initiated an effort to standardize the experiences in the current disparate group of surgical specialty fellowships. Some are accredited by the ACGME, others by the Fellowship Council, and others sponsored by specialty societies. Some have an examination at the end, others do not. There is not even standardized starting date. The curricula need to be well defined. There need to be milestones or EPAs for each of these postgraduate programs. Perhaps each fellowship should conclude with a summative examination and a more standardized certificate could be offered. The ABS is serving in the role of facilitator for this effort.
WHAT MIGHT OR MIGHT NOT CHANGE? Many different potential schemes for the duration and design of residency have been proposed.14 Currently, we have the 5-year residency and there is still a lot of effort going into “fixing the five,” including a recent effort initiated by the ACS. Others have proposed that we adopt 3 plus 3, 3 plus 2 plus 1, 4 plus 2, 0 plus 5, 0 plus 6, 0 plus 7 configurations. Each one of these has their proponents. Advantages of the early tracking models include earlier concentration in a specialty, maybe shorter duration of training, and better channeling of cases to the trainees who need to learn those cases. But the disadvantages are considerable. It is hard to establish a uniform training experience. Graduate medical education funding will not cover training after the first certificate. There are challenges if graduates earn multiple certificates. Interinstitutional transfers might frequently become necessary. What kind of certification do you give somebody after 3 years of general surgery training? Do you call it general surgery “light”? Dual certification might no longer be possibleda surgeon who finishes fellowship but did not go through a full 5 years of general surgery might not have certification to practice general surgery, and they might need to do that to make a living. Some specialties (eg, pediatric surgery and transplantation) desire 5-year fully trained people to start their fellowship. A FINAL PLEA Function of training should define form of training. Form should not define function. We must design our surgical education model based on education. Let’s start with a careful analysis of exactly who it is we want at the end of training.
Changes in Surgical Education and Training
1035
Let’s identify those characteristics and skills essential for the end product to possess, perhaps using EPAs to develop the optimal curriculum and structure to meet those needs. Some principles should be that our training should be intentional. We should not lose opportunities to teach our residents by running out of the operating room and never critiquing their performance. Training needs to be more efficient today. We have less time to do it. Assessment should be performance based; advancement should be competency based. Those of you who will comprise the ABS of the future must thoughtfully redesign the requirements to assure that certification continues to mean something. I would like to conclude with acknowledgement of a surgical mentor that I shared with New England Surgical Society President, Frederick R Radke. Forty years ago, Dr Arthur Naitove took two reprobate Dartmouth medical students and instilled in them a genuine love of surgery (Fig. 3). Through the two of us and many others, his teachings live on. Thank you. REFERENCES 1. Lewis FR, Klingensmith ME. Issues in general surgery residency trainingd2012. Ann Surg 2012;256:553e559. 2. Malangoni MA, Biester TW, Jones AT, et al. Operative experience of surgery residents: trends and challenges. J Surg Educ 2013;70:783e788. 3. Bucholz EM, Sue GR, Yeo H, et al. Our trainees’ confidence: results from a national survey of 4136 US general surgery residents. Arch Surg 2011;146:907e914. 4. Napolitano LM, Savarise M, Paramo JC, et al. Are general surgery residents ready to practice? A survey of the American College of Surgeons Board of Governors and Young Fellows Association. J Am Coll Surg 2014;218:1063e1072. 5. Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg 2013;258:440e449. 6. Friedell ML, VanderMeer TJ, Cheatham ML, et al. Perceptions of graduating general surgery chief residents: are they confident in their training? J Am Coll Surg 2014;218:695e703. 7. Jones K, Lebron RA, Mangram A, Dunn E. Practice management education during surgical residency. Am J Surg 2008;196:878e881. 8. McGreevy JM. Maximizing postgraduate surgical education in the future. Bull Am Coll Surg 2012;97:19e23. 9. Soper NJ, DaRosa DA. Presidential address: engendering operative autonomy in surgical training. Surgery 2014;156:745e751. 10. Cogbill TH, Malangoni MA, Potts JR, Valentine RJ. The general surgery milestones project. J Am Coll Surg 2014;218:1056e1062. 11. Sonnadara RR, Mui C, McQueen S, et al. Reflections on competency-based education and training for surgical residents. J Surg Educ 2014;71:151e158. 12. Ten Cate O. Competency-based education, entrustable professional activities, and the power of language. J Grad Med Educ 2013;5:6e7. 13. Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ 2013;5:157e158. 14. Stain SC, Cogbill TH, Ellison EC, et al. Surgical training models: a new vision. Broad-based general surgery and rural general surgery training. Curr Probl Surg 2012;49:565e623.
