Perceptions of Graduating General Surgery Chief Residents: Are They Confident in Their Training? Mark L Friedell, MD, FACS, Thomas J VanderMeer, MD, FACS, Michael L Cheatham, MD, FACS, George M Fuhrman, MD, FACS, Paul J Schenarts, MD, FACS, John D Mellinger, MD, FACS, Jon B Morris, MD, FACS Debate exists within the surgical education community about whether 5 years is sufficient time to train a general surgeon, whether graduating chief residents are confident in their skills, why residents choose to do fellowships, and the scope of general surgery practice today. STUDY DESIGN: In May 2013, a 16-question online survey was sent to every general surgery program director in the United States for dissemination to each graduating chief resident (CR). RESULTS: Of the 297 surveys returned, 76% of CRs trained at university programs, 81% trained at 5-year programs, and 28% were going directly into general surgery practice. The 77% of CRs who had done >950 cases were significantly more comfortable than those who had done less (p < 0.0001). Only a few CRs were uncomfortable performing a laparoscopic colectomy (7%) or a colonoscopy (6%), and 80% were comfortable being on call at a Level I trauma center. Compared with other procedures, CRs were most uncomfortable with open common bile duct explorations (27%), pancreaticoduodenectomies (38%), hepatic lobectomies (48%), and esophagectomies (60%) (p < 0.00001). Of those going into fellowships, 67% said they truly had an interest in that specialty and only 7% said it was because they were not confident in their surgical skills. CONCLUSIONS: Current graduates of general surgery residencies appear to be confident in their skills, including care of the trauma patient. Fellowships are being chosen primarily because of an interest in the subspecialty. General surgery residency no longer provides adequate training in esophageal or hepatopancreatobiliary surgery. (J Am Coll Surg 2014;218:695e706. 2014 by the American College of Surgeons)
BACKGROUND:
skills.3 Numerous surveys have sought to determine the competence and confidence of general surgery residents. All of these have addressed major concerns about the state of general surgery training in the United States.4-6 The only 2 studies that directly surveyed categorical general surgery residents were not specific to CRs and they did not ask about the performance of specific operations.3,7 Our survey is the first to look at graduating CRs exclusively and ask them about their overall confidence in their operative skills and patient management, the management of specific cases, and their reasons for either extending their training into fellowship or entering directly into practice. Our hypothesis, based on personal observation as program directors (PDs), was that most CRs are satisfied with their training and confident about their skills. The current status of surgical education and the scope of practice of today’s general surgeon are also interwoven into this study. A Blue Ribbon Committee Report on Surgical Education published in 2005 recommended that general surgery residency become 3 years of core training followed by 3 more years of subspecialty or additional general
During the past decade, there has been considerable debate about the confidence of the graduating general surgery chief resident (CR). The proportion of residents pursuing fellowship training has increased from 55% to upwards of 80% since 1992.1,2 Some have interpreted this as showing that graduates are concerned about their
Disclosure Information: Nothing to disclose. Presented at the Southern Surgical Association 125th Annual Meeting, Hot Springs, VA, December 2013. Received December 16, 2013; Accepted December 17, 2013. From the Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, MO (Friedell), Guthrie Clinic, Sayre, PA (VanderMeer), the Department of Surgery, Orlando Regional Medical Center, Orlando, FL (Cheatham), the Department of Surgery, Ochsner Clinic, New Orleans, LA (Fuhrman), the Department of Surgery, University of Nebraska School of Medicine, Omaha, NE (Schenarts), the Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL (Mellinger), and the Department of Surgery, University of Pennsylvania, Philadelphia, PA (Morris). Correspondence address: Mark L Friedell, MD, FACS, Department of Surgery, University of Missouri-Kansas City, 2301 Holmes St, Kansas City, MO 64108. email: [email protected]
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
695
ISSN 1072-7515/13/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2013.12.022
696
Friedell et al
Survey of Chief Resident Confidence
J Am Coll Surg
surgery training.8 This stimulated a national discussion, still ongoing, about the optimal structure of the residency. To date, the 5-year paradigm has been continued, with no basic changes. But with the increasing tendency toward subspecialization, it appears that general surgery is becoming progressively less broad based.
4 ¼ very comfortable) to facilitate statistical analysis. Mean “confidence scores” were calculated for each procedure. A mean summary confidence score for the 12 procedures was calculated for each CR. Overall confidence among procedures was analyzed using chi-square analysis with the Bonferroni correction (p < 0.0008) for multiple comparisons (n ¼ 66). Multivariate stepwise logistic regression analyses, performed using Minitab software (version 16.2.3, Minitab Inc.), were performed evaluating the summary confidence score as the dependent variable and demographic and program-related variables as the independent variables to identify predictors of procedural confidence. Analysis of variance was used to identify differences in procedural confidence by case volume. Statistical significance was defined as p < 0.05.
METHODS In May 2013, a 16-question survey created at www. surveymonkey.com was sent by email to every general surgery residency PD in the United States, to be forwarded to each of their CRs. During the next 45 days, the survey was resent twice to the PDs. The questions included items pertaining to demographics, the nature of the residency program, the number of major cases completed by graduation, fellowships, trauma experience, and comfort with independently performing 12 specific operations chosen from the Surgical Council on Resident Education curriculum under the auspices of the American Board of Surgery (ABS). The following cases were classified as “essential-common”: laparoscopic colectomy, colonoscopy with polypectomy, thyroidectomy, and modified radical mastectomy. The following cases were “essential-uncommon”: open common bile duct exploration (OCBDE), gastrectomy, distal pancreatectomy and sentinel lymph node biopsy. The following cases were “complex”: right hepatic lobectomy, pancreaticoduodenectomy, esophagectomy, and low anterior resection. The responses offered for this question were: “very comfortable,” “comfortable,” “somewhat comfortable,” and “uncomfortable.” There was also an open-ended question asking if there were any aspects of general surgery that the CR was ill-prepared to deal with independently (Table 1). The study was reviewed by the University of Missouri Kansas City School of Medicine IRB. It was approved and deemed exempt from a requirement for informed consent. Descriptive statistics were used to assess the survey responses and are reported as percentages. Statistical differences by demographic variables were analyzed using chi-square analysis. The 4 procedural confidence levels were assigned numerical scores (1 ¼ uncomfortable, 2 ¼ somewhat uncomfortable, 3 ¼ comfortable, and
RESULTS There were 297 survey respondents. Because there were 1,097 graduates from general surgery residency programs in 2013, based on data from the American College of Surgeons (ACS) and the ACGME, this gave a 27% response rate. Sixty-seven percent of respondents were male and 81% graduated from 5-year programs. Seventy-six percent of respondents were completing their training in a university medical center, 22% at an independent medical center, and 2% in a military residency program. Sixteen percent of the respondents had 2 to 3 CRs in their programs, 52% had 4 to 6, and 32% had >6. In response to the question “How many major cases will you have completed by graduation?” Forty percent responded between 951 and 1,150 and 36% responded >1,150 (Table 2). The number of major cases did not differ significantly between independent and academic medical centers, but there was a significant variance by region of the country (p ¼ 0.037) with CRs in the South and Northeast performing more cases and CRs in the West and Midwest performing fewer cases overall. Only a few CRs were uncomfortable performing the 4 operations described as essential-common: laparoscopic colectomy (7%), colonoscopy with polypectomy (6%), thyroidectomy (3%), and modified radical mastectomy (2%). Among the essential-uncommon operations, 27% were uncomfortable performing OCBDE, but only 11%, 14%, and 5% were uncomfortable completing gastrectomy, distal pancreatectomy, and SLNB, respectively. Finally, of the 4 operations listed as “complex,” the uncomfortable responses were esophagectomy (60%), right hepatic lobectomy (48%), pancreaticoduodenectomy (38%), and low anterior resection (7%) (Fig. 1). Of note, 80% of the respondents were comfortable being on-call at a Level 1 trauma center and, when asked how
Abbreviations and Acronyms
ABS ACS CR OCBDE PD RRC TTP
¼ ¼ ¼ ¼ ¼ ¼ ¼
American Board of Surgery American College of Surgeons chief resident open common bile duct exploration program director Residency Review Committee transition to practice
Vol. 218, No. 4, April 2014
Table 1.
