Surgical educators flag training gaps

INDIANAPOLIS – The nation’s elite surgical educators are up in arms over reported widespread deficiencies in the skill set and judgment of recent graduates of 5-year general surgery residencies.

The source of their ire is a detailed new survey of the nation’s subspecialty fellowship program directors. Today 80% of graduating general surgery residents seek these year-long fellowships to obtain advanced training in bariatric, colorectal, thoracic, hepatobiliary, or other surgical areas. The surveyed program directors indicated many trainees arrive unprepared in essential areas.

Photo courtesy Dr. Samer Mattar

"Many new fellows must gain basic and fundamental skills at the beginning of their fellowship before they can commence to benefit from the advanced skills that they originally came to obtain. The current high demand for fellowship training and the lack of readiness upon completion of general surgery residencies should be a call to action for all stakeholders in surgical training," Dr. Samer Mattar declared in presenting the survey results at the annual meeting of the American Surgical Association.

The survey was conducted by the Fellowship Council, an umbrella organization in charge of standardizing curricula, accrediting programs, and matching residents to fellowships. The group distributed the surveys to all 145 subspecialty fellowship program directors and drew a 63% response rate. That’s considered high for such a lengthy survey and is an indication of the importance educators place on the subject matter, said Dr. Mattar of Indiana University, Indianapolis.

The survey assessed five key educational domains: professionalism, independent practice, psychomotor skills, expertise in their chosen disease state, and scholarly focus.

"Incoming fellows exhibited high levels of professionalism, but there were deficiencies in autonomy and independence, psychomotor abilities, and – most profoundly – academics and scholarship," Dr. Mattar noted in summarizing the survey results.

The underlying theme of the responses is that many fellows are pursuing fellowship positions to make up for inadequacies in their residency rather than to push their skills to the next level. Among the key survey findings:

• Forty-three percent of program directors felt incoming fellows were unable to independently perform half an hour of a major procedure.

• Thirty percent of incoming fellows couldn’t independently perform basic operations such as laparoscopic cholecystectomy.

• Fifty-six percent were unable to laparoscopically suture and tie knots properly, and 26% couldn’t recognize anatomic planes through the laparoscope.

• One-quarter were deemed unable to recognize early signs of complications.

• Nearly 40% of program directors said new fellows display a lack of "patient ownership." "We promote patient ownership in our programs. We are somewhat disappointed and dismayed that the fellows feel that the patient is part of a service and not their own," Dr. Mattar commented.

• Only 51% of program directors indicated their incoming fellows demonstrated independence in the operating room and on call, although fellows did show marked improvement in these areas as the year went on.

• A large majority of program directors thought their fellows were disinterested in research and advancing the field, even though, as Dr. Mattar noted, "This is a mandate in our curriculum."

Discussant Dr. Michael G. Sarr was blunt: "This is a scary situation."

"There’s a clear message here from this study: We have a problem. I maintain that we have to stop being bullied by naive, public, politically driven agendas and by some of our own graybeard pundits – and I think we all know who those groups are – and once again take over the control of educating our successors," said Dr. Sarr, professor of surgery at the Mayo Medical School, Rochester, Minn.

He attributed the decline in graduating general surgery residents’ technical skills, patient ownership, and ability to function as trustworthy independent surgeons in large part to the mandated 80-hour maximum work week.

"We all admit and acknowledge that prior to the duty hours reduction of 2003, the expected duty hours most of us trained in were barbaric and often dangerous, and they involved too much scut work. But in the past the final product was superb," Dr. Sarr recalled.

He argued that while it would be folly to return to those days, some flexibility regarding the work hours limit would be beneficial.

"Should our politically driven ACGME [Accreditation Council for Graduate Medical Education] and our own RRC [Residency Review Committee] – yes, our own elected overseeing organization – liberalize its rigid, unbending, stringent rules to allow our residents to make more liberal decisions and to develop professionalism by exceeding their 80-hour work restriction when clinical situations demand their presence?" he asked.

Discussant Dr. Frank R. Lewis, executive director of the American Board of Surgery, said that even though the 80-hour work limit has effectively subtracted 6-12 months from the general surgery residency, he doesn’t believe this emotional and contentious issue is the main problem. He noted that at present the average number of operations done by a first-year resident is less than two per week, while second-year residents average only two to three per week.

"Our residents are spending 80 hours a week while doing two or three operations per week, which arguably could be done in half a day. It would be hard to imagine a less efficient educational process," Dr. Lewis complained.

He added that nobody should be surprised by the Fellowship Council survey results. During the past decade the failure rate on the American Board of Surgery’s oral exam has climbed steadily from 16% to 28%. At present the percentage of examinees who fail either the oral or written ABS exam the first time around is in the mid-30s.