MD, FACS
I have two connections to Samuel Jason Mixter. His great grandson, Chip Mixter, did a rotation at the Denver General Hospital when I was a second-year resident at the University of Colorado. He was a resident at the Mayo Clinic and wanted to get some trauma experience, so he rotated at Colorado and we became good friends. Chip Mixter is currently a plastic surgeon in Milwaukee, Wisconsin. I spoke with him before this talk because I wanted to know more about his family, and he sent me a photograph taken in 1907. The picture shows scrub nurse, Ms Curly on the left and William J Mixter and Charles G. Mixter standing on each side of their father, Samuel Jason Mixter, for whom this talk is named (Fig. 1). William J Mixter became the first Department Chair of Neurosurgery at Massachusetts General Hospital and Charles G Mixter was the head of General Surgery at Beth Israel Hospital. The family has a long history of excellence in surgery. The other connection I have is to the Mixter clamps. The baby Mixter is my favorite clamp and the one I frequently use to take autonomy away from my residents (Fig. 2). Here are my disclosures. I absolutely love general surgery. I would do it again in whatever smallest subdivision of a second there is. These opinions are mine and mine alone. They clearly reflect my experience of 8 years on the American Board of Surgery (ABS). The last disclosure is that I am not a seer; I cannot predict the future. The rationale for this talk is that I was the program director of a small surgery residency for 20 years and that was the activity that I enjoyed most about my practice. Teaching is the closest thing we have to surgical immortality. It goes on beyond us. We teach somebody, they take care of patients. We teach many trainees, they take care of many patients, and maybe they go on to teach other surgeons, and so on. Surgical education is currently at a crossroads and I am worried; who is going to take care of my family and me, and who are we going to leave behind? 30th Annual Samuel Jason Mixter Lecture. Presented at the 95th Annual Meeting of the New England Surgical Society, Stowe, VT, September 2014. Received October 10, 2014; Accepted November 13, 2014. From the Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI. Correspondence address: Thomas H Cogbill, MD, FACS, Department of General and Vascular Surgery, Gundersen Health System, 1900 South Ave C05-001, La Crosse, WI 54601. email: [email protected]
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
CURRENT STATE OF SURGICAL EDUCATION Surgery residency today has de facto been shortened by about 1 year if you consider the difference in hours.1 Knowledge has really exploded, it has not contracted, and the number of procedures that a resident needs to learn is greater, not fewer. Recent studies of resident operative experience demonstrate stable total operations, increased laparoscopic procedures, a considerable decrease in total open operations, a substantial decrease in the number of emergency operations and cases in which the resident serves as an assistant, including as a teaching assistant. Mark Malangoni and colleagues2 at the ABS reported that the frequency of operations performed a mean of >10 times during residency remains at about 20 cases. Of the essential or common operations listed in the Surgical Council on Resident Education curriculum, 34% were performed a median of <5 times and 4 had a median of 0. Residents experience less independence during residency training due to changes in our society, regulatory changes, medicalelegal concerns, and a few highly publicized cases of health care finance enforcement. It is obvious that more resident graduates today are not confident about going into practice and their ability to independently perform a number of common procedures.3 This concern was shared by fellowship program directors and by fellows of the American College of Surgeons (ACS) in two recent surveys.4,5 However, a recent survey of graduating chief residents refutes these concerns, finding this group confident in their skills.6 The ABS examination results through 2012 demonstrate that the first-time fail rate on the qualifying examination has at least been stable and perhaps decreased during the past 8 to 10 years. The certifying examination has had a different trend, with a steady increase in the first-time fail rate until 2013. Finally, you cannot have a talk about surgical training if you do not know anything about surgical workforce predictions. There is a huge mismatch. The greatest need in the United States is for general surgeons. The two areas of greatest need for general surgeons are in rural areas and in the inner city. The mismatch is that 80% of our graduates pursue fellowships that make it less likely that they will practice general surgery.
