2015 APDS SPRING MEETING
Early Results from the Flexibility in Surgical Training Research Consortium: Resident and Program Director Attitudes Toward Flexible Rotations in Senior Residency Mary E. Klingensmith, MD,* Michael Awad, MD, PhD,* Keith A. Delman, MD,† Karen Deveney, MD,‡ Thomas J. Fahey III, MD,§ Jason S. Lees, MD,║ Pamela Lipsett, MD,¶ John T. Mullen, MD,** Douglas S. Smink, MD, MPH,†† and Jeffrey Wayne, MD‡‡ Department of Surgery, Washington University, St Louis, Missouri; †Department of Surgery, Emory University, Atlanta, Georgia; ‡Department of Surgery, Oregon Health and Science University, Portland, Oregon; § Department of Surgery, New York Presbyterian-Weill Cornell Medical Center, New York, New York; ║ Department of Surgery, University of Oklahoma, Oklahoma City, Oklahoma; ¶Department of Surgery, Johns Hopkins University, Baltimore, Maryland; **Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; ††Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts; and ‡‡ Department of Surgery, Northwestern University, Chicago, Illinois *
OBJECTIVE: To assess the attitudes of residents and
program directors (PDs) involved in flexible training to gauge satisfaction with this training paradigm and elicit limitations.
DESIGN: Anonymous surveys were sent to residents and
PDs in participant programs. Respondents were asked to rate responses on a 5-point Likert scale (1 ¼ strongly disagree and 5 ¼ strongly agree). SETTING: A total of 9 residency programs that are
collaborating to prospectively study the effect of flexible tracks on resident performance and outcome.
PARTICIPANTS: A total of 138 residents who were in
clinical years 4 and 5 and 10 PDs. RESULTS: Of the 138 possible residents, 100 responded to the resident survey (72.5% response rate). Among resident respondents, 33% were participating in a flexible track option. The most frequently listed specialties of focus were cardiothoracic surgery (19%), vascular surgery (13%), acute care surgery (11%), colorectal surgery (8%), surgical oncology (7%), and pediatric surgery (7%). Participants in flexible tracks tended to strongly agree that their career would be enhanced by flexible rotations; interestingly, of those not in
Correspondence: Inquiries to Mary E. Klingensmith, MD, Department of Surgery, Washington University in Saint Louis, 660 South Euclid, Campus Box 8109, Saint Louis, MO 631130; fax: (314) 362-8790; E-mail: [email protected], [email protected]
flexible tracks, most tended to also agree that flexible rotations would enhance their future careers. Flexible track participants report receiving greater autonomy on flexible rotations and believe they would be better prepared for fellowship and career. They express overall very high satisfaction with the flexible experience. Limitations expressed by residents (in flexible tracks or not) include uncertainty for how this paradigm serves those interested in comprehensive general surgery, concern about scheduling difficulties, and some displeasure in missing high-volume general surgery rotations in lieu of specialty-focused rotations. The PD survey was completed by 8 of 9 PDs for a response rate of 89%. All the respondents agreed or strongly agreed that careers of residents are enhanced by flexible rotations and that important operative and clinical experiences are gained. Overall, 87.5% of PD respondents agreed or strongly agreed that those in flexible tracks have greater opportunities for mentorship in their chosen field. PDs also expressed high levels of satisfaction with flexible rotations. Limitations include concerns that the flexibility option presents scheduling difficulties and does not go far enough in reforming postgraduate education. CONCLUSIONS: This survey of 9 residency programs
participating in flexible tracks indicates satisfaction with this training option. The role of comprehensive general surgery as a training end point and scheduling difficulties remain as major challenges. Outcomes of graduates in these tracks and control peers are being prospectively evaluated. ( J Surg 72:
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 e151 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.05.007
C 2015 Association of Program Directors in e151-e157. J Surgery. Published by Elsevier Inc. All rights reserved.)
KEY WORDS: graduate medical education, surgery resi-
dency training, general surgery, subspecialty surgery training, autonomy, postgraduate education COMPETENCIES: Patient Care, Medical Knowledge, Prac-
tice-Based Learning and Improvement, Systems-Based Practice
INTRODUCTION The training of surgical residents in the United States is evolving, as more and more trainees are electing to pursue fellowship training with a de facto increase in the length of training. This shift has occurred concurrent to other forces that have affected the training environment.1 Some of these include the reduction in duty hours; the increasing subspecialization of surgery as a whole and consequent fragmentation of training experiences; the increased requirements for supervision of trainees, resulting in less opportunity for trainee independence at more senior levels; and changes in technology that have affected the nature of what surgeons do. Despite these changes, the paradigm for surgical training has not evolved. A recent modification in training requirements by the American Board of Surgery (ABS) and Residency Review Committee (RRC) in Surgery presents a needed opportunity for change: in 2011, the ABS began allowing programs to have flexibility in training in the postgraduate year 3 to postgraduate year 5 years, with as many as 12 of the 36 months of senior residency spent in training in a single content area.2 This flexibility rule makes earlier specialty training possible in numerous specialty areas, with trainees able to track to their area of subspecialty interest sooner than traditional fellowship training would allow. The option is available to all interested