"That’s arguably an absurd failure rate for a 5-year training program in a group of people who should have mastered the subject," the surgeon added.

He asserted that most of the factors responsible for the decline in the competence of graduating general surgery residents are beyond the control of academic surgeons. These factors include the gutting of surgical clerkship opportunities in the fourth year of medical school, along with changes in the surgical landscape that have caused once-popular operations to essentially go away due to technical advances or improved drug therapy.

Discussant Dr. Mark A. Malangoni, associate executive director of the ABS, noted that the more complex open surgery operations previously done by general surgery residents have in many cases been converted to complex laparoscopic procedures that have become the purview of the subspecialty fellowships. Why not abolish the fellowships and drive all those interesting cases and that dedicated training effort back into the residency years? he asked.

That’s not going to happen, Dr. Mattar replied, citing the huge market demand and need for these fellowships.

"They’re very rewarding to all stakeholders," he added.

But constructive changes are afoot, according to Dr. Mattar. Plans are well underway to change the fourth year of medical school so that students interested in a career in surgery can begin to prepare for it then. And there are also efforts to custom-tailor the final year of general surgery residency so that residents can prepare for their fellowship year. Toward that end the Fellowship Council has moved the fellowship match date up to June so residents who know they are fellowship bound can put their fifth year to the best use.

The survey was conducted by the Fellowship Council, an umbrella organization with oversight over surgical subspecialty fellowships. Dr. Mattar reported having no financial conflicts.

[email protected]

INDIANAPOLIS – The nation’s elite surgical educators are up in arms over reported widespread deficiencies in the skill set and judgment of recent graduates of 5-year general surgery residencies.

The source of their ire is a detailed new survey of the nation’s subspecialty fellowship program directors. Today 80% of graduating general surgery residents seek these year-long fellowships to obtain advanced training in bariatric, colorectal, thoracic, hepatobiliary, or other surgical areas. The surveyed program directors indicated many trainees arrive unprepared in essential areas.

Photo courtesy Dr. Samer Mattar

"Many new fellows must gain basic and fundamental skills at the beginning of their fellowship before they can commence to benefit from the advanced skills that they originally came to obtain. The current high demand for fellowship training and the lack of readiness upon completion of general surgery residencies should be a call to action for all stakeholders in surgical training," Dr. Samer Mattar declared in presenting the survey results at the annual meeting of the American Surgical Association.

The survey was conducted by the Fellowship Council, an umbrella organization in charge of standardizing curricula, accrediting programs, and matching residents to fellowships. The group distributed the surveys to all 145 subspecialty fellowship program directors and drew a 63% response rate. That’s considered high for such a lengthy survey and is an indication of the importance educators place on the subject matter, said Dr. Mattar of Indiana University, Indianapolis.

The survey assessed five key educational domains: professionalism, independent practice, psychomotor skills, expertise in their chosen disease state, and scholarly focus.

"Incoming fellows exhibited high levels of professionalism, but there were deficiencies in autonomy and independence, psychomotor abilities, and – most profoundly – academics and scholarship," Dr. Mattar noted in summarizing the survey results.

The underlying theme of the responses is that many fellows are pursuing fellowship positions to make up for inadequacies in their residency rather than to push their skills to the next level. Among the key survey findings:

• Forty-three percent of program directors felt incoming fellows were unable to independently perform half an hour of a major procedure.

• Thirty percent of incoming fellows couldn’t independently perform basic operations such as laparoscopic cholecystectomy.

• Fifty-six percent were unable to laparoscopically suture and tie knots properly, and 26% couldn’t recognize anatomic planes through the laparoscope.

• One-quarter were deemed unable to recognize early signs of complications.

• Nearly 40% of program directors said new fellows display a lack of "patient ownership." "We promote patient ownership in our programs. We are somewhat disappointed and dismayed that the fellows feel that the patient is part of a service and not their own," Dr. Mattar commented.

• Only 51% of program directors indicated their incoming fellows demonstrated independence in the operating room and on call, although fellows did show marked improvement in these areas as the year went on.

• A large majority of program directors thought their fellows were disinterested in research and advancing the field, even though, as Dr. Mattar noted, "This is a mandate in our curriculum."

Discussant Dr. Michael G. Sarr was blunt: "This is a scary situation."

"There’s a clear message here from this study: We have a problem. I maintain that we have to stop being bullied by naive, public, politically driven agendas and by some of our own graybeard pundits – and I think we all know who those groups are – and once again take over the control of educating our successors," said Dr. Sarr, professor of surgery at the Mayo Medical School, Rochester, Minn.