1032
http://dx.doi.org/10.1016/j.jamcollsurg.2014.11.019 ISSN 1072-7515/14
Vol. 220, No. 6, June 2015
Cogbill
WHAT IS NOT LIKELY TO CHANGE There are a few trends in current surgical education that we must accept as immutable. First, the ABS is still going to give examinations. The pathway to certification will continue to involve a written examination followed by an oral examination. Maintenance of certification is here to stay, although there is some controversy at the American Board of Medical Specialties as to exactly what this is going to look like. I think that the ABS has tried really hard to not make maintenance of certification too burdensome for its diplomates. Second, are we really going to abolish the ACGME duty-hour regulations? No. Society has changed, our residents are of a different generation and I am proud of them. The good old days really were not that great if you think about it, and if we cannot educate residents in an 80-hour work week, we really have to change how we teach. We are not going to go back to loosely supervised surgery. Society has changed. Our patients have different expectations and our trainees have different expectations. Was it really okay for me to do my first craniotomy on a patient when I was 6 weeks out of medical school and I had seen my first one that morning and my attending was 45 minutes from the hospital? We are not going to observe an increase in the number of open cases. We have got to stop worrying about this. Minimally invasive surgery is well established. There are going to be minimally invasive and endovascular solutions for the complicated cases for which we currently rely on infrequent open operations. We just need to innovate. Many conditions (eg, peptic ulcer disease and solid organ injury) no longer require surgery, and more conditions (perhaps appendicitis and colonic diverticulitis) are not going to require surgery or often might not. Can we mandate fewer fellowships? No. The market is much more likely to affect change in the specialties selected by our graduates. However, any time that we meddle with training, we need to understand that there will be potential effects on other parts of training, and we should design something that does not harm general surgery, as that is where there is the greatest need. WHAT IS LIKELY TO CHANGE? I am going to focus on just the first 3 stages of training today: preresidency, residency, and immediately postresidency or the transition to practice. What about preresidency preparation is likely to change? Many medical schools currently offer a surgical “boot camp” to teach basic surgical skills to students who are planning to enter surgical residency. Some residencies have put a basic surgical skill module at the beginning of residency. This needs to be a requirement and needs to happen before residency so residents can come to residency already having knowledge of
Changes in Surgical Education and Training
1033
Figure 1. Photograph taken at Massachusetts General Hospital in 1907 of scrub nurse Ms Curly, William J Mixter, Samuel Jason Mixter, and Charles G Mixter (left to right).
basic technical skills, how to preoperatively assess a patient, how to take care of common postoperative problems, and how to effectively communicate with each other and with other hospital personnel. A joint statement made by the ABS, ACS, the Association of Program Directors in Surgery, and the Association for Surgical Education supporting a requirement for a preresidency preparatory course will appear in the October issue of each of the 8 major surgery journals. What is likely to change during residency? We will see significant changes in curriculum, procedural training, and evaluation. The ABS has recently made several moves to redesign surgical residency. There have been some substantial core curriculum changes based on Surgical Council on Resident Education. The curriculum will continue to undergo redefinition to include those conditions and procedures that are central to general surgery practice and a de-emphasis on the remainder. It does not mean to
Figure 2. Photograph of baby Mixter or small right angle clamp.
1034
Cogbill
Changes in Surgical Education and Training
Figure 3. Photograph of Dartmouth surgeon Arthur Naitove, MD. (From: Geisel School of Medicine at Dartmouth, with permission.)