residency training programs and is exercised by advance request to the ABS for permission to enroll a given resident in a flexible track. Details for obtaining the permission for this voluntary program can be found on the ABS website.2 For the purposes of the present study, the application of this flexibility rule is termed “FIST” (Flexibility in Surgical Training). This modification to training requirements built upon the early successes of a pilot project in 2 specialties: vascular and cardiothoracic (CT) surgery. The Early Specialization Project in these specialties has been summarized elsewhere.3 Although currently relatively few programs participate in Early Specialization Project (vascular 6 and thoracic 10), they have been successful in achieving their stated goals of allowing trainees to get to their area of specialty training sooner, with an additional 12 months of training in the area of interest. As of this writing, board passage rates in both surgery and the accompanying subspecialty (vascular or CT) have been quite good (personal communication). Thus, the expansion of the flexibility rule to e152
all areas that require general surgery certification as prerequisite was based on the success of the vascular and CT pilots. To date, the flexibility rule has been used in a limited fashion in training programs, and in those that have used it, there has been tremendous variability in how rotations have been selected for trainees who are preparing themselves for a variety of subspecialties. There has been no substantial administrative guidance provided to help residency programs understand how to best use this rule to the benefit of trainees. To address this issue, a FIST consortium formed in August 2012 of 9 residency programs around the country that agreed to work together to collaborate on1 standardizing the curricula in the “flexible” training tracks, and2 prospectively analyzing data from the trainees in these tracks to work toward optimal trainee outcome, as future residency redesign may be informed by this data. This proposal was endorsed by the surgery RRC in November 2012. To develop a standardized curriculum, the consortium representatives consulted the specialty-specific guidelines on the ABS “flexible rotations” web page and worked collaboratively with representatives from the pediatric surgery and trauma/burn/critical care subboards of the ABS, as well as the Transplant Advisory and Advanced Surgical Education councils of the ABS, to develop more robust recommendations for rotations in specific content areas. These were reviewed by consortium members and used by the program director (PDs) at consortium sites to develop rotation schedules for trainees desiring flexible training in a given area. Consortium sites began flexible training opportunities that are the focus of this study, beginning with the academic year that started on July 1, 2013. The current study was designed to assess the attitudes of residents and PDs involved in flexible training at sites included in our multi-institutional study, to gauge satisfaction with this training paradigm and elicit limitations.
MATERIALS AND METHODS All participant programs followed the ABS guidelines set forth to obtain permission for application of the flexibility rule for each trainee enrolled. Institutional review board approval was obtained at each study site to allow for prospective evaluation of this training paradigm. By design, the study includes flexible options confined to the clinical R4 and clinical R5 years, as the participating programs decided as a group to limit application of the flexibility rule primarily to these 2 years of training. The participating programs include Washington University, Emory, Brigham and Women’s Hospital, Massachusetts General Hospital, Johns Hopkins, Northwestern, University of Oklahoma, Oregon Health and Science University, and New York Presbyterian-Cornell. As per the RRC guidelines, rotational assignments were in compliance with rules regarding the prohibition of fellows and chief residents sharing responsibility for patients, or working directly together. These measures were taken to both
Journal of Surgical Education Volume 72/Number 6 November/December 2015
FIGURE 1. Distribution of intended subspecialty focus for all resident respondents. Note: Gen Surg, General Surgery; CT, Cardiothoracic Surgery; Peds, Pediatric Surgery; Vasc, Vascular Surgery; Endo, Endocrine Surgery; MIS, Minimally Invasive Surgery; CRS, Colorectal Surgery; TxP, Transplantation Surgery; ACS, Acute Care Surgery; Plas, Plastic Surgery; HPB, Hepatobiliary Surgery; Brst, Breast Surgery; Onc, Surgical Oncology.
comply with the RRC guidelines and preserve the independent and semiautonomous experiences that are hallmarks to the resident experiences in the participant programs. All residents in the 9 participating programs in the clinical R4 and clinical R5 years were surveyed during the month of April 2014. Similarly, the 9 PDs were surveyed during a similar time frame (April 2014). Surveys were developed by the advisory group for the prospective multiinstitutional study and delivered via e-mail using an anonymous online polling system (SurveyMonkey, Palo Alto, CA). Reminder e-mails were sent on 2 separate occasions to all participants over a 1-month period. Institutional review board approval was obtained at each participant site in the FIST consortium. Results for all respondents were analyzed, and where comparisons between FIST track and non–FIST
track participants were relevant, tests of significance were made using the Student t test.
RESULTS Resident Survey Demographics Of 138 possible residents, 100 responded to the resident survey (72.5% response rate). The average age of respondents was 33 years (range: 29-46); 33% were women. Among resident respondents, 54% were in clinical R4 level and 46% were in clinical R5 level. Overall, 33% of respondents were participating in a flexible track option.