He attributed the decline in graduating general surgery residents’ technical skills, patient ownership, and ability to function as trustworthy independent surgeons in large part to the mandated 80-hour maximum work week.

"We all admit and acknowledge that prior to the duty hours reduction of 2003, the expected duty hours most of us trained in were barbaric and often dangerous, and they involved too much scut work. But in the past the final product was superb," Dr. Sarr recalled.

He argued that while it would be folly to return to those days, some flexibility regarding the work hours limit would be beneficial.

"Should our politically driven ACGME [Accreditation Council for Graduate Medical Education] and our own RRC [Residency Review Committee] – yes, our own elected overseeing organization – liberalize its rigid, unbending, stringent rules to allow our residents to make more liberal decisions and to develop professionalism by exceeding their 80-hour work restriction when clinical situations demand their presence?" he asked.

Discussant Dr. Frank R. Lewis, executive director of the American Board of Surgery, said that even though the 80-hour work limit has effectively subtracted 6-12 months from the general surgery residency, he doesn’t believe this emotional and contentious issue is the main problem. He noted that at present the average number of operations done by a first-year resident is less than two per week, while second-year residents average only two to three per week.

"Our residents are spending 80 hours a week while doing two or three operations per week, which arguably could be done in half a day. It would be hard to imagine a less efficient educational process," Dr. Lewis complained.

He added that nobody should be surprised by the Fellowship Council survey results. During the past decade the failure rate on the American Board of Surgery’s oral exam has climbed steadily from 16% to 28%. At present the percentage of examinees who fail either the oral or written ABS exam the first time around is in the mid-30s.

"That’s arguably an absurd failure rate for a 5-year training program in a group of people who should have mastered the subject," the surgeon added.

He asserted that most of the factors responsible for the decline in the competence of graduating general surgery residents are beyond the control of academic surgeons. These factors include the gutting of surgical clerkship opportunities in the fourth year of medical school, along with changes in the surgical landscape that have caused once-popular operations to essentially go away due to technical advances or improved drug therapy.

Discussant Dr. Mark A. Malangoni, associate executive director of the ABS, noted that the more complex open surgery operations previously done by general surgery residents have in many cases been converted to complex laparoscopic procedures that have become the purview of the subspecialty fellowships. Why not abolish the fellowships and drive all those interesting cases and that dedicated training effort back into the residency years? he asked.

That’s not going to happen, Dr. Mattar replied, citing the huge market demand and need for these fellowships.

"They’re very rewarding to all stakeholders," he added.

But constructive changes are afoot, according to Dr. Mattar. Plans are well underway to change the fourth year of medical school so that students interested in a career in surgery can begin to prepare for it then. And there are also efforts to custom-tailor the final year of general surgery residency so that residents can prepare for their fellowship year. Toward that end the Fellowship Council has moved the fellowship match date up to June so residents who know they are fellowship bound can put their fifth year to the best use.

The survey was conducted by the Fellowship Council, an umbrella organization with oversight over surgical subspecialty fellowships. Dr. Mattar reported having no financial conflicts.

[email protected]

INDIANAPOLIS – The nation’s elite surgical educators are up in arms over reported widespread deficiencies in the skill set and judgment of recent graduates of 5-year general surgery residencies.

The source of their ire is a detailed new survey of the nation’s subspecialty fellowship program directors. Today 80% of graduating general surgery residents seek these year-long fellowships to obtain advanced training in bariatric, colorectal, thoracic, hepatobiliary, or other surgical areas. The surveyed program directors indicated many trainees arrive unprepared in essential areas.

Photo courtesy Dr. Samer Mattar

"Many new fellows must gain basic and fundamental skills at the beginning of their fellowship before they can commence to benefit from the advanced skills that they originally came to obtain. The current high demand for fellowship training and the lack of readiness upon completion of general surgery residencies should be a call to action for all stakeholders in surgical training," Dr. Samer Mattar declared in presenting the survey results at the annual meeting of the American Surgical Association.

The survey was conducted by the Fellowship Council, an umbrella organization in charge of standardizing curricula, accrediting programs, and matching residents to fellowships. The group distributed the surveys to all 145 subspecialty fellowship program directors and drew a 63% response rate. That’s considered high for such a lengthy survey and is an indication of the importance educators place on the subject matter, said Dr. Mattar of Indiana University, Indianapolis.

The survey assessed five key educational domains: professionalism, independent practice, psychomotor skills, expertise in their chosen disease state, and scholarly focus.

"Incoming fellows exhibited high levels of professionalism, but there were deficiencies in autonomy and independence, psychomotor abilities, and – most profoundly – academics and scholarship," Dr. Mattar noted in summarizing the survey results.