Survey Questions
Survey question
1. What is your sex? 2. How many chief residents are in your program? d 23 d 46 d More than 6 3. What type is your residency? d University medical center d Independent medical center d Military medical center 4. In what region of the country is your residency? d West d Midwest d South d Northeast 5. How many major cases will you have completed by graduation? d 750850 d 851950 d 9511150 d More than 1150 6. How many years of training is your residency? d 5 years d 6 years d 7 years d More than 7 years 7. How did you receive your trauma experience during residency? d Level I at my institution d Level II at my institution d Level III at my institution d Away rotation at Level I d Away rotation at Level II 8. After graduation, are you going directly into general surgery practice? 9. Because you are not doing a fellowship, how influential were the following factors in making your decision? (check all that apply) d Too much timedI have already invested a lot of time in my surgical training d I am confident in my surgical skills d Financially, it is more beneficial for me to enter practice directly after residency d Overall, I see no added benefit or value to undergoing further training d I want a broad-based traditional general surgery practice d Other (please specify) 10. If you will be entering a fellowship, which of the following will you be entering? d Pediatric surgery d Minimally invasive/bariatric d Plastic surgery d Cardiothoracic surgery d Thoracic surgery d Transplantation surgery d Hepatobiliary surgery d Hand surgery d Breast surgery d Surgical oncology (Continued)
Friedell et al
Survey of Chief Resident Confidence
697
Table 1. Continued Survey question
Colorectal surgery Trauma surgery d Surgical critical care d Acute care surgery d Unsure d Other Why are you pursing the fellowship? d It makes me more marketable d I truly have an interest in that aspect of surgery d It increases my earning potential d I do not feel confident in my surgical skills d It will aid in establishing my academic career d Better lifestyle If you graduated from a 5-year program and are going directly into general surgery practice, would you have decided on a career in general surgery if it were a 6-year or more training program? If you are going directly into general surgery practice, would you do an extra “Transition to Practice” fellowship to better prepare yourself for practice if it were available? What is your confidence level to independently perform the following? d Laparoscopic colectomy d Colonoscopy with biopsy/polypectomy d Thyroidectomy d Modified radical mastectomy d Open common duct exploration d Gastrectomy d Distal pancreatectomy d SLNB for melanoma d Right hepatic lobectomy d Whipple d Esophagectomy d Low anterior resection Would you be comfortable being on call at a Level I trauma center at the conclusion of your chief residency? Are there any aspects of general surgery that you believe you are ill prepared to deal with independently? d d
11.
12.
13. 14.
15. 16.
they received their trauma experience during residency, a presumably corresponding 84% stated, “At the Level I center at my institution.” Chief residents’ confidence in performing OCBDE, pancreaticoduodenectomy, right hepatic lobectomy, and esophagectomy was significantly lower than for the other 8 operative procedures (p < 0.00001). Stepwise multiple regression analysis was performed to identify which demographic factors (ie, sex, region, years of training, type of training program, and number of major cases) were significantly associated with procedural confidence. Number of cases (p ¼ 0.002), region (p ¼ 0.037), and male sex (p ¼ 0.047) were significantly associated with procedural confidence, and type of training program (p ¼ 0.056)dindependent vs academicdand years of training (p ¼ 0.149) were not.
698
Friedell et al
Survey of Chief Resident Confidence
Table 2. Characteristics of Chief Residents and Programs Demographics
Sex Male Female Chief residents in program 23 46 >6 Region West Midwest South Northeast Type of residency program University medical center Independent medical center Military medical center Major cases completed 750850 851950 9511150 >1,150 Years of training 5 6 7 >7
n
%
198 99
67 33
48 153 96
16 52 32
35 93 95 74
12 31 32 25
225 65 7
76 22 2
25 44 120 108
9 15 40 36
242 22 31 2
82 7 10 1
In evaluating the significant difference in procedural confidence by region, CRs in the South and Northeast were more likely to perform >950 major cases than their counterparts in the West and Midwest (p ¼ 0.037). In evaluating procedural confidence by sex, male CRs were significantly more likely to have performed a greater number of major cases than their female counterparts, especially in the 950 to 1,150 case level (p ¼ 0.01). Lower case numbers might explain the diminished confidence of women both in this survey and in Buckholz and colleagues’ data.9 Overall level of confidence among those CRs who had done >950 cases was statistically higher than those who had performed fewer cases (p < 0.0001). For the essential common operations, performing at least 850 major cases appeared to correlate with a comfortable level of procedural confidence. At least 950 cases were necessary to have significantly more confidence with laparoscopic colectomy and >1,150 cases were needed to achieve significant confidence with colonoscopy/biopsy, and modified radical mastectomy (Fig. 2). For the essential uncommon operations, at least 950 major cases were
J Am Coll Surg
sufficient to achieve a comfortable level of confidence for SLNB, but >1,150 major cases were necessary to achieve such a confidence level for OCBDE, gastrectomy, and distal pancreatectomy (Fig. 3). For complex operations, at least 950 major cases were sufficient to achieve a comfortable level of confidence for low anterior resection, but even with >1,150 major cases, there was never a substantial comfort level for right hepatic lobectomy, pancreaticoduonectomy, and esophagectomy (Fig. 4). When CRs were asked about their plans after general surgery residency, 28% responded that they were going directly into general surgery practice, with 72% going into fellowships. Statistically significant differences were noted between residents from independent medical centers, university medical centers, and military medical centers about the decision to do a fellowship (p < 0.0001). Assuming that the 7 military surgeons had limited ability to decide on their subsequent practice and so were excluded from the analysis, the remaining 2 groups (university and independent) were still significantly different (p ¼ 0.002) with respect to their decision to pursue fellowship training. This has been suggested previously.10 When asked why they decided not to do a fellowship, the 2 most common answers were “I am confident in my skills” (26%) and “I want a broad-based traditional practice” (28%). When those who graduated from a 5-year program were asked if they would have decided on a career in general surgery if it were 6 years or longer, 38% said that they would not have done so. Finally, for those CRs going directly into general surgery practice, only 25% said that they would be interested in the transition to practice (TTP) in general surgery fellowship being offered under the auspices of the ACS. As case volume increased, the interest in doing a transitional year decreased markedly. This finding was suggestive, although not statistically significant (p ¼ 0.07). Of the 14 fellowships offered in the survey, the top choices were minimally invasive/bariatric (16.5%), vascular surgery (13%), surgical oncology (10%), cardiothoracic surgery (9%), plastic surgery (9%), and surgical critical care (8%). When those pursuing a fellowship were asked why, 67% responded that they truly had an interest in that discipline and only 7% stated that they were not confident in their skills. For the open-ended question, “Are there any aspects of general surgery that you feel ill-prepared to deal with independently?” the most common answer was hepatopancreatobiliary surgery, followed by approximately equal numbers of responses stating esophageal, thoracic, gastric, advanced laparoscopic and vascular surgery, and business/ administration. These responses also gave insight into the
Vol. 218, No. 4, April 2014
Friedell et al
Survey of Chief Resident Confidence
699
Figure 1. Comfort level with various operations.