FIGURE 2. Distribution of intended subspecialty focus for those residents in flexible tracks. Note: Gen Surg, General Surgery; CT, Cardiothoracic Surgery; Peds, Pediatric Surgery; Vasc, Vascular Surgery; Endo, Endocrine Surgery; MIS, Minimally Invasive Surgery; CRS, Colorectal Surgery; TxP, Transplantation Surgery; ACS, Acute Care Surgery; Plas, Plastic Surgery; HPB, Hepatobiliary Surgery; Brst, Breast Surgery; Onc, Surgical Oncology. Journal of Surgical Education Volume 72/Number 6 November/December 2015
e153
TABLE 1. Comparison of Mean Rating (⫾ Standard Deviation) on a 5-Point Likert Scale Between FIST and Non-FIST Respondents Those in FIST Track
Query Flexible tracks are not worth the scheduling headaches My career would be enhanced by having had a flexible option Flexible tracks have improved residency training in the United States I would be able to provide better care for patients because of flexible track participation FIST programs may work well for participants but disrupt the training of those who do not participate
Among all resident respondents, the most frequently listed intended specialties of focus were CT surgery (19%), general surgery (18%), vascular surgery (13%), acute care surgery (11%), colorectal surgery (8%), surgical oncology (7%), and pediatric surgery (7%), as shown in Figure 1. However, for those in flexible tracks, the distributions of intended specialties were shifted significantly toward CT surgery (33%), with plastic surgery (12%); colorectal surgery and breast surgery (9%); and pediatric surgery, general surgery, oncology, and minimally invasive surgery (each 6%) accounting for the remainder (Fig. 2). Attitudes Toward Flexible Track Options All respondents were asked their opinions on several aspects of the flexible track option. A number of attitudinal statements regarding the FIST option were presented, and respondents were asked to respond on a 5-point Likert scale (1 ¼ strongly agree, 3 ¼ neutral, and 5 ¼ strongly disagree). Responses were analyzed to determine if differences in opinions existed between the 2 groups. For each statement, mean response (⫾ standard deviation) was calculated. Comparisons of responses
4.19 1.72 2.19 2.03
⫾ ⫾ ⫾ ⫾
1.03 0.98 1.01 1.03
3.28 ⫾ 1.10
Those Not in FIST Track
p Value
⫾ ⫾ ⫾ ⫾
1.18 1.18 0.95 1.09
0.08 0.04 0.16 0.07
2.53 ⫾ 1.08
0.25
3.94 2.41 2.65 2.68
between the 2 groups (those in FIST tracks vs those not) are summarized in Table 1. As is shown, those in FIST tracks tended to strongly agree that their careers would be enhanced by participation in these tracks, more so than did participants who were not in the tracks. Additionally, most respondents endorsed a feeling that the scheduling challenges of FIST were “worth it,” but they were neutral as to whether the flexibility option has improved residency training in the United States. FIST participants tended to believe that the flexibility option would allow them to provide better care for patients because of participating; this response was not significantly different from non-FIST participants. Lastly, non-FIST participants tended to agree more strongly with the statement that “FIST programs may work well for participants but disrupt the training of those who do not participate,” but the differences in responses between the groups did not reach statistical significance. Attitudes of FIST Track Participants Flexible track participants were asked a number of questions regarding their overall impressions of the FIST experience.
TABLE 2. Summary of Attitudinal Responses of FIST Participants % Agree/ % Strongly Agree Neutral I have missed out on operative experiences because of participating in a flexible track I have had operative experiences I would not otherwise have gotten because of my flexible track I have had clinical experiences I would not otherwise have gotten because of my flexible track I have missed out on clinical experiences because of participating in a flexible track I would be better prepared for my fellowship because of participating in a flexible track I have had or would have greater mentorship in my subspecialty because of my flexible track I have had or would have greater mastery of my subspecialty because of my flexible track I have had or would have greater autonomy in training in my subspecialty because of my specialty track Flexible training would make me better prepared for board certification examinations Overall, I am pleased with my experiences to date with flexible training
e154
% Disagree/ Strongly Disagree
24.9
3.2
7.19
81.3
0
18.7
81.3
6.3
12.4
18.8
9.3
71.9
90.6
6.3
3.1
84.4
6.3
9.3
90.6
0
9.4
71.9
18.8
9.3
25
56.3
18.7
84.4
12.5
3.1
Journal of Surgical Education Volume 72/Number 6 November/December 2015
TABLE 3. Summary of Program Director Attitudinal Responses % Agree/ % Strongly Agree Neutral Flexible tracks are not worth the scheduling headaches Flexible tracks have improved residency training in the United States My residents would be more competitive for a fellowship if they participate in FIST My graduates would be able to provide better care for patients because of FIST participation My residents would receive greater mentorship in their subspecialty because of flexible track experiences My residents would achieve greater mastery in their subspecialty because of flexible track experiences My residents would achieve greater autonomy in their subspecialty because of flexible track experiences Overall, I am pleased with my programs' experiences to date with flexible training
Their responses are summarized in Table 2. Most of the respondents in the FIST tracks report gaining operative and clinical experiences because of flexible track participation, a feeling of greater preparedness for fellowship, greater mentorship and autonomy in their subspecialty area of focus, and an overall sense of satisfaction with the flexible track option. Comments Regarding Advantages and Limitations to Flexible Track Options All respondents were asked to comment on the questions “what do you like about the flexible track” and “what don’t you like about the flexible track.” Reported advantages to flexible track options included exposure to clinical experiences of greater interest, improved opportunities for mentorship, greater flexibility in designing senior-level rotations of interest, and tailoring training specifically to an individual’s career goals. Limitations expressed included uncertainty for how this paradigm serves those interested in careers in general surgery, concern about scheduling difficulties, and some displeasure in missing high-volume general surgery rotations in lieu of specialty-focused rotations. Program Director Survey The PD survey was completed by 8 of 9 PDs for a response rate of 89%. All the respondents agreed or strongly agreed that careers of residents are enhanced by flexible rotations and that important operative and clinical experiences are gained. The summaries of other responses are detailed in Table 3. Comments Regarding Advantages and Limitations to Flexible Track Options All PD respondents were asked to comment on the questions “what do you like about the flexible track option for your trainees?” and “what don’t you like about the
% Disagree/ Strongly Disagree
0 50 37.5
37.5 50 50
62.5 0 12.5
50
37.5
12.5
87.5
12.5
0
62.5
37.5
0
75
12.5
12.5
75
12.5
12.5
flexible track option for your trainees.” Reported advantages included earlier transition to a trainee’s intended specialty focus, an ability to focus educational opportunities on those who might most benefit, and potential for increased autonomy for trainees as relationships with mentors mature. Limitations included concerns that the current rules do not go far enough in allowing focused training and scheduling concerns, including accommodating multiple trainees interested in a given field, making certain that parity of “good” rotations exists between residents who are participating and not participating in flexible tracks and avoiding the appearances of FIST residents as “favored” in obtaining special or unique clinical experiences.
