ORIGINAL REPORTS

Career Plans and Perceptions in Readiness to Practice of Graduating General Surgery Residents in Canada Ashlie Nadler, MD,* Shady Ashamalla, MD,† Jaime Escallon, MD,‡,§ Najma Ahmed, PhD,║ and Frances C. Wright, MD† Division of General Surgery, University of Toronto, Toronto, Ontario, Canada; †Division of Surgical Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; ‡Division of Surgical Oncology, Mount Sinai Hospital, Toronto, Ontario, Canada; §Division of Surgical Oncology, University Health Network, Toronto, Ontario, Canada; and ║Division of General Surgery, St Michael’s Hospital, Toronto, Ontario, Canada *

INTRODUCTION: Overall, 25% of American general

CONCLUSIONS: An overwhelming majority of general

surgery residents identified as not feeling confident operating independently at graduation, which may contribute to 70% pursuing further training. This study was undertaken to identify intended career plans of general surgery graduates in Canada on a national level, and perceived strengths and weaknesses of training that would affect transition to early practice.

surgery graduates plan to pursue fellowship training to meet career goals of working in urban, academic centers, rather than a perceived lack of competence. It is vital to describe operative competency expectations for residents and to promote a variety of practice opportunities following C 2014 graduation. ( J Surg 72:205-211. Crown Copyright J Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery. All rights reserved.)

METHODS: Questionnaires were distributed to graduating general surgery residents at a Canadian national review course in 2012 and 2013. Data were analyzed for overall trends. RESULTS: Overall, 75% (78/104) of graduating residents

responded in 2012 and 53% (50/95) in 2013. Greater than 60% of respondents were entering a fellowship program upon graduation (49/78 in 2012 and 37/50 in 2013); the most common fellowship choices were minimally invasive surgery (24% in 2012 and 39% in 2013) or surgical oncology (16% in 2012). Most residents reported that they were completing subspecialty training to meet career goals (64/85 overall) rather than feeling unprepared for practice (0/85 overall). Most residents planned on practicing in urban centers (54%) and academic hospitals (73%). Residents perceived a need for assistance for laparoscopic adrenalectomy, neck dissection, laparoscopic splenectomy, laparoscopic low anterior resection, groin dissection, and thyroidectomy.

Correspondence: Inquiries to Ashlie Nadler, MD, Division of General Surgery, University of Toronto, Odette Cancer Centre T2-057, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5; fax: (416) 480-4210; e-mail: ashlie. [email protected]

KEY WORDS: general surgery, graduates, residency, com-

petence, career plans, work-hour restrictions COMPETENCIES: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement

INTRODUCTION General surgery training programs face the task of preparing graduates for both direct entry into practice and fellowship training for further subspecialization. During residency, trainees are expected to gain exposure and competence in a broad spectrum of clinical situations and operative procedures regardless of career plans. However, few graduates enter directly into practice,1 which raises questions about why residents are choosing to pursue fellowship training rather than entering directly into practice. In the United States, it has been reported that 70% of general surgery graduates pursue fellowship training.2 This elongation of training has been attributed to a lack of competence afforded through a 5-year residency program.2 Importantly, approximately 25% of American trainees felt that they would not be confident operating independently at graduation.3,4 Program directors have expressed concern that further work-hour restrictions in the United States may

Journal of Surgical Education  Crown Copyright & 2014 Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery. 1931-7204/$30.00 All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.10.001

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reduce residents’ ability to achieve competence within a 5-year residency program, particularly in general surgery.5 Christmas et al.6 found that work-hour restrictions significantly decreased the total number of cases performed by final-year surgical residents and concluded that a reduced workweek had the greatest influence on the chief year operative experience. Drake et al.7 also identified a decrease in operative caseload following the implementation of an 80-hour workweek in the United States in 2003. A recent member survey by the Canadian Association of General Surgeons identified that practicing surgeons perceived a gradual decline in technical skills among senior residents.8 The authors suggested that the deterioration in operative competency necessitates further training through fellowships. They attribute the perceived deterioration in skills to an increase in subspecialization, a lack of surgeons with broad-based practices in academic training programs, and an overemphasis on research. However, other authors have suggested that fellowships enable graduates to gain additional operative and clinical experience.1 Little is known about general surgery graduating residents’ perceived competence and their intended career paths in Canada. Demographics and career plans of residents are not available to residency training programs at a national level. In addition, specific procedural competency expectations are not defined by national surgery boards. This study aimed to identify intended career plans of general surgery graduates on a national level, and perceived operative strengths and weaknesses of their training that would affect transition to practice.