DISCUSSION During the past decade, the question, “are we training general surgery residents to become competent?” continues to be discussed, particularly after the restriction of duty hours in 2003. A Blue Ribbon Committee Report recommended lengthening general surgery training by 1 year, with 3 years of core training followed by 3 more years of subspecialty or additional general surgery training.8 But this goal of attempting to make one size fit all has never been accepted by the surgical education
community as a whole, and the 5-year program remains standard. At the same time, the practice of general surgery has changed. In 1986, Braasch described broad-based general surgeons as “the lost sheep” with other disciplines and subspecialists in surgery encroaching on them.11 Today the scope has narrowed even more. Vascular surgery is done almost exclusively by those trained in open and endovascular techniques.12 Hepatopancreatobiliary and esophageal cases have followed suit, particularly since it has been shown that higher volumes of these complex cases produce better outcomes.13-15 However, minimally invasive surgery and endoscopy have increased dramatically in general surgery practice. Currently, the procedures most frequently performed by general surgeons
Figure 2. Mean procedural confidence for “essentialcommon” operations.
Figure 3. Mean procedural confidence for “essentialuncommon” operations.
graduates’ beliefs about making the transition to attending surgeon and the scope of practice of general surgery (Table 3).
700
Friedell et al
Figure 4. Mean procedural confidence for “complex” operations.
are abdominal and alimentary tract in nature, with many of the endoscopic and minimally invasive surgery cases at the top of the list.16,17 A recent study of CR case logs during a 23-year period showed that thoracic, trauma, and vascular cases steadily declined, and alimentary and intra-abdominal cases increased from 47% of the CR experience to 65%dmuch of it due to laparoscopic surgery. In fact, the current mean CR experience for laparoscopic colectomy in the study was 9 cases.18 Both the ABS and the Residency Review Committee (RRC) for surgery recognized the importance of minimally invasive surgery and endoscopy in the practice of today’s general surgeon Table 3.
J Am Coll Surg
Survey of Chief Resident Confidence
and the RRC has increased the minimum requirements for these cases. Concerns about the competence of the graduating CR have been raised from several different stakeholders. A survey of general surgery PDs in 2006 asked which procedures their graduating general surgery residents should be confident to perform.4 Of the 121 procedures identified, only 18 of them were performed a mean of >10 times during residency, and 83 of them were performed a mean of 950 total major cases in residency being more comfortable. Confidence also increased as case volume increased. In this regard, it would be appropriate for the RRC to consider increasing the 750 total case and the complex laparoscopy case minimums as has been recommended by others.24,25 Because 70% to 80% of graduates of general surgery residency programs are now entering fellowship training, there is concern that the residents themselves lack confidence in their skills. Yeo and colleagues surveyed PGY1 through 5 categorical general surgery residents at the conclusion of the 2008 ABS In-Training Examination.7 Overall resident satisfaction with their training varied significantly across training years (p ¼ 0.001), with the lowest levels in PGY2 and PGY3. Views about the need to complete specialty training also differed across the years (p < 0.001), with the least concern among PGY5 residents. More recently, Coleman and colleagues distributed a survey to surgery residents via PDs at 55 preselected residency programs.3 When asked if a 5-year general surgery residency prepared them to practice general surgery, 38% of residents overall responded “no” or “unsure.” But the figures decreased with each increasing year of residency from PGY1 (53.3%) to PGY5 (23%), just as in Yeo and colleagues’ study. Coleman and colleagues also concluded that the majority of residents in their survey wanted a 6year, 3-3 structured residency, which does not correlate with the 38% of our respondents who would not have chosen to do general surgery if the residency was longer than 5 years. The problem with these 2 studies is that only the responses of the CRs really matter, case numbers were not examined, and questions about specific cases were not asked. In fact, the Coleman and colleagues’ study only included 108 CRs, compared with 297 in ours. An important finding in our survey is the fact that fellowships are being chosen primarily because of an interest in the field rather than lack of comfort with surgical skills and >97% of Coleman and colleagues’ respondents going into fellowship stated that they were truly interested in the subspecialty. The responses of the CRs to our survey appear to mirror the practice of most general surgeons today. Very few were uncomfortable with the essential common and the essential uncommon procedures, with the exception of the OCBDE. The majority were also comfortable working at a Level I trauma center, suggesting that the acute care surgery experience in most programs is very
702
Friedell et al
Survey of Chief Resident Confidence
good. However, the CRs were least comfortable with the following complex cases: pancreaticoduodenectomy, right hepatic lobectomy, and esophagectomy. This was echoed in the open-ended question as well (Table 3). In a small study of recent graduates from a large university program, approximately 50% believed that right hepatectomy, distal pancreatectomy, pancreaticoduodenectomy, and esophagectomy were irrelevant to their practice, that they were not competent to do them, or both.26 The CRs in this survey as well as the young surgeons in the ACS survey appear more positive and comfortable about the current status of general surgery training and practice than are many of the more senior members of the surgical community. Most of our respondents came from 5-year programs. This is consistent with the description of the modern general surgeon articulated by Stain: expert in the management of the alimentary tract (except liver, pancreas, and esophagus), abdomen, breast, endocrine, and acute care surgery; expert in minimally invasive surgery; and training accomplished in 5 years.25 This last point is very important at a time when we have an impending shortage of general surgeons because 38% of respondents in this survey stated that they would not have pursued general surgery if the training was longer than 5 years. Given the predicted (and current) shortage of general surgeons in the United States, particularly in rural areas,27,28 it is important to note, from this survey, that independent programs are producing proportionately more general surgeons than university programs. Chief residents from independent programs showed more confidence compared with university programs, although at a borderline significance level (p ¼ 0.056), and they did show a significant increase in confidence for the performance of OCBDE (p ¼ 0.04). Data from Sullivan and colleagues’ survey also showed a statistically significant difference in favor of community programs for satisfaction with operative experience and lack of worry about performing procedures independently.29 In this regard, the “Little Red Book” online at the ACS website provides a great deal of information on general surgery residencies to medical students deciding on a career in surgery, particularly those wanting to go directly into general surgery. Leaders in surgery might need to shift their educational paradigm to interest more students and residents in general surgery.28 The Louisville group commented several years ago: “we ask whether the general surgery residency that has a marked minority of its trainees choose to practice general surgery is indeed fulfilling its core calling adequately.”30 And, more recently, Cogbill noted: “Many surgical residencies define their success by the number of graduates who pursue postgraduate fellowships or join university departments of surgery. The practice of