CONCLUSIONS This survey of 9 residency programs participating in flexible tracks indicates satisfaction with this training option by both resident trainees and PDs. Our response rate of 72.5% among resident respondents is quite favorable for a voluntary survey, and we think that this adds validity to our findings. Residents participating in FIST tracks, as well as their PDs, believe that the flexible option enhances residents’ careers, allows for increased operative and clinical experiences, as well as increased mentorship and autonomy in the subspecialty area of interest. Although scheduling challenges are reported, most respondents indicate that those challenges are worthwhile. However, disruption to the experiences of those not participating in flexible training is a real concern, as is a loss of focus for those trainees who may desire a career in general surgery, as most of the FIST track experiences reported in this study are focused on subspecialty areas. The importance of preserving a robust experience for those NOT in flexible tracks is given emphasis by these survey results. PDs who responded to our survey note this as a challenge, and with this shared
Journal of Surgical Education Volume 72/Number 6 November/December 2015
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knowledge, providing emphasis on this in programs participating in flexible tracks is critical to ensure a rigorous and meaningful educational experience for all residents, regardless of track participation. Several recent studies have suggested that graduates of residency programs are ill prepared for future practice, whether fellowship or independent practice.4,5 This concern has been shared by fellowship directors and fellows of the American College of Surgeons.6,7 Data from the present study indicate that FIST programs may provide some antidote to these challenges, as increased autonomy and increased mentorship in the specialty area of focus is reported among FIST participants, as well as an expected increase in clinical and operative experiences. Whether these ultimately may translate into increased confidence and skill remains to be determined. However, it would seem that these attributes may indeed have such an effect. A limitation to the FIST project, as implemented in the programs participating in this study, is that general surgery is underrepresented among the specialty areas of focus among flexible track participants: only 6% of respondents indicate this as an area of intended career focus, whereas this is the intended specialty for 18% of all residents who responded to this survey. As more trainees pursue fellowship training, there are fewer graduates to fill the growing deficit of general surgeons needed to serve the public. This trend has resulted in fewer general surgeons in practice today, with a 25% decline seen over the past 2 decades8 and projected 18% decline over the coming 2 decades.9 Rural areas seem to be particularly affected. As the trend toward specialty training continues, worsening of the workforce shortage is predicted, which has raised alarm among many thought leaders in surgery.10,11 As was indicated by resident respondents in this survey, it is unclear how general surgery fits into this training paradigm; interestingly, the PDs who completed this survey did not list this as a limitation to the training paradigm, perhaps in part because they see this flexibility option as tailored to those who desire subspecialty training. If the flexibility option is widely implemented, careful consideration will have to be given to ensure that training of general surgeons is protected, as the public continues to need the care that general surgeons are uniquely qualified to deliver. Indeed, recent recertification data suggest that many subspecialists in practice continue to have a case mix typical of general surgeons,12 suggesting that the training of those who intend to practice in subspecialty areas must include broad-based general surgery principles and case volumes. Additionally, we see a potential attribute to the flexibility option being that residents experience the “flexible track” option later in their training, when decisions regarding career path are largely set. Attrition from a selected specialty focus is less likely among more senior residents; yet, if it does occur for an individual in these tracks, that trainee is still well prepared for general surgery
e156
practice, as all requirements for board certification must be met, including case minimums and distribution, as for all residency graduates. Limitations to the current study include the limited number and variety of residency programs that are participating in this prospective study. Most of the participating programs are university based, are academically oriented, and have an average of 46 residents per year. Additionally, each PD who participated is part of the research consortium and likely brings some favorable feelings regarding the flexible option to the survey. Thus, the experiences are not generalizable to all training programs. However, implementation of the flexibility option is likely to be easier at larger, university-based programs, as they tend to have greater numbers of fellowships, and scheduling may be easier, as rotations for senior residents can be interchanged with those that fellows in the subspecialty of interest occupy. Additionally, the present study surveys resident and PD perceptions on a number of issues; the current study lacks objective data on trainee performance, case numbers, or judgment. The consortium of programs is prospectively collecting case logs and performance on standardized examinations and intends to provide these data in the future to inform the discussion on the use of the flexibility option. Expansion of the flexibility option to a wider variety of programs, with assessment of outcomes, would be helpful to inform the debate on residency redesign in the future. A further limitation is that the survey period (April 2014) was at a time when participants had only 10 months of experience with the flexibility option. Although likely adequate to allow respondents time to formulate opinions regarding the flexibility option, it is possible that with additional time and experience with flexible training, opinions may change. A limitation to this survey is that it represents a single assessment of attitudes. Future work could determine whether, in fact, these attitudes do change with time. In summary, the present study indicates that in the programs represented in this study, implementation of the flexibility option has been a positive experience for participants, overall, with increased clinical experiences, mentorship, and autonomy as major gains. Scheduling difficulties and the position of general surgery as a training end point remain as major challenges to widespread adoption. Outcomes of graduates in these tracks, and their control peers, are being prospectively evaluated.
REFERENCES 1. Lewis FR, Klingensmith ME. Issues in general surgery
training—2012. Ann Surg. 2012;256(4):553-557.
Journal of Surgical Education Volume 72/Number 6 November/December 2015
2. American Board of Surgery website, Available at:
〈http://www.absurgery.org/default.jsp?policyflexrota tions〉 Accessed 04.04.15.
trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013;258(10): 440-449.
3. Klingensmith ME, Valentine RJ. Early experience with
8. Lynge DC, Larson EH, Thompson MJ, Rosenblatt RA,
alternative training pathways: a view from the trenches. J Surg Educ. 2009;66(2):80-84.
Hart LG. A longitudinal analysis of the General Surgery Workforce in the United States, 1981-2005. Arch Surg. 2008;143(7):345-350.
4. 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: 907-914.
