Change in Paradigm for Change in Time

Becoming credentialed and becoming successful may require different skill sets after surgical training. Concern remains that current models of surgical training may not be optimized to meet these expectations as currently implemented. Surgical education at the highest level should prepare trainees to have the competency and skills to not only meet expectations, but to adapt. Residency need not be a race of annual examination, but a strategic component of adult education that taken in all its parts, provides a complete product after training.

The current measures of objective testing for surgical trainees cover content both relevant and obsolete to further stratify examinees. The annual examination measures knowledge but does not correlate with technical skill or operative performance.^1,2 When used appropriately, objective testing may allow programs to proactively intervene on behalf of low-performing residents to give them a greater chance for success.³ In contradistinction to the original intentions, objective testing in surgical education is used to promote, defer, suppress and restrain, as opposed to rehabilitate.

Based on the current implementation, surgical testing needs restructuring, but this concern is merely a symptom of a larger problem. Surgical training has not evolved to fit what is required for the modern-day resident. William Halsted established graduate medical training for surgeons based on previous international systems of training. At Johns Hopkins, this surgical training modality required residents to be residential inhabitants of their training institutions such. This same model promulgates pyramidal systems of graduated responsibility and planned attrition, rendering trainees vulnerable to years of training with no end in sight.

Although this pyramid no longer exists in its truest form, and resident work hours have become a major concern regarding safety measures, only a few additional changes have been made over time in the educational aspect of surgical training. The length of general surgery training has remained at five to eight years despite the need of many institutions requiring subspecialty-trained practitioners. The number of general surgeons performing complex foregut, carotid surgery and oncologic surgery has decreased. As surgical technique and technological advances continue, there are some who point to overlapping practitioners with specialty training as the reason why the general surgeon of old no longer exists. The general surgery resident of today is not like the general surgery resident of old given the breadth of subspecialty programs, such as ENT, ortho, plastic, cardiac, vascular and neurosurgery, which have direct training routes, some of which are no longer attainable after general surgery training. The attrition exists because many institutions require residents to not only complete five categorical years of training, but some also require one to three years of research prior to being considered for fellowship.

Surgical attrition in the general surgery programs has increased to 20%, according to several studies.^4,5 Training length has been cited as one of several reasons for surgical attrition. One can learn from the training models of orthopedic surgery, neurologic surgery, integrated vascular surgery and integrated cardiothoracic surgery. These subspecialty training programs recruit from medical schools and provide the trainee with an increased service time and exposure to their definitive specialty of practice, with no requirement of being board certified in foundational training specialty. Should one plan on a career in general surgery, a consideration can be made for this individual to continue a fifth year for general surgery boards, but four years of general surgery prior to additional training may provide resolution.

We should refrain from using archaic educational models to train future leaders in this specialty. The current training models have led to attrition and burnout. To improve surgical training, we must consider cessation of the current five-year training model for the future subspecialist whose time in fellowship is much shorter in comparison to that of residency.

As general surgery remains the major pathway to a multitude of subspecialties, many programs have limited several service rotations, thus reducing exposure for the very specialties general surgery currently is gatekeeper to. Many residents leave general surgery having rotated on cardiac surgery services, leaving them with little to no exposure.

Leaders must be cognizant of the goals of the fellowship surgeon, as no randomized controlled trial establishes a set number of gallbladder removals to increase the competency of the future cardiac surgeon operating on the beating heart; yet five years, excluding research, are dedicated to the foundation of surgery training and general surgery boarding with only two years to gain mastery in one’s definitive career, which may have been unequally represented in residency.

Out of necessity, other pathways continue to be formed but remain roads less traveled. The official 4-3 program as documented by thoracic surgery training does not formally exist in other specialties. The 4-3 program allows for an internal applicant in general surgery to begin thoracic surgery as a PGY-5 and complete it as a PGY-7. This paradigm of surgical training maintains board specialization in general surgery while also offering the flexibility of increasing time on planned specialization. In the absence of these opportunities, some surgical graduates continue to be unprepared for practice and seek additional subsequent fellowships to accomplish what could not be done within the formal training period.

The time is now for surgical education retooling with a focus on becoming trainee-oriented. This solution, when implemented, will align the goals of both the trainees and trainers. Previous methods of training surgeons may be less efficient in today’s time given the changes in health care, changes in trainees, and advances in technological innovation.

References

1. Krishnamurthy S, Satish U, Foster T, et al. Components of critical decision making and ABSITE assessment: toward a more comprehensive evaluation. J Grad Med Educ. 2009;1(2): 273-277.
2. Scott DJ, Valentine RJ, Jones DB. Evaluating surgical competency with the American Board of Surgery In-Training Examination, skill testing, and intraoperative assessment. Surgery. 2000;128(4):613-622.
3. Yost MJ, Gardner J, Bell RM, et al. Predicting academic performance in surgical training. J Surg Educ. 2015;72(3):491-499.
4. Yeo H, Bucholz E, Ann Sosa J. A national study of attrition in general surgery training: which residents leave and where do they go? Ann Surg. 2010;252(3):529-536.
5. Freischlag JA, Silva MM. Preventing general surgery residency attrition—it is all about the mentoring. JAMA Surg. 2017;152(3):272-273.