J Am Coll Surg
general surgery in a rural hospital has its own unique set of formidable challenges and rich rewards. Our graduates who are willing to make this commitment are a source of equal pride.”31 The major limitations of this study are those of any survey. There are unknown differences between responders and nonresponders. The response rate was 27%, which could be due partially to the fact that the survey was not sent directly to the CRs but was distributed by PDs. Incorrect email addresses of PDs and CRs could have been a problem. Also, because the survey was selfassessment, was it accurate? However, it has been shown that self-assessment of technical skills by surgical residents can actually underestimate their abilities compared with the assessment of the faculty.32
CONCLUSIONS In general, the results of this survey support our hypothesis that graduating surgery residents have a sense of confidence and are optimistic about their future. Although at least 70% choose to enter fellowships, it is because of a genuine interest in the subspecialty rather than concern for their surgical skills. They seem to be confident with common essential operations, most of the uncommon essential operations, and with care of the trauma patient. Case volume is an important determiner of confidence, with >950 cases in training being important. The ABS has recommended changes that should increase operating room exposure and case numbers in the junior years and allow senior residents more flexibility to prepare for their careers. The RRC should consider increasing minimum total and complex laparoscopy case numbers. With most of the residents in this survey coming from 5-year programs and 38% of them saying they would not go into general surgery if the length of training was extended to 6 years, no additional attempts should be made to restructure general surgery residency training. For those residents who are uncomfortable with their general surgery skills, the TTP fellowship offers them an excellent bridge to practice. Finally, it appears that the scope of general surgery practice has narrowed even more, with hepatopancreatobiliary and esophageal surgery being identified by the CRs as beyond the domain of most graduating residents. Author Contributions Study conception and design: Friedell, VanderMeer, Fuhrman Acquisition of data: Friedell Analysis and interpretation of data: Friedell, VanderMeer, Cheatham, Fuhrman, Schenarts, Mellinger, Morris
Vol. 218, No. 4, April 2014
Drafting of manuscript: Friedell, Cheatham Critical revision: Friedell, VanderMeer, Cheatham, Fuhrman, Schenarts, Mellinger, Morris REFERENCES 1. Stitzenberg KB, Sheldon GF. Progressive specialization within general surgery: adding to the complexity of workforce planning. J Am Coll Surg 2005;201:925e932. 2. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: long-term data from The American Board of Surgery. J Am Coll Surg 2008;206:182e788. 3. Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV. Early subspecialization and perceived competence in surgical training: are residents ready? J Am Coll Surg 2013;216: 764e773. 4. Bell RH, Biester TW, Tabuenca A, et al. Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg 2009;249:719e724. 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. Napolitano LM, Savarise M, Paramo J, 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. In press. 7. Yeo H, Viola K, Berg D, et al. Attitudes, training experiences, and professional expectations of US general surgery residents. JAMA 2009;302:1301e1308. 8. Debas HT, Bass BL, Brennan MF, et al. American Surgical Association Blue Ribbon Committee report on surgical education: 2004. Ann Surg 2005;241:1e8. 9. Buckholz EM, Sue GR, Yeo H, et al. Our trainees’ confidence: results from a national survey of 4136 US general surgery residents. Arch Surg 2011;146:907e915. 10. Adra SW, Trickey AW, Crosby ME, et al. General surgery vs. fellowship: the role of the independent academic medical center. J Surg Educ 2012;69:740e745. 11. Braasch JW. The lost sheep. Arch Surg 1986;121:385e390. 12. Valentine RJ, Rhodes RS, Jones A, Biester TW. Evolving patterns of vascular surgery care in the United States: a report from the American Board of Surgery. J Am Coll Surg 2013; 216:886e893. 13. Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117e2127. 14. Fisher WE, Hodges SE, Wu MF, et al. Assessment of the learning curve for pancreaticoduodenectomy. Am J Surg 2012;203:684e690. 15. Derogar M, Sadr-Azodi O, Johar A, et al. Hospital and surgeon volume in relation to survival after esophageal cancer surgery in a population-based study. J Clin Oncol 2013;31: 551e557. 16. Valentine RJ, Jones A, Biester TW, et al. General surgery workloads and practice patterns in the United States, 2007 to 2009. Ann Surg 2011;24:520e526. 17. Decker MR, Dodgion CM, Kwok AC, et al. Specialization and the current practices of general surgeons. J Am Coll Surg 2014;218:8–15.
Friedell et al
Discussion
703
18. Drake FT, Horvath KD, Goldin AB, Gow KW. The general surgery chief resident operative experience. JAMA Surg 2013;148:841e847. 19. Richardson JD. ACS transition to practice program offers residents additional opportunities to hone skills. Bull Am Coll Surg 2013;98:23e27. 20. Patel AT, Bohmer RM, Barbour JR, Fried MP. National assessment of business-of-medicine training and its implications for the development of a business-of-medicine curriculum. Laryngoscope 2005;115:51e55. 21. Satiani B. Business knowledge in surgeons. Am J Surg 2004; 188:13e16. 22. Jones K, Lebron RA, Mangram A, Dunn E. Practice management education during surgical residency. Am J Surg 2008; 196:878e882. 23. Lewis FL, Klingensmith ME. Issues in general surgery residency training2012. Ann Surg 2012;256:553e559. 24. Bell RH. Why Johnny can’t operate. Surgery 2009;146:533e542. 25. Stain SC. How to change general surgery residency training. Adv Surg 2011;45:275e284. 26. Fronza JS, Prystowsky JP, DaRosa D, Fryer JP. Surgical residents’ perception of competence and relevance of the clinical curriculum to future practice. J Surg Educ 2012;69: 792e797. 27. Fischer JE. The impending disappearance of the general surgeon. JAMA 2007;298:2191e2193. 28. Polk HC, Bland KI, Ellison EC, et al. A proposal for enhancing the general surgical workforce and access to surgical care. Ann Surg 2012;255:611e617. 29. Sullivan MC, Sue G, Bucholz E, et al. Effect of program type on the training experiences of 248 university, community, and US military-based general surgery residencies. J Am Coll Surg 2012;214:53e60. 30. Cheadle WG, Franklin GA, Richardson D, Polk HC. Broadbased general surgery training is a model of continued utility for the future. Ann Surg 2004;239:627e636. 31. Cogbill TH, Jarman BT. Rural general surgery training: the Gundersen Lutheran approach. Surg Clin North Am 2009; 89:1309e1312. 32. Minter RM, Gruppen LD, Napolitano KS, Gauger PG. Gender differences in the self-assessment of surgical residents. Am J Surg 2005;189:647e650.