9. Fraher EP, Knapton A, Sheldon GF, Meyer A,
5. Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV.
10. Polk HC Jr, Bland KI, Ellison EC, et al. A proposal for
Early subspecialization and perceived competence in surgical training: are residents ready? J Am Coll Surg. 2013;216(4):764-773.
enhancing the general surgical workforce and access to surgical care. Ann Surg. 2012;255(12):611-617.
6. 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(8):1063-1072. 7. Mattar
SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares
Ricketts TC. Projecting surgeon supply using a dynamic model. Ann Surg. 2013;257(12):867-872.
11. Richardson JD. General surgeon shortage in the
United States: fact or fiction, causes and consequences. Soc Work Public Health. 2011;26(4):513-523.
12. Valentine RJ, Jones A, Biester TW, Cogbill TH,
Borman KR, Rhodes RS. General surgery workloads and practice patterns in the United States, 2007 to 2009: a 10 year update from the American Board of Surgery. Ann Surg. 2011;254(10):520-525.
Journal of Surgical Education Volume 72/Number 6 November/December 2015
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Early Results from the Flexibility in Surgical Training Research Consortium: Resident and Program Director Attitudes Toward Flexible Rotations in Senior Residency Mary E. Klingensmith, MD,* Michael Awad, MD, PhD,* Keith A. Delman, MD,† Karen Deveney, MD,‡ Thomas J. Fahey III, MD,§ Jason S. Lees, MD,║ Pamela Lipsett, MD,¶ John T. Mullen, MD,** Douglas S. Smink, MD, MPH,†† and Jeffrey Wayne, MD‡‡ Department of Surgery, Washington University, St Louis, Missouri; †Department of Surgery, Emory University, Atlanta, Georgia; ‡Department of Surgery, Oregon Health and Science University, Portland, Oregon; § Department of Surgery, New York Presbyterian-Weill Cornell Medical Center, New York, New York; ║ Department of Surgery, University of Oklahoma, Oklahoma City, Oklahoma; ¶Department of Surgery, Johns Hopkins University, Baltimore, Maryland; **Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; ††Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts; and ‡‡ Department of Surgery, Northwestern University, Chicago, Illinois *
OBJECTIVE: To assess the attitudes of residents and
program directors (PDs) involved in flexible training to gauge satisfaction with this training paradigm and elicit limitations.
DESIGN: Anonymous surveys were sent to residents and
PDs in participant programs. Respondents were asked to rate responses on a 5-point Likert scale (1 ¼ strongly disagree and 5 ¼ strongly agree). SETTING: A total of 9 residency programs that are
collaborating to prospectively study the effect of flexible tracks on resident performance and outcome.
PARTICIPANTS: A total of 138 residents who were in
clinical years 4 and 5 and 10 PDs. RESULTS: Of the 138 possible residents, 100 responded to the resident survey (72.5% response rate). Among resident respondents, 33% were participating in a flexible track option. The most frequently listed specialties of focus were cardiothoracic surgery (19%), vascular surgery (13%), acute care surgery (11%), colorectal surgery (8%), surgical oncology (7%), and pediatric surgery (7%). Participants in flexible tracks tended to strongly agree that their career would be enhanced by flexible rotations; interestingly, of those not in
Correspondence: Inquiries to Mary E. Klingensmith, MD, Department of Surgery, Washington University in Saint Louis, 660 South Euclid, Campus Box 8109, Saint Louis, MO 631130; fax: (314) 362-8790; E-mail: [email protected], [email protected]
flexible tracks, most tended to also agree that flexible rotations would enhance their future careers. Flexible track participants report receiving greater autonomy on flexible rotations and believe they would be better prepared for fellowship and career. They express overall very high satisfaction with the flexible experience. Limitations expressed by residents (in flexible tracks or not) include uncertainty for how this paradigm serves those interested in comprehensive general surgery, concern about scheduling difficulties, and some displeasure in missing high-volume general surgery rotations in lieu of specialty-focused rotations. The PD survey was completed by 8 of 9 PDs for a response rate of 89%. All the respondents agreed or strongly agreed that careers of residents are enhanced by flexible rotations and that important operative and clinical experiences are gained. Overall, 87.5% of PD respondents agreed or strongly agreed that those in flexible tracks have greater opportunities for mentorship in their chosen field. PDs also expressed high levels of satisfaction with flexible rotations. Limitations include concerns that the flexibility option presents scheduling difficulties and does not go far enough in reforming postgraduate education. CONCLUSIONS: This survey of 9 residency programs
participating in flexible tracks indicates satisfaction with this training option. The role of comprehensive general surgery as a training end point and scheduling difficulties remain as major challenges. Outcomes of graduates in these tracks and control peers are being prospectively evaluated. ( J Surg 72:
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 e151 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.05.007
C 2015 Association of Program Directors in e151-e157. J Surgery. Published by Elsevier Inc. All rights reserved.)