The underlying theme of the responses is that many fellows are pursuing fellowship positions to make up for inadequacies in their residency rather than to push their skills to the next level. Among the key survey findings:

• Forty-three percent of program directors felt incoming fellows were unable to independently perform half an hour of a major procedure.

• Thirty percent of incoming fellows couldn’t independently perform basic operations such as laparoscopic cholecystectomy.

• Fifty-six percent were unable to laparoscopically suture and tie knots properly, and 26% couldn’t recognize anatomic planes through the laparoscope.

• One-quarter were deemed unable to recognize early signs of complications.

• Nearly 40% of program directors said new fellows display a lack of "patient ownership." "We promote patient ownership in our programs. We are somewhat disappointed and dismayed that the fellows feel that the patient is part of a service and not their own," Dr. Mattar commented.

• Only 51% of program directors indicated their incoming fellows demonstrated independence in the operating room and on call, although fellows did show marked improvement in these areas as the year went on.

• A large majority of program directors thought their fellows were disinterested in research and advancing the field, even though, as Dr. Mattar noted, "This is a mandate in our curriculum."

Discussant Dr. Michael G. Sarr was blunt: "This is a scary situation."

"There’s a clear message here from this study: We have a problem. I maintain that we have to stop being bullied by naive, public, politically driven agendas and by some of our own graybeard pundits – and I think we all know who those groups are – and once again take over the control of educating our successors," said Dr. Sarr, professor of surgery at the Mayo Medical School, Rochester, Minn.

He attributed the decline in graduating general surgery residents’ technical skills, patient ownership, and ability to function as trustworthy independent surgeons in large part to the mandated 80-hour maximum work week.

"We all admit and acknowledge that prior to the duty hours reduction of 2003, the expected duty hours most of us trained in were barbaric and often dangerous, and they involved too much scut work. But in the past the final product was superb," Dr. Sarr recalled.

He argued that while it would be folly to return to those days, some flexibility regarding the work hours limit would be beneficial.

"Should our politically driven ACGME [Accreditation Council for Graduate Medical Education] and our own RRC [Residency Review Committee] – yes, our own elected overseeing organization – liberalize its rigid, unbending, stringent rules to allow our residents to make more liberal decisions and to develop professionalism by exceeding their 80-hour work restriction when clinical situations demand their presence?" he asked.

Discussant Dr. Frank R. Lewis, executive director of the American Board of Surgery, said that even though the 80-hour work limit has effectively subtracted 6-12 months from the general surgery residency, he doesn’t believe this emotional and contentious issue is the main problem. He noted that at present the average number of operations done by a first-year resident is less than two per week, while second-year residents average only two to three per week.

"Our residents are spending 80 hours a week while doing two or three operations per week, which arguably could be done in half a day. It would be hard to imagine a less efficient educational process," Dr. Lewis complained.

He added that nobody should be surprised by the Fellowship Council survey results. During the past decade the failure rate on the American Board of Surgery’s oral exam has climbed steadily from 16% to 28%. At present the percentage of examinees who fail either the oral or written ABS exam the first time around is in the mid-30s.

"That’s arguably an absurd failure rate for a 5-year training program in a group of people who should have mastered the subject," the surgeon added.

He asserted that most of the factors responsible for the decline in the competence of graduating general surgery residents are beyond the control of academic surgeons. These factors include the gutting of surgical clerkship opportunities in the fourth year of medical school, along with changes in the surgical landscape that have caused once-popular operations to essentially go away due to technical advances or improved drug therapy.

Discussant Dr. Mark A. Malangoni, associate executive director of the ABS, noted that the more complex open surgery operations previously done by general surgery residents have in many cases been converted to complex laparoscopic procedures that have become the purview of the subspecialty fellowships. Why not abolish the fellowships and drive all those interesting cases and that dedicated training effort back into the residency years? he asked.

That’s not going to happen, Dr. Mattar replied, citing the huge market demand and need for these fellowships.

"They’re very rewarding to all stakeholders," he added.

But constructive changes are afoot, according to Dr. Mattar. Plans are well underway to change the fourth year of medical school so that students interested in a career in surgery can begin to prepare for it then. And there are also efforts to custom-tailor the final year of general surgery residency so that residents can prepare for their fellowship year. Toward that end the Fellowship Council has moved the fellowship match date up to June so residents who know they are fellowship bound can put their fifth year to the best use.

The survey was conducted by the Fellowship Council, an umbrella organization with oversight over surgical subspecialty fellowships. Dr. Mattar reported having no financial conflicts.

[email protected]