Discussion DR RUSSELL G POSTIER (Oklahoma City, OK): Dr Friedell’s paper is well written, his data are appropriate to the question asked, and his conclusion fits the data. The underlying question being asked really is, are graduating chief residents in general surgery training programs today doing additional subspecialty training because they are interested in the subspecialty or because they are not comfortable doing general surgery at the conclusion of their training in an unsupervised setting? This is an extremely important question, as we all know, because it has serious implications for general surgery training. If the graduating residents are entering subspecialty fellowships because they are truly interested in the subspecialty or because they want to lessen their exposure to general surgery emergency call or because they believe it offers a better lifestyle or better income, then it
BACKGROUND:
skills.3 Numerous surveys have sought to determine the competence and confidence of general surgery residents. All of these have addressed major concerns about the state of general surgery training in the United States.4-6 The only 2 studies that directly surveyed categorical general surgery residents were not specific to CRs and they did not ask about the performance of specific operations.3,7 Our survey is the first to look at graduating CRs exclusively and ask them about their overall confidence in their operative skills and patient management, the management of specific cases, and their reasons for either extending their training into fellowship or entering directly into practice. Our hypothesis, based on personal observation as program directors (PDs), was that most CRs are satisfied with their training and confident about their skills. The current status of surgical education and the scope of practice of today’s general surgeon are also interwoven into this study. A Blue Ribbon Committee Report on Surgical Education published in 2005 recommended that general surgery residency become 3 years of core training followed by 3 more years of subspecialty or additional general
During the past decade, there has been considerable debate about the confidence of the graduating general surgery chief resident (CR). The proportion of residents pursuing fellowship training has increased from 55% to upwards of 80% since 1992.1,2 Some have interpreted this as showing that graduates are concerned about their
Disclosure Information: Nothing to disclose. Presented at the Southern Surgical Association 125th Annual Meeting, Hot Springs, VA, December 2013. Received December 16, 2013; Accepted December 17, 2013. From the Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, MO (Friedell), Guthrie Clinic, Sayre, PA (VanderMeer), the Department of Surgery, Orlando Regional Medical Center, Orlando, FL (Cheatham), the Department of Surgery, Ochsner Clinic, New Orleans, LA (Fuhrman), the Department of Surgery, University of Nebraska School of Medicine, Omaha, NE (Schenarts), the Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL (Mellinger), and the Department of Surgery, University of Pennsylvania, Philadelphia, PA (Morris). Correspondence address: Mark L Friedell, MD, FACS, Department of Surgery, University of Missouri-Kansas City, 2301 Holmes St, Kansas City, MO 64108. email: [email protected]
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
695
ISSN 1072-7515/13/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2013.12.022
696
Friedell et al
Survey of Chief Resident Confidence
J Am Coll Surg
surgery training.8 This stimulated a national discussion, still ongoing, about the optimal structure of the residency. To date, the 5-year paradigm has been continued, with no basic changes. But with the increasing tendency toward subspecialization, it appears that general surgery is becoming progressively less broad based.
4 ¼ very comfortable) to facilitate statistical analysis. Mean “confidence scores” were calculated for each procedure. A mean summary confidence score for the 12 procedures was calculated for each CR. Overall confidence among procedures was analyzed using chi-square analysis with the Bonferroni correction (p < 0.0008) for multiple comparisons (n ¼ 66). Multivariate stepwise logistic regression analyses, performed using Minitab software (version 16.2.3, Minitab Inc.), were performed evaluating the summary confidence score as the dependent variable and demographic and program-related variables as the independent variables to identify predictors of procedural confidence. Analysis of variance was used to identify differences in procedural confidence by case volume. Statistical significance was defined as p < 0.05.
METHODS In May 2013, a 16-question survey created at www. surveymonkey.com was sent by email to every general surgery residency PD in the United States, to be forwarded to each of their CRs. During the next 45 days, the survey was resent twice to the PDs. The questions included items pertaining to demographics, the nature of the residency program, the number of major cases completed by graduation, fellowships, trauma experience, and comfort with independently performing 12 specific operations chosen from the Surgical Council on Resident Education curriculum under the auspices of the American Board of Surgery (ABS). The following cases were classified as “essential-common”: laparoscopic colectomy, colonoscopy with polypectomy, thyroidectomy, and modified radical mastectomy. The following cases were “essential-uncommon”: open common bile duct exploration (OCBDE), gastrectomy, distal pancreatectomy and sentinel lymph node biopsy. The following cases were “complex”: right hepatic lobectomy, pancreaticoduodenectomy, esophagectomy, and low anterior resection. The responses offered for this question were: “very comfortable,” “comfortable,” “somewhat comfortable,” and “uncomfortable.” There was also an open-ended question asking if there were any aspects of general surgery that the CR was ill-prepared to deal with independently (Table 1). The study was reviewed by the University of Missouri Kansas City School of Medicine IRB. It was approved and deemed exempt from a requirement for informed consent. Descriptive statistics were used to assess the survey responses and are reported as percentages. Statistical differences by demographic variables were analyzed using chi-square analysis. The 4 procedural confidence levels were assigned numerical scores (1 ¼ uncomfortable, 2 ¼ somewhat uncomfortable, 3 ¼ comfortable, and
RESULTS There were 297 survey respondents. Because there were 1,097 graduates from general surgery residency programs in 2013, based on data from the American College of Surgeons (ACS) and the ACGME, this gave a 27% response rate. Sixty-seven percent of respondents were male and 81% graduated from 5-year programs. Seventy-six percent of respondents were completing their training in a university medical center, 22% at an independent medical center, and 2% in a military residency program. Sixteen percent of the respondents had 2 to 3 CRs in their programs, 52% had 4 to 6, and 32% had >6. In response to the question “How many major cases will you have completed by graduation?” Forty percent responded between 951 and 1,150 and 36% responded >1,150 (Table 2). The number of major cases did not differ significantly between independent and academic medical centers, but there was a significant variance by region of the country (p ¼ 0.037) with CRs in the South and Northeast performing more cases and CRs in the West and Midwest performing fewer cases overall. Only a few CRs were uncomfortable performing the 4 operations described as essential-common: laparoscopic colectomy (7%), colonoscopy with polypectomy (6%), thyroidectomy (3%), and modified radical mastectomy (2%). Among the essential-uncommon operations, 27% were uncomfortable performing OCBDE, but only 11%, 14%, and 5% were uncomfortable completing gastrectomy, distal pancreatectomy, and SLNB, respectively. Finally, of the 4 operations listed as “complex,” the uncomfortable responses were esophagectomy (60%), right hepatic lobectomy (48%), pancreaticoduodenectomy (38%), and low anterior resection (7%) (Fig. 1). Of note, 80% of the respondents were comfortable being on-call at a Level 1 trauma center and, when asked how
Abbreviations and Acronyms
ABS ACS CR OCBDE PD RRC TTP
¼ ¼ ¼ ¼ ¼ ¼ ¼
American Board of Surgery American College of Surgeons chief resident open common bile duct exploration program director Residency Review Committee transition to practice
Vol. 218, No. 4, April 2014
Table 1.