KEY WORDS: graduate medical education, surgery resi-
dency training, general surgery, subspecialty surgery training, autonomy, postgraduate education COMPETENCIES: Patient Care, Medical Knowledge, Prac-
tice-Based Learning and Improvement, Systems-Based Practice
INTRODUCTION The training of surgical residents in the United States is evolving, as more and more trainees are electing to pursue fellowship training with a de facto increase in the length of training. This shift has occurred concurrent to other forces that have affected the training environment.1 Some of these include the reduction in duty hours; the increasing subspecialization of surgery as a whole and consequent fragmentation of training experiences; the increased requirements for supervision of trainees, resulting in less opportunity for trainee independence at more senior levels; and changes in technology that have affected the nature of what surgeons do. Despite these changes, the paradigm for surgical training has not evolved. A recent modification in training requirements by the American Board of Surgery (ABS) and Residency Review Committee (RRC) in Surgery presents a needed opportunity for change: in 2011, the ABS began allowing programs to have flexibility in training in the postgraduate year 3 to postgraduate year 5 years, with as many as 12 of the 36 months of senior residency spent in training in a single content area.2 This flexibility rule makes earlier specialty training possible in numerous specialty areas, with trainees able to track to their area of subspecialty interest sooner than traditional fellowship training would allow. The option is available to all interested residency training programs and is exercised by advance request to the ABS for permission to enroll a given resident in a flexible track. Details for obtaining the permission for this voluntary program can be found on the ABS website.2 For the purposes of the present study, the application of this flexibility rule is termed “FIST” (Flexibility in Surgical Training). This modification to training requirements built upon the early successes of a pilot project in 2 specialties: vascular and cardiothoracic (CT) surgery. The Early Specialization Project in these specialties has been summarized elsewhere.3 Although currently relatively few programs participate in Early Specialization Project (vascular 6 and thoracic 10), they have been successful in achieving their stated goals of allowing trainees to get to their area of specialty training sooner, with an additional 12 months of training in the area of interest. As of this writing, board passage rates in both surgery and the accompanying subspecialty (vascular or CT) have been quite good (personal communication). Thus, the expansion of the flexibility rule to e152
all areas that require general surgery certification as prerequisite was based on the success of the vascular and CT pilots. To date, the flexibility rule has been used in a limited fashion in training programs, and in those that have used it, there has been tremendous variability in how rotations have been selected for trainees who are preparing themselves for a variety of subspecialties. There has been no substantial administrative guidance provided to help residency programs understand how to best use this rule to the benefit of trainees. To address this issue, a FIST consortium formed in August 2012 of 9 residency programs around the country that agreed to work together to collaborate on1 standardizing the curricula in the “flexible” training tracks, and2 prospectively analyzing data from the trainees in these tracks to work toward optimal trainee outcome, as future residency redesign may be informed by this data. This proposal was endorsed by the surgery RRC in November 2012. To develop a standardized curriculum, the consortium representatives consulted the specialty-specific guidelines on the ABS “flexible rotations” web page and worked collaboratively with representatives from the pediatric surgery and trauma/burn/critical care subboards of the ABS, as well as the Transplant Advisory and Advanced Surgical Education councils of the ABS, to develop more robust recommendations for rotations in specific content areas. These were reviewed by consortium members and used by the program director (PDs) at consortium sites to develop rotation schedules for trainees desiring flexible training in a given area. Consortium sites began flexible training opportunities that are the focus of this study, beginning with the academic year that started on July 1, 2013. The current study was designed to assess the attitudes of residents and PDs involved in flexible training at sites included in our multi-institutional study, to gauge satisfaction with this training paradigm and elicit limitations.
MATERIALS AND METHODS All participant programs followed the ABS guidelines set forth to obtain permission for application of the flexibility rule for each trainee enrolled. Institutional review board approval was obtained at each study site to allow for prospective evaluation of this training paradigm. By design, the study includes flexible options confined to the clinical R4 and clinical R5 years, as the participating programs decided as a group to limit application of the flexibility rule primarily to these 2 years of training. The participating programs include Washington University, Emory, Brigham and Women’s Hospital, Massachusetts General Hospital, Johns Hopkins, Northwestern, University of Oklahoma, Oregon Health and Science University, and New York Presbyterian-Cornell. As per the RRC guidelines, rotational assignments were in compliance with rules regarding the prohibition of fellows and chief residents sharing responsibility for patients, or working directly together. These measures were taken to both
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FIGURE 1. Distribution of intended subspecialty focus for all resident respondents. Note: Gen Surg, General Surgery; CT, Cardiothoracic Surgery; Peds, Pediatric Surgery; Vasc, Vascular Surgery; Endo, Endocrine Surgery; MIS, Minimally Invasive Surgery; CRS, Colorectal Surgery; TxP, Transplantation Surgery; ACS, Acute Care Surgery; Plas, Plastic Surgery; HPB, Hepatobiliary Surgery; Brst, Breast Surgery; Onc, Surgical Oncology.
comply with the RRC guidelines and preserve the independent and semiautonomous experiences that are hallmarks to the resident experiences in the participant programs. All residents in the 9 participating programs in the clinical R4 and clinical R5 years were surveyed during the month of April 2014. Similarly, the 9 PDs were surveyed during a similar time frame (April 2014). Surveys were developed by the advisory group for the prospective multiinstitutional study and delivered via e-mail using an anonymous online polling system (SurveyMonkey, Palo Alto, CA). Reminder e-mails were sent on 2 separate occasions to all participants over a 1-month period. Institutional review board approval was obtained at each participant site in the FIST consortium. Results for all respondents were analyzed, and where comparisons between FIST track and non–FIST
track participants were relevant, tests of significance were made using the Student t test.
RESULTS Resident Survey Demographics Of 138 possible residents, 100 responded to the resident survey (72.5% response rate). The average age of respondents was 33 years (range: 29-46); 33% were women. Among resident respondents, 54% were in clinical R4 level and 46% were in clinical R5 level. Overall, 33% of respondents were participating in a flexible track option.