METHODS Questionnaires were designed by a committee of general surgeons at the University of Toronto with an interest and expertise in surgical education. It included questions related to demographics, career plans, and perceived strengths and weaknesses for selected competencies. Competencies of interest for specific procedures were selected based on core competencies defined by the Royal College of Physicians and Surgeons of Canada (RCPSC) and the American Board of Surgery.9,10 The committee generated a list of potential

general surgery procedures for assessing perceived competence. The list was then reduced to include competencies that fit into 1 of 2 categories, which were established by consensus by the committee. The first group included procedures that residents would be expected to have mastered at the end of residency (i.e., sentinel lymph node biopsy), and the second group included those that were more advanced and were anticipated to require further subspecialty training to achieve competence (i.e., laparoscopic adrenalectomy). The specific procedures and groups are shown in Table 1. Questions addressed perceptions that graduating residents held of their performance regarding independent completion of such operations. A pilot study was conducted using the questionnaire among a group of residents at our institution for face and content validity, and it was revised accordingly. The questionnaires were distributed to graduating general surgery residents at an annual national review course, the Canadian General Surgery Review, initially in 2012 (cohort 1). The review course was selected for distribution of questionnaires as it is widely attended by graduating general surgery residents from across Canada. The course was designed for graduating general surgery residents; however, attendance was not limited to graduates only. As such, attendees who were not currently graduating, had previously graduated, or did not complete residency in Canada were excluded from the analysis. The questionnaire was then revised based on responses from the initial cohort of graduates in 2012 to clarify and facilitate questionnaire completion and reduce reporting bias. The revised questionnaire was distributed to a second cohort of graduates at a subsequent national review course in 2013 (cohort 2). Follow-up emails were sent to cohort 1 following the review course to improve response rates via an online questionnaire. Email responses were collected from April to August 2012. Consent was implied by completion of the questionnaire, as outlined in a cover letter to potential respondents. The number of graduating general surgery residents in 2012 and 2013 was obtained from the program directors of each of the 16 individual training programs. Data were analyzed using Microsoft Excel for overall trends in demographics, career plans, and perceptions. The Mann-Whitney U test was used to calculate statistical

TABLE 1. General Surgery Procedures Designated by Consensus by Level of Competency Expected at the Time of Graduation Expected to Master at the End of Residency Training

Anticipated to Require Further Subspecialty Training to Achieve Competence

Open right hemicolectomy Laparoscopic right hemicolectomy Cricothyroidotomy Thyroidectomy Open splenectomy Sentinel lymph node biopsy Mastectomy Open low anterior resection

Component separation Neck dissection Groin dissection Laparoscopic adrenalectomy Laparoscopic splenectomy Laparoscopic low anterior resection

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differences between residents pursuing a fellowship compared with those entering directly into practice. Ethics approval was obtained from the Sunnybrook Health Sciences Centre Research Ethics Board.

RESULTS Demographics and Career Plans There were 104 and 95 graduating residents in 2012 and 2013, respectively. The response rate was 75% (78/104) in 2012 and 53% (50/95) in 2013. In total, 81 responses were obtained in 2012, 10 of which were excluded. In 2012, there were 71 questionnaires included from the review course and an additional 7 included from email respondents. There were 54 responses obtained in 2013, 4 of which were similarly excluded. In 2013, all the questionnaires were completed at the review course. Flow diagrams of respondents are shown in Figures 1 and 2. Overall, 56% of the respondents in 2012 were women, and 38% in 2013. In 2012, 63% of graduates were entering a fellowship program, compared with 74% of those in 2013. Only 19% of graduates (21% for cohort 1 and 16% for cohort 2) were entering directly into practice with a fulltime job (Table 2). Most graduates wanted to work in academic tertiary care or academic-affiliated hospitals (73%). Similarly, most graduates wanted to practice in an area with a population