Survey Questions
Survey question
1. What is your sex? 2. How many chief residents are in your program? d 23 d 46 d More than 6 3. What type is your residency? d University medical center d Independent medical center d Military medical center 4. In what region of the country is your residency? d West d Midwest d South d Northeast 5. How many major cases will you have completed by graduation? d 750850 d 851950 d 9511150 d More than 1150 6. How many years of training is your residency? d 5 years d 6 years d 7 years d More than 7 years 7. How did you receive your trauma experience during residency? d Level I at my institution d Level II at my institution d Level III at my institution d Away rotation at Level I d Away rotation at Level II 8. After graduation, are you going directly into general surgery practice? 9. Because you are not doing a fellowship, how influential were the following factors in making your decision? (check all that apply) d Too much timedI have already invested a lot of time in my surgical training d I am confident in my surgical skills d Financially, it is more beneficial for me to enter practice directly after residency d Overall, I see no added benefit or value to undergoing further training d I want a broad-based traditional general surgery practice d Other (please specify) 10. If you will be entering a fellowship, which of the following will you be entering? d Pediatric surgery d Minimally invasive/bariatric d Plastic surgery d Cardiothoracic surgery d Thoracic surgery d Transplantation surgery d Hepatobiliary surgery d Hand surgery d Breast surgery d Surgical oncology (Continued)
Friedell et al
Survey of Chief Resident Confidence
697
Table 1. Continued Survey question
Colorectal surgery Trauma surgery d Surgical critical care d Acute care surgery d Unsure d Other Why are you pursing the fellowship? d It makes me more marketable d I truly have an interest in that aspect of surgery d It increases my earning potential d I do not feel confident in my surgical skills d It will aid in establishing my academic career d Better lifestyle If you graduated from a 5-year program and are going directly into general surgery practice, would you have decided on a career in general surgery if it were a 6-year or more training program? If you are going directly into general surgery practice, would you do an extra “Transition to Practice” fellowship to better prepare yourself for practice if it were available? What is your confidence level to independently perform the following? d Laparoscopic colectomy d Colonoscopy with biopsy/polypectomy d Thyroidectomy d Modified radical mastectomy d Open common duct exploration d Gastrectomy d Distal pancreatectomy d SLNB for melanoma d Right hepatic lobectomy d Whipple d Esophagectomy d Low anterior resection Would you be comfortable being on call at a Level I trauma center at the conclusion of your chief residency? Are there any aspects of general surgery that you believe you are ill prepared to deal with independently? d d
11.
12.
13. 14.
15. 16.
they received their trauma experience during residency, a presumably corresponding 84% stated, “At the Level I center at my institution.” Chief residents’ confidence in performing OCBDE, pancreaticoduodenectomy, right hepatic lobectomy, and esophagectomy was significantly lower than for the other 8 operative procedures (p < 0.00001). Stepwise multiple regression analysis was performed to identify which demographic factors (ie, sex, region, years of training, type of training program, and number of major cases) were significantly associated with procedural confidence. Number of cases (p ¼ 0.002), region (p ¼ 0.037), and male sex (p ¼ 0.047) were significantly associated with procedural confidence, and type of training program (p ¼ 0.056)dindependent vs academicdand years of training (p ¼ 0.149) were not.
698
Friedell et al
Survey of Chief Resident Confidence
Table 2. Characteristics of Chief Residents and Programs Demographics
Sex Male Female Chief residents in program 23 46 >6 Region West Midwest South Northeast Type of residency program University medical center Independent medical center Military medical center Major cases completed 750850 851950 9511150 >1,150 Years of training 5 6 7 >7
n
%
198 99
67 33
48 153 96
16 52 32
35 93 95 74
12 31 32 25
225 65 7
76 22 2
25 44 120 108
9 15 40 36
242 22 31 2
82 7 10 1
In evaluating the significant difference in procedural confidence by region, CRs in the South and Northeast were more likely to perform >950 major cases than their counterparts in the West and Midwest (p ¼ 0.037). In evaluating procedural confidence by sex, male CRs were significantly more likely to have performed a greater number of major cases than their female counterparts, especially in the 950 to 1,150 case level (p ¼ 0.01). Lower case numbers might explain the diminished confidence of women both in this survey and in Buckholz and colleagues’ data.9 Overall level of confidence among those CRs who had done >950 cases was statistically higher than those who had performed fewer cases (p < 0.0001). For the essential common operations, performing at least 850 major cases appeared to correlate with a comfortable level of procedural confidence. At least 950 cases were necessary to have significantly more confidence with laparoscopic colectomy and >1,150 cases were needed to achieve significant confidence with colonoscopy/biopsy, and modified radical mastectomy (Fig. 2). For the essential uncommon operations, at least 950 major cases were
J Am Coll Surg
sufficient to achieve a comfortable level of confidence for SLNB, but >1,150 major cases were necessary to achieve such a confidence level for OCBDE, gastrectomy, and distal pancreatectomy (Fig. 3). For complex operations, at least 950 major cases were sufficient to achieve a comfortable level of confidence for low anterior resection, but even with >1,150 major cases, there was never a substantial comfort level for right hepatic lobectomy, pancreaticoduonectomy, and esophagectomy (Fig. 4). When CRs were asked about their plans after general surgery residency, 28% responded that they were going directly into general surgery practice, with 72% going into fellowships. Statistically significant differences were noted between residents from independent medical centers, university medical centers, and military medical centers about the decision to do a fellowship (p < 0.0001). Assuming that the 7 military surgeons had limited ability to decide on their subsequent practice and so were excluded from the analysis, the remaining 2 groups (university and independent) were still significantly different (p ¼ 0.002) with respect to their decision to pursue fellowship training. This has been suggested previously.10 When asked why they decided not to do a fellowship, the 2 most common answers were “I am confident in my skills” (26%) and “I want a broad-based traditional practice” (28%). When those who graduated from a 5-year program were asked if they would have decided on a career in general surgery if it were 6 years or longer, 38% said that they would not have done so. Finally, for those CRs going directly into general surgery practice, only 25% said that they would be interested in the transition to practice (TTP) in general surgery fellowship being offered under the auspices of the ACS. As case volume increased, the interest in doing a transitional year decreased markedly. This finding was suggestive, although not statistically significant (p ¼ 0.07). Of the 14 fellowships offered in the survey, the top choices were minimally invasive/bariatric (16.5%), vascular surgery (13%), surgical oncology (10%), cardiothoracic surgery (9%), plastic surgery (9%), and surgical critical care (8%). When those pursuing a fellowship were asked why, 67% responded that they truly had an interest in that discipline and only 7% stated that they were not confident in their skills. For the open-ended question, “Are there any aspects of general surgery that you feel ill-prepared to deal with independently?” the most common answer was hepatopancreatobiliary surgery, followed by approximately equal numbers of responses stating esophageal, thoracic, gastric, advanced laparoscopic and vascular surgery, and business/ administration. These responses also gave insight into the
Vol. 218, No. 4, April 2014
Friedell et al
Survey of Chief Resident Confidence
699
Figure 1. Comfort level with various operations.