FIGURE 2. Distribution of intended subspecialty focus for those residents in flexible tracks. Note: Gen Surg, General Surgery; CT, Cardiothoracic Surgery; Peds, Pediatric Surgery; Vasc, Vascular Surgery; Endo, Endocrine Surgery; MIS, Minimally Invasive Surgery; CRS, Colorectal Surgery; TxP, Transplantation Surgery; ACS, Acute Care Surgery; Plas, Plastic Surgery; HPB, Hepatobiliary Surgery; Brst, Breast Surgery; Onc, Surgical Oncology. Journal of Surgical Education Volume 72/Number 6 November/December 2015
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TABLE 1. Comparison of Mean Rating (⫾ Standard Deviation) on a 5-Point Likert Scale Between FIST and Non-FIST Respondents Those in FIST Track
Query Flexible tracks are not worth the scheduling headaches My career would be enhanced by having had a flexible option Flexible tracks have improved residency training in the United States I would be able to provide better care for patients because of flexible track participation FIST programs may work well for participants but disrupt the training of those who do not participate
Among all resident respondents, the most frequently listed intended specialties of focus were CT surgery (19%), general surgery (18%), vascular surgery (13%), acute care surgery (11%), colorectal surgery (8%), surgical oncology (7%), and pediatric surgery (7%), as shown in Figure 1. However, for those in flexible tracks, the distributions of intended specialties were shifted significantly toward CT surgery (33%), with plastic surgery (12%); colorectal surgery and breast surgery (9%); and pediatric surgery, general surgery, oncology, and minimally invasive surgery (each 6%) accounting for the remainder (Fig. 2). Attitudes Toward Flexible Track Options All respondents were asked their opinions on several aspects of the flexible track option. A number of attitudinal statements regarding the FIST option were presented, and respondents were asked to respond on a 5-point Likert scale (1 ¼ strongly agree, 3 ¼ neutral, and 5 ¼ strongly disagree). Responses were analyzed to determine if differences in opinions existed between the 2 groups. For each statement, mean response (⫾ standard deviation) was calculated. Comparisons of responses
4.19 1.72 2.19 2.03
⫾ ⫾ ⫾ ⫾
1.03 0.98 1.01 1.03
3.28 ⫾ 1.10
Those Not in FIST Track
p Value
⫾ ⫾ ⫾ ⫾
1.18 1.18 0.95 1.09
0.08 0.04 0.16 0.07
2.53 ⫾ 1.08
0.25
3.94 2.41 2.65 2.68
between the 2 groups (those in FIST tracks vs those not) are summarized in Table 1. As is shown, those in FIST tracks tended to strongly agree that their careers would be enhanced by participation in these tracks, more so than did participants who were not in the tracks. Additionally, most respondents endorsed a feeling that the scheduling challenges of FIST were “worth it,” but they were neutral as to whether the flexibility option has improved residency training in the United States. FIST participants tended to believe that the flexibility option would allow them to provide better care for patients because of participating; this response was not significantly different from non-FIST participants. Lastly, non-FIST participants tended to agree more strongly with the statement that “FIST programs may work well for participants but disrupt the training of those who do not participate,” but the differences in responses between the groups did not reach statistical significance. Attitudes of FIST Track Participants Flexible track participants were asked a number of questions regarding their overall impressions of the FIST experience.
TABLE 2. Summary of Attitudinal Responses of FIST Participants % Agree/ % Strongly Agree Neutral I have missed out on operative experiences because of participating in a flexible track I have had operative experiences I would not otherwise have gotten because of my flexible track I have had clinical experiences I would not otherwise have gotten because of my flexible track I have missed out on clinical experiences because of participating in a flexible track I would be better prepared for my fellowship because of participating in a flexible track I have had or would have greater mentorship in my subspecialty because of my flexible track I have had or would have greater mastery of my subspecialty because of my flexible track I have had or would have greater autonomy in training in my subspecialty because of my specialty track Flexible training would make me better prepared for board certification examinations Overall, I am pleased with my experiences to date with flexible training
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% Disagree/ Strongly Disagree
24.9
3.2
7.19
81.3
0
18.7
81.3
6.3
12.4
18.8
9.3
71.9
90.6
6.3
3.1
84.4
6.3
9.3
90.6
0
9.4
71.9
18.8
9.3
25
56.3
18.7
84.4
12.5
3.1
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TABLE 3. Summary of Program Director Attitudinal Responses % Agree/ % Strongly Agree Neutral Flexible tracks are not worth the scheduling headaches Flexible tracks have improved residency training in the United States My residents would be more competitive for a fellowship if they participate in FIST My graduates would be able to provide better care for patients because of FIST participation My residents would receive greater mentorship in their subspecialty because of flexible track experiences My residents would achieve greater mastery in their subspecialty because of flexible track experiences My residents would achieve greater autonomy in their subspecialty because of flexible track experiences Overall, I am pleased with my programs' experiences to date with flexible training
Their responses are summarized in Table 2. Most of the respondents in the FIST tracks report gaining operative and clinical experiences because of flexible track participation, a feeling of greater preparedness for fellowship, greater mentorship and autonomy in their subspecialty area of focus, and an overall sense of satisfaction with the flexible track option. Comments Regarding Advantages and Limitations to Flexible Track Options All respondents were asked to comment on the questions “what do you like about the flexible track” and “what don’t you like about the flexible track.” Reported advantages to flexible track options included exposure to clinical experiences of greater interest, improved opportunities for mentorship, greater flexibility in designing senior-level rotations of interest, and tailoring training specifically to an individual’s career goals. Limitations expressed included uncertainty for how this paradigm serves those interested in careers in general surgery, concern about scheduling difficulties, and some displeasure in missing high-volume general surgery rotations in lieu of specialty-focused rotations. Program Director Survey The PD survey was completed by 8 of 9 PDs for a response rate of 89%. All the respondents agreed or strongly agreed that careers of residents are enhanced by flexible rotations and that important operative and clinical experiences are gained. The summaries of other responses are detailed in Table 3. Comments Regarding Advantages and Limitations to Flexible Track Options All PD respondents were asked to comment on the questions “what do you like about the flexible track option for your trainees?” and “what don’t you like about the
% Disagree/ Strongly Disagree
0 50 37.5
37.5 50 50
62.5 0 12.5
50
37.5
12.5
87.5
12.5
0
62.5
37.5
0
75
12.5
12.5
75
12.5
12.5
flexible track option for your trainees.” Reported advantages included earlier transition to a trainee’s intended specialty focus, an ability to focus educational opportunities on those who might most benefit, and potential for increased autonomy for trainees as relationships with mentors mature. Limitations included concerns that the current rules do not go far enough in allowing focused training and scheduling concerns, including accommodating multiple trainees interested in a given field, making certain that parity of “good” rotations exists between residents who are participating and not participating in flexible tracks and avoiding the appearances of FIST residents as “favored” in obtaining special or unique clinical experiences.