FIGURE 2. Flow diagram of questionnaire respondents in 2013.

of more than 300,000 people (54%). Overall, 84% of graduates indicated that they were pursuing a fellowship to meet career goals. None of the respondents indicated that they were pursuing a fellowship because they did not feel ready to enter practice. In terms of fellowships, in cohort 1, most residents were entering fellowships in minimally invasive surgery (MIS, 24%) or surgical oncology (16%). In cohort 2, most were entering fellowships in MIS (39%), followed by intensive care, colorectal surgery, and vascular surgery (8% each). Overall, 66% of residents were pursing fellowships in Canada, whereas 33% of graduates from 2012 and 17% of graduates from 2013 were going to the United States for further subspecialty training. Perceived Competencies In terms of perceived competence at the time of graduation, most residents identified laparoscopic adrenalectomy, neck dissection, laparoscopic splenectomy, laparoscopic low anterior resection, groin dissection, and thyroidectomy as the procedures in which they required assistance for most or part of the operation. All of these procedures, except thyroidectomy, were anticipated to require further subspecialty training to achieve competence at the time of graduation by consensus by the study committee. Perceptions regarding performance of surgical procedures can be seen in Figure 3. A significant difference was observed in perceived competence between residents entering into fellowship and those entering directly into practice for mastectomy (p ¼ 0.048) and axillary sentinel lymph node biopsy (p ¼ 0.009). No difference was observed between residents entering into fellowship and those entering directly into practice for all other procedures.

DISCUSSION FIGURE 1. Flow diagram of questionnaire respondents in 2012.

In our 2-year study of graduating general surgery residents, most respondents reported pursuing fellowships to meet

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TABLE 2. Summary of Demographics and Career Plans of Graduating General Surgery Residents in 2012 (Cohort 1) and 2013 (Cohort 2)

Sex Male Female Residency location Ontario Quebec Manitoba Saskatchewan Alberta British Columbia Maritimes Additional degree None Master’s PhD Other Timing of degree Surgeon Scientist Program (SSP) During residency, non-SSP Before residency Plan at graduation Fellowship Practice Leave of absence Locum No job, just call Clinical associate Looking for a job Other Type of practice Academic tertiary care hospital Academic-affiliated community hospital Non–academic-affiliated community hospital Other Size of practice o50,000 people 50,000 to 100,000 people 100,000 to 300,000 people 4300,000 people Other Type of fellowship Acute care surgery Breast surgery Colorectal surgery Hepatobiliary surgery Intensive care Minimally invasive/bariatric surgery Pediatric surgery Surgical oncology Thoracic surgery Transplant surgery Trauma surgery Vascular surgery Other Location of fellowship Canada United States International Unknown 208

Cohort 1

Cohort 2

Total

Percent (n)

Percent (n)

Percent (n)

n ¼ 78 44% (34) 56% (44) n ¼ 78 37% (29) 27% (21) 4% (3) 4% (3) 9% (7) 10% (8) 9% (7) n ¼ 78 63% (49) 29% (23) 6% (5) 1% (1) n ¼ 30 20% (6) 37% (11) 43% (13) n ¼ 78 63% (49) 21% (16) 1% (1) 8% (6) 1% (1) 3% (2) 3% (2) 1% (1) n ¼ 77 38% (29) 35% (27) 14% (11) 13% (10) n ¼ 78 6% (5) 15% (12) 22% (17) 51% (40) 5% (4) n ¼ 49 2% (1) 0% (0) 6% (3) 0% (0) 8% (4) 24% (12) 4% (2) 16% (8) 4% (2) 0% (0) 8% (4) 12% (6) 16% (8) n ¼ 49 57% (28) 33% (16) 6% (3) 4% (2)