DISCUSSION During the past decade, the question, “are we training general surgery residents to become competent?” continues to be discussed, particularly after the restriction of duty hours in 2003. A Blue Ribbon Committee Report recommended lengthening general surgery training by 1 year, with 3 years of core training followed by 3 more years of subspecialty or additional general surgery training.8 But this goal of attempting to make one size fit all has never been accepted by the surgical education
community as a whole, and the 5-year program remains standard. At the same time, the practice of general surgery has changed. In 1986, Braasch described broad-based general surgeons as “the lost sheep” with other disciplines and subspecialists in surgery encroaching on them.11 Today the scope has narrowed even more. Vascular surgery is done almost exclusively by those trained in open and endovascular techniques.12 Hepatopancreatobiliary and esophageal cases have followed suit, particularly since it has been shown that higher volumes of these complex cases produce better outcomes.13-15 However, minimally invasive surgery and endoscopy have increased dramatically in general surgery practice. Currently, the procedures most frequently performed by general surgeons
Figure 2. Mean procedural confidence for “essentialcommon” operations.
Figure 3. Mean procedural confidence for “essentialuncommon” operations.
graduates’ beliefs about making the transition to attending surgeon and the scope of practice of general surgery (Table 3).
700
Friedell et al
Figure 4. Mean procedural confidence for “complex” operations.
are abdominal and alimentary tract in nature, with many of the endoscopic and minimally invasive surgery cases at the top of the list.16,17 A recent study of CR case logs during a 23-year period showed that thoracic, trauma, and vascular cases steadily declined, and alimentary and intra-abdominal cases increased from 47% of the CR experience to 65%dmuch of it due to laparoscopic surgery. In fact, the current mean CR experience for laparoscopic colectomy in the study was 9 cases.18 Both the ABS and the Residency Review Committee (RRC) for surgery recognized the importance of minimally invasive surgery and endoscopy in the practice of today’s general surgeon Table 3.
J Am Coll Surg
Survey of Chief Resident Confidence
and the RRC has increased the minimum requirements for these cases. Concerns about the competence of the graduating CR have been raised from several different stakeholders. A survey of general surgery PDs in 2006 asked which procedures their graduating general surgery residents should be confident to perform.4 Of the 121 procedures identified, only 18 of them were performed a mean of >10 times during residency, and 83 of them were performed a mean of 950 total major cases in residency being more comfortable. Confidence also increased as case volume increased. In this regard, it would be appropriate for the RRC to consider increasing the 750 total case and the complex laparoscopy case minimums as has been recommended by others.24,25 Because 70% to 80% of graduates of general surgery residency programs are now entering fellowship training, there is concern that the residents themselves lack confidence in their skills. Yeo and colleagues surveyed PGY1 through 5 categorical general surgery residents at the conclusion of the 2008 ABS In-Training Examination.7 Overall resident satisfaction with their training varied significantly across training years (p ¼ 0.001), with the lowest levels in PGY2 and PGY3. Views about the need to complete specialty training also differed across the years (p < 0.001), with the least concern among PGY5 residents. More recently, Coleman and colleagues distributed a survey to surgery residents via PDs at 55 preselected residency programs.3 When asked if a 5-year general surgery residency prepared them to practice general surgery, 38% of residents overall responded “no” or “unsure.” But the figures decreased with each increasing year of residency from PGY1 (53.3%) to PGY5 (23%), just as in Yeo and colleagues’ study. Coleman and colleagues also concluded that the majority of residents in their survey wanted a 6year, 3-3 structured residency, which does not correlate with the 38% of our respondents who would not have chosen to do general surgery if the residency was longer than 5 years. The problem with these 2 studies is that only the responses of the CRs really matter, case numbers were not examined, and questions about specific cases were not asked. In fact, the Coleman and colleagues’ study only included 108 CRs, compared with 297 in ours. An important finding in our survey is the fact that fellowships are being chosen primarily because of an interest in the field rather than lack of comfort with surgical skills and >97% of Coleman and colleagues’ respondents going into fellowship stated that they were truly interested in the subspecialty. The responses of the CRs to our survey appear to mirror the practice of most general surgeons today. Very few were uncomfortable with the essential common and the essential uncommon procedures, with the exception of the OCBDE. The majority were also comfortable working at a Level I trauma center, suggesting that the acute care surgery experience in most programs is very
702
Friedell et al
Survey of Chief Resident Confidence
good. However, the CRs were least comfortable with the following complex cases: pancreaticoduodenectomy, right hepatic lobectomy, and esophagectomy. This was echoed in the open-ended question as well (Table 3). In a small study of recent graduates from a large university program, approximately 50% believed that right hepatectomy, distal pancreatectomy, pancreaticoduodenectomy, and esophagectomy were irrelevant to their practice, that they were not competent to do them, or both.26 The CRs in this survey as well as the young surgeons in the ACS survey appear more positive and comfortable about the current status of general surgery training and practice than are many of the more senior members of the surgical community. Most of our respondents came from 5-year programs. This is consistent with the description of the modern general surgeon articulated by Stain: expert in the management of the alimentary tract (except liver, pancreas, and esophagus), abdomen, breast, endocrine, and acute care surgery; expert in minimally invasive surgery; and training accomplished in 5 years.25 This last point is very important at a time when we have an impending shortage of general surgeons because 38% of respondents in this survey stated that they would not have pursued general surgery if the training was longer than 5 years. Given the predicted (and current) shortage of general surgeons in the United States, particularly in rural areas,27,28 it is important to note, from this survey, that independent programs are producing proportionately more general surgeons than university programs. Chief residents from independent programs showed more confidence compared with university programs, although at a borderline significance level (p ¼ 0.056), and they did show a significant increase in confidence for the performance of OCBDE (p ¼ 0.04). Data from Sullivan and colleagues’ survey also showed a statistically significant difference in favor of community programs for satisfaction with operative experience and lack of worry about performing procedures independently.29 In this regard, the “Little Red Book” online at the ACS website provides a great deal of information on general surgery residencies to medical students deciding on a career in surgery, particularly those wanting to go directly into general surgery. Leaders in surgery might need to shift their educational paradigm to interest more students and residents in general surgery.28 The Louisville group commented several years ago: “we ask whether the general surgery residency that has a marked minority of its trainees choose to practice general surgery is indeed fulfilling its core calling adequately.”30 And, more recently, Cogbill noted: “Many surgical residencies define their success by the number of graduates who pursue postgraduate fellowships or join university departments of surgery. The practice of