“dumb down” surgical training; it means concentrate on what is important. More modular curricula will be developed. As examples, the ABS already requires completion of Advanced Cardiovascular Life Support, ATLS, Fundamentals of Laparoscopic Surgery, and Fundamentals of Endoscopic Surgery. What is common to each of these modules is a defined curriculum, specific technical skills that a person must practice, and then assessment to assure that they have learned something. In an effort to assure that residents gain operative experience earlier in their training, the ABS, in concert with the Residency Review CommitteeeSurgery, has established that a minimum of 250 cases be completed by the end of the PGY2. A minimum of 25 teaching assistant cases was also established. There will be increased emphasis on minimally invasive surgical cases and endoscopy. Evaluation will include increased assessment of a resident’s operative skills with procedurespecific tools for analysis. Practice management skills do not get enough attention in our residencies today.7 This is another reason that our graduates might not be confident to go out into practice. We should teach them how to code and reimburse, how to run a busy clinic, how to protect themselves against a malpractice suit, how to read a contract, how to communicate with referral doctors, and how to actually do something with patient satisfaction that is meaningful. What is procedural training likely to look like? I believe that we must include more time for deliberate practice and reflection. These are adult educational methods. Adult education experts have said that simple repetition is not the greatest of all teachers. Without time for feedback or reflection on one’s performance, a trainee does not learn very much and continues to make the same mistakes over and over.8 Every time we come out of the operating room, we should ask the resident, “how do you think it went; what did you do well; what could you
J Am Coll Surg
have done better?” Then, “this is what I think you did well; this is where I think you need to practice.” There is going to be less reliance on case numbers. Numbers have been a surrogate for experience for too long. Competence is what we train to now. Maybe we should be training to proficiency. The PASS (procedural autonomy and supervision system) program or credentialing during residency clearly look like they are going to have a role in our future to allow residents more independence in decision making and assure patient safety.9 We are going to see more simulation training. Although simulation laboratories are currently required for all surgical residencies, a robust simulation curriculum with teaching modules and assessment needs to be implemented. We should observe significant improvements in methods of evaluation. The ACGME surgery milestones allow us to track resident’s performance in a number of different areas that relate to the 6 competencies along an expected trajectory.10 These are not actual activities in which a learner must demonstrate proficiency before they can advance. The milestones allow us to track performance against other residents of the same level. The future is going to be in competency-based advancement.11 This effort should begin with determining the entrustable professional activities (EPA) that define general surgery. An EPA is an essential task or responsibility of professional practice that will eventually be entrusted to the unsupervised performance by a trainee.12,13 In other words, what are the activities that are absolutely essential for a general surgeon to know and be able to do? As part of assessment during residency, we will sign off on EPAs as all of the key steps are achieved by our trainees. This will allow the competency committee to credential during residency, which might be the answer to offering an autonomous experience during residency, because if a resident can be credentialed to do a procedure, then the level of supervision can be lessened. Advancement occurs whenever all of the level-specific EPAs are achieved. Currently, a variety of postgraduate fellowships are providing structured autonomy and a transition to practice for 80% of residency graduates. The ACS Transition to Practice programs were developed as a possible parallel pathway for graduates anticipating general surgery practice. It is unknown whether Transition to Practice programs will really catch on or become the required pathway for general surgery. Personally, I believe that an additional year is not necessary for most graduates. However, we need to help those who are going into practice to develop some onboarding recommendations so we can help them ease into practice with mentorship. The basic principles of the ACS Transition to Practice programs include an intake assessment to catalog the resident graduate’s previous experience,
Vol. 220, No. 6, June 2015
Cogbill
outline their goals for their intended future career, and try to map out their first year to meet those needs. Flexibility is inherent in the design of the curriculum. There is an autonomous experience in the operating room and in the clinic, on call, and with practice management. Outcomes are tracked, discussed, and an assessment is made. Finally, this year, the ABS has initiated an effort to standardize the experiences in the current disparate group of surgical specialty fellowships. Some are accredited by the ACGME, others by the Fellowship Council, and others sponsored by specialty societies. Some have an examination at the end, others do not. There is not even standardized starting date. The curricula need to be well defined. There need to be milestones or EPAs for each of these postgraduate programs. Perhaps each fellowship should conclude with a summative examination and a more standardized certificate could be offered. The ABS is serving in the role of facilitator for this effort.