CONCLUSIONS This survey of 9 residency programs participating in flexible tracks indicates satisfaction with this training option by both resident trainees and PDs. Our response rate of 72.5% among resident respondents is quite favorable for a voluntary survey, and we think that this adds validity to our findings. Residents participating in FIST tracks, as well as their PDs, believe that the flexible option enhances residents’ careers, allows for increased operative and clinical experiences, as well as increased mentorship and autonomy in the subspecialty area of interest. Although scheduling challenges are reported, most respondents indicate that those challenges are worthwhile. However, disruption to the experiences of those not participating in flexible training is a real concern, as is a loss of focus for those trainees who may desire a career in general surgery, as most of the FIST track experiences reported in this study are focused on subspecialty areas. The importance of preserving a robust experience for those NOT in flexible tracks is given emphasis by these survey results. PDs who responded to our survey note this as a challenge, and with this shared
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knowledge, providing emphasis on this in programs participating in flexible tracks is critical to ensure a rigorous and meaningful educational experience for all residents, regardless of track participation. Several recent studies have suggested that graduates of residency programs are ill prepared for future practice, whether fellowship or independent practice.4,5 This concern has been shared by fellowship directors and fellows of the American College of Surgeons.6,7 Data from the present study indicate that FIST programs may provide some antidote to these challenges, as increased autonomy and increased mentorship in the specialty area of focus is reported among FIST participants, as well as an expected increase in clinical and operative experiences. Whether these ultimately may translate into increased confidence and skill remains to be determined. However, it would seem that these attributes may indeed have such an effect. A limitation to the FIST project, as implemented in the programs participating in this study, is that general surgery is underrepresented among the specialty areas of focus among flexible track participants: only 6% of respondents indicate this as an area of intended career focus, whereas this is the intended specialty for 18% of all residents who responded to this survey. As more trainees pursue fellowship training, there are fewer graduates to fill the growing deficit of general surgeons needed to serve the public. This trend has resulted in fewer general surgeons in practice today, with a 25% decline seen over the past 2 decades8 and projected 18% decline over the coming 2 decades.9 Rural areas seem to be particularly affected. As the trend toward specialty training continues, worsening of the workforce shortage is predicted, which has raised alarm among many thought leaders in surgery.10,11 As was indicated by resident respondents in this survey, it is unclear how general surgery fits into this training paradigm; interestingly, the PDs who completed this survey did not list this as a limitation to the training paradigm, perhaps in part because they see this flexibility option as tailored to those who desire subspecialty training. If the flexibility option is widely implemented, careful consideration will have to be given to ensure that training of general surgeons is protected, as the public continues to need the care that general surgeons are uniquely qualified to deliver. Indeed, recent recertification data suggest that many subspecialists in practice continue to have a case mix typical of general surgeons,12 suggesting that the training of those who intend to practice in subspecialty areas must include broad-based general surgery principles and case volumes. Additionally, we see a potential attribute to the flexibility option being that residents experience the “flexible track” option later in their training, when decisions regarding career path are largely set. Attrition from a selected specialty focus is less likely among more senior residents; yet, if it does occur for an individual in these tracks, that trainee is still well prepared for general surgery
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practice, as all requirements for board certification must be met, including case minimums and distribution, as for all residency graduates. Limitations to the current study include the limited number and variety of residency programs that are participating in this prospective study. Most of the participating programs are university based, are academically oriented, and have an average of 46 residents per year. Additionally, each PD who participated is part of the research consortium and likely brings some favorable feelings regarding the flexible option to the survey. Thus, the experiences are not generalizable to all training programs. However, implementation of the flexibility option is likely to be easier at larger, university-based programs, as they tend to have greater numbers of fellowships, and scheduling may be easier, as rotations for senior residents can be interchanged with those that fellows in the subspecialty of interest occupy. Additionally, the present study surveys resident and PD perceptions on a number of issues; the current study lacks objective data on trainee performance, case numbers, or judgment. The consortium of programs is prospectively collecting case logs and performance on standardized examinations and intends to provide these data in the future to inform the discussion on the use of the flexibility option. Expansion of the flexibility option to a wider variety of programs, with assessment of outcomes, would be helpful to inform the debate on residency redesign in the future. A further limitation is that the survey period (April 2014) was at a time when participants had only 10 months of experience with the flexibility option. Although likely adequate to allow respondents time to formulate opinions regarding the flexibility option, it is possible that with additional time and experience with flexible training, opinions may change. A limitation to this survey is that it represents a single assessment of attitudes. Future work could determine whether, in fact, these attitudes do change with time. In summary, the present study indicates that in the programs represented in this study, implementation of the flexibility option has been a positive experience for participants, overall, with increased clinical experiences, mentorship, and autonomy as major gains. Scheduling difficulties and the position of general surgery as a training end point remain as major challenges to widespread adoption. Outcomes of graduates in these tracks, and their control peers, are being prospectively evaluated.
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