J Am Coll Surg
general surgery in a rural hospital has its own unique set of formidable challenges and rich rewards. Our graduates who are willing to make this commitment are a source of equal pride.”31 The major limitations of this study are those of any survey. There are unknown differences between responders and nonresponders. The response rate was 27%, which could be due partially to the fact that the survey was not sent directly to the CRs but was distributed by PDs. Incorrect email addresses of PDs and CRs could have been a problem. Also, because the survey was selfassessment, was it accurate? However, it has been shown that self-assessment of technical skills by surgical residents can actually underestimate their abilities compared with the assessment of the faculty.32
CONCLUSIONS In general, the results of this survey support our hypothesis that graduating surgery residents have a sense of confidence and are optimistic about their future. Although at least 70% choose to enter fellowships, it is because of a genuine interest in the subspecialty rather than concern for their surgical skills. They seem to be confident with common essential operations, most of the uncommon essential operations, and with care of the trauma patient. Case volume is an important determiner of confidence, with >950 cases in training being important. The ABS has recommended changes that should increase operating room exposure and case numbers in the junior years and allow senior residents more flexibility to prepare for their careers. The RRC should consider increasing minimum total and complex laparoscopy case numbers. With most of the residents in this survey coming from 5-year programs and 38% of them saying they would not go into general surgery if the length of training was extended to 6 years, no additional attempts should be made to restructure general surgery residency training. For those residents who are uncomfortable with their general surgery skills, the TTP fellowship offers them an excellent bridge to practice. Finally, it appears that the scope of general surgery practice has narrowed even more, with hepatopancreatobiliary and esophageal surgery being identified by the CRs as beyond the domain of most graduating residents. Author Contributions Study conception and design: Friedell, VanderMeer, Fuhrman Acquisition of data: Friedell Analysis and interpretation of data: Friedell, VanderMeer, Cheatham, Fuhrman, Schenarts, Mellinger, Morris
Vol. 218, No. 4, April 2014
Drafting of manuscript: Friedell, Cheatham Critical revision: Friedell, VanderMeer, Cheatham, Fuhrman, Schenarts, Mellinger, Morris REFERENCES 1. Stitzenberg KB, Sheldon GF. Progressive specialization within general surgery: adding to the complexity of workforce planning. J Am Coll Surg 2005;201:925e932. 2. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: long-term data from The American Board of Surgery. J Am Coll Surg 2008;206:182e788. 3. Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV. Early subspecialization and perceived competence in surgical training: are residents ready? J Am Coll Surg 2013;216: 764e773. 4. Bell RH, Biester TW, Tabuenca A, et al. Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg 2009;249:719e724. 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. Napolitano LM, Savarise M, Paramo J, 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. In press. 7. Yeo H, Viola K, Berg D, et al. Attitudes, training experiences, and professional expectations of US general surgery residents. JAMA 2009;302:1301e1308. 8. Debas HT, Bass BL, Brennan MF, et al. American Surgical Association Blue Ribbon Committee report on surgical education: 2004. Ann Surg 2005;241:1e8. 9. Buckholz EM, Sue GR, Yeo H, et al. Our trainees’ confidence: results from a national survey of 4136 US general surgery residents. Arch Surg 2011;146:907e915. 10. Adra SW, Trickey AW, Crosby ME, et al. General surgery vs. fellowship: the role of the independent academic medical center. J Surg Educ 2012;69:740e745. 11. Braasch JW. The lost sheep. Arch Surg 1986;121:385e390. 12. Valentine RJ, Rhodes RS, Jones A, Biester TW. Evolving patterns of vascular surgery care in the United States: a report from the American Board of Surgery. J Am Coll Surg 2013; 216:886e893. 13. Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117e2127. 14. Fisher WE, Hodges SE, Wu MF, et al. Assessment of the learning curve for pancreaticoduodenectomy. Am J Surg 2012;203:684e690. 15. Derogar M, Sadr-Azodi O, Johar A, et al. Hospital and surgeon volume in relation to survival after esophageal cancer surgery in a population-based study. J Clin Oncol 2013;31: 551e557. 16. Valentine RJ, Jones A, Biester TW, et al. General surgery workloads and practice patterns in the United States, 2007 to 2009. Ann Surg 2011;24:520e526. 17. Decker MR, Dodgion CM, Kwok AC, et al. Specialization and the current practices of general surgeons. J Am Coll Surg 2014;218:8–15.
Friedell et al
Discussion
703
18. Drake FT, Horvath KD, Goldin AB, Gow KW. The general surgery chief resident operative experience. JAMA Surg 2013;148:841e847. 19. Richardson JD. ACS transition to practice program offers residents additional opportunities to hone skills. Bull Am Coll Surg 2013;98:23e27. 20. Patel AT, Bohmer RM, Barbour JR, Fried MP. National assessment of business-of-medicine training and its implications for the development of a business-of-medicine curriculum. Laryngoscope 2005;115:51e55. 21. Satiani B. Business knowledge in surgeons. Am J Surg 2004; 188:13e16. 22. Jones K, Lebron RA, Mangram A, Dunn E. Practice management education during surgical residency. Am J Surg 2008; 196:878e882. 23. Lewis FL, Klingensmith ME. Issues in general surgery residency training2012. Ann Surg 2012;256:553e559. 24. Bell RH. Why Johnny can’t operate. Surgery 2009;146:533e542. 25. Stain SC. How to change general surgery residency training. Adv Surg 2011;45:275e284. 26. Fronza JS, Prystowsky JP, DaRosa D, Fryer JP. Surgical residents’ perception of competence and relevance of the clinical curriculum to future practice. J Surg Educ 2012;69: 792e797. 27. Fischer JE. The impending disappearance of the general surgeon. JAMA 2007;298:2191e2193. 28. Polk HC, Bland KI, Ellison EC, et al. A proposal for enhancing the general surgical workforce and access to surgical care. Ann Surg 2012;255:611e617. 29. Sullivan MC, Sue G, Bucholz E, et al. Effect of program type on the training experiences of 248 university, community, and US military-based general surgery residencies. J Am Coll Surg 2012;214:53e60. 30. Cheadle WG, Franklin GA, Richardson D, Polk HC. Broadbased general surgery training is a model of continued utility for the future. Ann Surg 2004;239:627e636. 31. Cogbill TH, Jarman BT. Rural general surgery training: the Gundersen Lutheran approach. Surg Clin North Am 2009; 89:1309e1312. 32. Minter RM, Gruppen LD, Napolitano KS, Gauger PG. Gender differences in the self-assessment of surgical residents. Am J Surg 2005;189:647e650.
Discussion DR RUSSELL G POSTIER (Oklahoma City, OK): Dr Friedell’s paper is well written, his data are appropriate to the question asked, and his conclusion fits the data. The underlying question being asked really is, are graduating chief residents in general surgery training programs today doing additional subspecialty training because they are interested in the subspecialty or because they are not comfortable doing general surgery at the conclusion of their training in an unsupervised setting? This is an extremely important question, as we all know, because it has serious implications for general surgery training. If the graduating residents are entering subspecialty fellowships because they are truly interested in the subspecialty or because they want to lessen their exposure to general surgery emergency call or because they believe it offers a better lifestyle or better income, then it