WHAT MIGHT OR MIGHT NOT CHANGE? Many different potential schemes for the duration and design of residency have been proposed.14 Currently, we have the 5-year residency and there is still a lot of effort going into “fixing the five,” including a recent effort initiated by the ACS. Others have proposed that we adopt 3 plus 3, 3 plus 2 plus 1, 4 plus 2, 0 plus 5, 0 plus 6, 0 plus 7 configurations. Each one of these has their proponents. Advantages of the early tracking models include earlier concentration in a specialty, maybe shorter duration of training, and better channeling of cases to the trainees who need to learn those cases. But the disadvantages are considerable. It is hard to establish a uniform training experience. Graduate medical education funding will not cover training after the first certificate. There are challenges if graduates earn multiple certificates. Interinstitutional transfers might frequently become necessary. What kind of certification do you give somebody after 3 years of general surgery training? Do you call it general surgery “light”? Dual certification might no longer be possibleda surgeon who finishes fellowship but did not go through a full 5 years of general surgery might not have certification to practice general surgery, and they might need to do that to make a living. Some specialties (eg, pediatric surgery and transplantation) desire 5-year fully trained people to start their fellowship. A FINAL PLEA Function of training should define form of training. Form should not define function. We must design our surgical education model based on education. Let’s start with a careful analysis of exactly who it is we want at the end of training.
Changes in Surgical Education and Training
1035
Let’s identify those characteristics and skills essential for the end product to possess, perhaps using EPAs to develop the optimal curriculum and structure to meet those needs. Some principles should be that our training should be intentional. We should not lose opportunities to teach our residents by running out of the operating room and never critiquing their performance. Training needs to be more efficient today. We have less time to do it. Assessment should be performance based; advancement should be competency based. Those of you who will comprise the ABS of the future must thoughtfully redesign the requirements to assure that certification continues to mean something. I would like to conclude with acknowledgement of a surgical mentor that I shared with New England Surgical Society President, Frederick R Radke. Forty years ago, Dr Arthur Naitove took two reprobate Dartmouth medical students and instilled in them a genuine love of surgery (Fig. 3). Through the two of us and many others, his teachings live on. Thank you. REFERENCES 1. Lewis FR, Klingensmith ME. Issues in general surgery residency trainingd2012. Ann Surg 2012;256:553e559. 2. Malangoni MA, Biester TW, Jones AT, et al. Operative experience of surgery residents: trends and challenges. J Surg Educ 2013;70:783e788. 3. Bucholz EM, Sue GR, Yeo H, et al. Our trainees’ confidence: results from a national survey of 4136 US general surgery residents. Arch Surg 2011;146:907e914. 4. Napolitano LM, Savarise M, Paramo JC, et al. Are general surgery residents ready to practice? A survey of the American College of Surgeons Board of Governors and Young Fellows Association. J Am Coll Surg 2014;218:1063e1072. 5. Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg 2013;258:440e449. 6. Friedell ML, VanderMeer TJ, Cheatham ML, et al. Perceptions of graduating general surgery chief residents: are they confident in their training? J Am Coll Surg 2014;218:695e703. 7. Jones K, Lebron RA, Mangram A, Dunn E. Practice management education during surgical residency. Am J Surg 2008;196:878e881. 8. McGreevy JM. Maximizing postgraduate surgical education in the future. Bull Am Coll Surg 2012;97:19e23. 9. Soper NJ, DaRosa DA. Presidential address: engendering operative autonomy in surgical training. Surgery 2014;156:745e751. 10. Cogbill TH, Malangoni MA, Potts JR, Valentine RJ. The general surgery milestones project. J Am Coll Surg 2014;218:1056e1062. 11. Sonnadara RR, Mui C, McQueen S, et al. Reflections on competency-based education and training for surgical residents. J Surg Educ 2014;71:151e158. 12. Ten Cate O. Competency-based education, entrustable professional activities, and the power of language. J Grad Med Educ 2013;5:6e7. 13. Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ 2013;5:157e158. 14. Stain SC, Cogbill TH, Ellison EC, et al. Surgical training models: a new vision. Broad-based general surgery and rural general surgery training. Curr Probl Surg 2012;49:565e623.