By Christina Frangou
Savannah, Ga.—Speaking at the 2014 Scientific Meeting of the Southeastern Surgical Congress, Frank R. Lewis, MD, executive director of the American Board of Surgery, suggested that fellowship training should be incorporated as a requirement for all surgeons after residency.
“Long-term changes in ethical, legal and financial factors have reduced resident autonomy and left residents less prepared for practice,” Dr. Lewis said.
“These factors within residency are not changeable. Therefore, we need to focus on the potential for fellowship as an opportunity for getting greater autonomy and independence.”
He stressed that his comments reflect his personal views and not those of the American Board of Surgery (ABS).
It is a time of ongoing debate in the surgical community about the current five-year system of training: Does it provide sufficient time to train a skilled general surgeon?
A number of recent studies indicate that it does not (J Am Coll Surg 2014 Feb 6. [Epub ahead of print]). One year ago this spring, at the American Surgical Association meeting, surgeons presented results from a survey of fellowship program directors who said residents were inadequately prepared for fellowship and independent practice. One-fifth of the respondents said new fellows arrived unready for the operating room and 38% demonstrated a lack of patient ownership. The respondents said that 30% of the new fellows could not independently perform a laparoscopic cholecystectomy and 66% were deemed unable to operate unsupervised for 30 minutes during a major procedure (Ann Surg 2013;258:440-449). Fellowship program directors felt new fellows lacked adequate laparoscopic skills, with 30% unable to atraumatically manipulate tissue, 26% unable to recognize anatomical planes and 56% unable to suture.
Other studies demonstrated that residents, too, feel unprepared for independent practice after residency. In a 2011 report, only 72% of residents said they believed their operative ability was “level appropriate,” whereas 26% reported concerns that they would not feel confident enough to perform procedures independently before completing their residency (Arch Surg 2011;146:907-914).
In his presentation, Dr. Lewis identified five principal causes contributing to the current problems in residency:
Reduced surgical exposure and experience in medical school
The highly variable teaching effectiveness at different institutions.
A reduced breadth and complexity of surgical resident experience.
The 80-hour workweek.
Reduced opportunity for autonomy and independent decision making in the senior years of residency.
“Nostalgia is not going to solve these problems. We’re not going to go back to what we had 20 years ago.”
Dr. Lewis proposed several changes that would boost medical student and resident exposure to surgery. These changes would make residency training more efficient and lead to greater autonomy and more independent clinical decision making by senior residents and fellows.
The redesign of surgical education needs to begin in medical school, he said. The American College of Surgeons and some medical schools have created surgical boot camps held during the final weeks of medical school. These camps are targeted to medical students who have matched to a surgical program. Students spend anywhere from four to 12 weeks learning surgery-specific skills to bring their procedural training to a minimal level.
Dr. Lewis called for a fundamental paradigm change in resident training. A new system should be founded on uniform and clearly defined expectations for residents for each year of training, he said. Part of such a change would include greater use of online training and assessment tools, such as the American Board of Surgery’s SCORE® Curriculum Outline for General Surgery Residency. Dr. Lewis said that residents would be able to take more responsibility for their own education if expectations were better defined.
He stressed the need for more uniformity among residency programs. Results of board exams demonstrate the broad variability of teaching among institutions. Of 250 surgical residency programs in the United States, residents of only nine achieved perfect scores on their oral and board exams. About 17% of programs fall below the threshold set by the Residency Review Committee.
The effects of duty-hour restrictions cannot be overlooked, he said. Reductions in resident work hours mean trainees spend less time in the hospital gaining exposure to urgent and emergent operative cases, he said. Programs need to ensure that more resident time is spent in the operating room, he said.
Residents, particularly at the junior level, lack sufficient time in the operating room, he said. Interns, on average, do less than 100 cases in their first year, a rate of about two per week. Second-year residents do about 125 cases, or two to three per week, he estimated. “That’s a relatively poor payoff for the amount of time they put in at the hospital.”
And at the upper level, senior residents are losing cases to fellows, resulting in an insufficient amount of advanced laparoscopic cases for senior residents at many programs.
The 80-hour workweek equates to a loss of somewhere between 2,400 and 4,800 hours of in-hospital experience for residents, or between six and 12 months of residency, Dr. Lewis said. Most of those lost hours are during evenings and weekends, times when residents tended to have more independence and autonomy, and performed more urgent and emergent cases, he said.
Resident independence has been further curtailed by legal constraints over the past several decades; by increased financial pressure on attendings to generate relative value units for departmental income; and by ethical and regulatory changes, he said.
“What we conclude from all this is that increased autonomy and independence for residents today is probably not possible during residency. It’s really only going to be possible during post-residency fellowships when they are board eligible.”
Dr. Lewis proposed the only way to compensate for the lost hours of residency training is to somehow lengthen the training period. Fellowship provides that opportunity, he said, but standards and quality of fellowship are variable under the current system.
“Post-residency fellowships all need to be brought under a single accreditation umbrella, in my opinion,” Dr. Lewis said.
Mandatory fellowship training would be possible without additional graduate medical education funding. Fellows can bill for procedures and generate adequate income to cover their salaries, he said.
The Royal Colleges of Surgeons in Glasgow, Edinburgh, England, Australia and New Zealand mandate specialty fellowship training as an integral part of surgery training.
Not everyone agrees that fellowship training is the answer. William G. Cheadle, MD, professor and program director of surgery at the University of Louisville, in Kentucky, argued that residents could be trained effectively under the current five-year program if they were to have adequate exposure to operative cases. But to do so may require cutting back on fellowships at institutions where residents don’t get enough time in the operating room, he suggested.
“If you can prove that your general surgery program is capable of training general surgeons, then it’s fine to have fellowships. But you should not have them if it’s taking away from the quality of your residency program,” said Dr. Cheadle.
He said that five of the seven chief residents at the University of Louisville this year are going directly into surgical practice without a fellowship. “That’s proof that you can train great broad-based general surgeons, which are just what the public needs, in a five-year residency. But you must find ways to ensure they have exposure to cases. To do that, we credential them at the chief level so they develop some autonomy.”
The challenge for surgical residency programs is to teach residents more in a shorter time period than ever, said David J. Cole, MD, chair of surgery at the Medical University of South Carolina, Charleston.
“The training paradigm, the Halstedian model that we still have some significant version of today, is largely a time-based model. Do your time, we hope you’re good. That’s how it’s been. The challenge now is to switch to a competency-based model.”
A competency-based model requires flexibility but flexibility does not exist under the current system, he said. One option may be to develop a program in which residents spend the first three years learning core surgical principles, after which they move to a more specialized track.
“No matter what model we use, my hope is that the continual drumbeat of work-hour restriction doesn’t continue. There have been very positive benefits of the 80-hour workweek [but] the most recent changes are now hurting the people that were trying to help, which are the junior residents,” Dr. Cole said.