The finding that more than 25% of general surgery residents are not confident that they can practice independently after finishing their residency training has prompted the American College of Surgeons (ACS) to create "Transition to Practice" fellowships.

A pilot program at five medical schools and one rural community teaching hospital will place newly graduated residents with community hospital surgeons who will serve as mentors.

The program was introduced in an article in the February 2013 issue of the ACS Bulletin. It says, "current fifth-year residents often lack confidence in their capabilities and may be ill-prepared to enter practice due to a lack of general surgery mentorship and limited exposure to open surgical procedures."

The article goes on to say that the deterioration in training is due to "a number of factors, including reduced work hours, fewer hands-on experiences, and reduced volume of cases, especially emergency cases. Of particular concern is the lack of continuity of care and supervision."

But one of the members of the committee that planned the program said, "The transition from being a chief resident on June 30 to a surgeon in independent practice on July 1 is a daunting step. They haven’t done an operation without an attending across the table."

So which is it—not enough supervision or too much?

It seems to me the ACS feels that general surgery residency training is inadequate.

This confirms what I have said in previous blogs. Last July, I suggested that open surgery fellowships might be necessary to train residents who lacked sufficient exposure to open cases during their residencies. In January of 2012, I pointed out that residents who have never operated alone (the situation in most training programs—confirmed by the ACS) are analogous to pilots who have never soloed before. Would you want to fly with such a pilot? Back in November of 2011, I reviewed the paper that reported the lack of confidence expressed by 27% of residents who were surveyed. I have heard that in a paper about to appear in a major surgery journal, that number is approaching 40%.

If we can't produce confident graduates, why not simply change the way we train them instead of adding another year to the already long process (4 years of college, 4 years of med school, 5 years of surgery residency)?

I have discussed several areas of the curriculum that could be reduced or eliminated, such as insisting that all residents do research whether they want to or not, the heavy emphasis on basic science and the needless transplant rotation.

With a little thought, I am sure more changes could be made so that graduating residents will not feel the need to "transition to practice."

What do you think about "Transition to Practice" fellowships?

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 800 page views per day, and he has over 4900 followers on Twitter.