n ¼ 47 62% (29) 38% (18) n ¼ 50 38% (19) 22% (11) 6% (3) 10% (5) 10% (5) 4% (2) 10% (5) n ¼ 50 68% (34) 28% (14) 2% (1) 2% (1) n ¼ 16 44% (7) 31% (5) 25% (4) n ¼ 50 74% (37) 16% (8) 0% (0) 10% (5) 0% (0) 0% (0) 0% (0) 0% (0) n ¼ 49 24% (12) 49% (24) 18% (9) 8% (4) n ¼ 49 6% (3) 10% (5) 24% (12) 57% (28) 2% (1) n ¼ 36 3% (1) 6% (2) 8% (3) 6% (2) 8% (3) 39% (14) 6% (2) 6% (2) 0% (0) 0% (0) 3% (1) 8% (3) 8% (3) n ¼ 30 80% (24) 17% (5) 3% (1) 0% (0)

n ¼ 125 50% (63) 50% (62) n ¼ 128 38% (48) 25% (32) 5% (6) 6% (8) 9% (12) 8% (10) 9% (12) n ¼ 128 65% (83) 29% (37) 5% (6) 2% (2) n ¼ 46 28% (13) 35% (16) 37% (17) n ¼ 128 67% (86) 19% (24) 1% (1) 9% (11) 1% (1) 2% (2) 2% (2) 1% (1) n ¼ 126 33% (41) 40% (51) 16% (20) 11% (14) n ¼ 127 6% (8) 13% (17) 23% (29) 54% (68) 4% (5) n ¼ 85 2% (2) 2% (2) 7% (6) 2% (2) 8% (7) 31% (26) 5% (4) 12% (10) 2% (2) 0% (0) 6% (5) 11% (9) 13% (11) n ¼ 79 66% (52) 27% (21) 5% (4) 3% (2)

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TABLE 2 (continued)

Reason for fellowship Meet career goals Increase likelihood of getting a job Keep options open Not ready to enter practice Other

career goals, and not because of a perceived lack of preparedness for practice. However, there were some procedures in which competency would be expected at the time of graduation, such as thyroidectomy, that respondents felt they required further training to perform independently. In general, advanced MIS and surgical

Cohort 1

Cohort 2

Total

Percent (n)

Percent (n)

Percent (n)

n ¼ 49 84% (41) 4% (2) 4% (2) 0% (0) 8% (4)

n ¼ 36 64% (23) 11% (4) 6% (2) 0% (0) 19% (7)

n ¼ 85 75% (64) 7% (6) 5% (4) 0% (0) 13% (11)

oncology procedures were perceived as requiring the most assistance, and these perceived areas of deficiency mirror areas in which fellowship training was sought. Our results parallel those of other studies, suggesting that this is not an isolated finding.3,4 Gillman and Vergis11 reported that graduating Canadian general surgery residents feel compe-

FIGURE 3. Perceived performance of surgical procedures by graduating general surgery residents in 2012 and 2013. Journal of Surgical Education  Volume 72/Number 2  March/April 2015

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tent in basic general surgery procedures, and less comfortable performing advanced laparoscopic, and specialized procedures. Friedell (2014) also reported that American chief residents pursued fellowships out of an interest in the subspecialty and not a lack of perceived competence. Residents in their study also felt confident performing essential operations, but were uncomfortable with advanced hepatobiliary procedures.12 Both Canadian and American general surgery residency training programs are 5-year programs. In both the systems, some programs offer the option to extend training to undertake research. Both the RCPSC and the American Accreditation Council for Graduate Medical Education (ACGME) define expected competencies to be attained by the completion of general surgery residency training.9,13 However, Canadian institutions focus on competency-based evaluations, whereas the ACGME also uses case volume as a metric for evaluation. Despite the growing trend toward subspecialization, graduating residents should be expected to obtain competence in common general surgery procedures. In part, perceived competence may be low for certain procedures because there is a lack of explicit definitions of what procedures need to be mastered by the end of residency training. Neither the American Board of Surgery nor the RCSPC offer a defined list of procedures that residents are expected to master, rather a list of general categories in which skills should be obtained. Although this may have been sufficient in the past, the current breadth and depth of general surgery demands a defined list of competencies, as it is unrealistic to expect graduates to master the entire scope of general surgery. In a study by Bell et al.,2 program directors identified 121 procedures in which they expected graduating general surgery residents to be able to perform independently. However, when comparing these procedures with the operative experience of chief residents, 52% of the procedures were most commonly reported as never having been performed during residency. In addition, Fronza et al.4 found that graduates felt prepared to perform only 24% of procedures encompassing the scope of general surgery. Overall, 39% of the operations identified by graduates were believed to be irrelevant to most of their practices. Competency-based training, in which residents undertake rotations until required skills and knowledge have been obtained, rather than for set time period of training, has been proposed as 1 way to maintain resident case numbers and allow for a minimum level of proficiency.14 However, this model of training seems unreachable when specific procedural competencies have yet to be defined. It is imperative that an up-to-date standardized list of operations in which graduates should be competent be created and used nationally. Input from both program directors and residents should be incorporated. In our study, significantly more residents entering directly into practice perceived requiring less assistance for breast procedures, which were 210

among those anticipated to be mastered by the end of residency, than those pursuing a fellowship. A defined list of procedures would allow all residents to have adequate training in areas identified as being key operations to master during residency, regardless of practice type upon graduation. At our institution, specific procedures have been identified as part of the guidelines for promotion to the subsequent academic year.15 This may allow residents to develop an awareness of what level of competency is expected to progress, and it may be useful as a competency-based evaluation tool. The RCSPC currently uses a competency-based metric and plans to incorporate specific milestones into residency training to further ensure competence at the time of graduation.16 The ACGME provides mean case numbers and benchmarks for American surgical residents.17 Although case logs are mandatory in Canada, no minimum case requirements or targets exist on a national level. Friedell et al.12 found that case volume (greater than 950 cases) was a significant factor affecting the confidence of graduating residents. Although mean case numbers should be documented and published in Canada for comparison, competency-based evaluations over volume-based evaluations appear to be the focus of current accreditation standards set forth from the RCSPC. After completing training, only 7% of our respondents were pursuing fellowship training to make themselves more employable. Unfortunately, in a recent study from the RCPSC, 28.3% of new general surgery certificants stated that they were unable to find employment.18 This was attributed partly to an increased reliance on residents at academic centers, resulting in an excess of graduates. The number of trainees to whom positions are offered may need to be addressed by individual training programs or on a national level to balance the supply and demand of practicing and graduating general surgeons. However, the study by the RCPSC also noted that for more than 90% of those who did not have a job, it was related to not wanting to relocate or work in a community hospital or rural setting. In our study, greater than 70% of graduates wanted to work in academic tertiary care or academic-affiliated hospitals and more than 50% wanted to practice in a city with a population of greater than 300,000 people. This highlights the imbalance between supply and demand across the country, as not all graduates can work in highly academic and urban settings. Expectations of available practice environments should be discussed and explored early in residency training. Efforts should be made to attract candidates with an interest in practicing in smaller, community practices and to provide exposure to such practices throughout residency. Graduates who are unable to find full-time employment are anecdotally taking part-time positions that consist mainly of covering call for other surgeons without any elective operative time. These positions include call only, temporary clinical associate positions in which one assists

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with the elective practice of other surgeons and covers calls, and locums in which one covers the practice of another surgeon for a defined period of time (i.e., vacation, maternity leave). The RCPSC report on employment states that unemployed graduates are combining locum and parttime positions.18 Limitations in the current study are imposed by the questionnaire design. Residents’ perceptions of their training are self-reported and are therefore subject to bias. Residents may be hesitant to fully express their opinions for fear of being identified based on the data collected, even though confidentiality and privacy were assured. This may lead to reporting of a higher level of competence than that actually perceived by residents completing the survey. Residents who had very low perceived competence levels may not have completed the survey at all, potentially inflating the reported perceptions of training. This study is unique in that it is the first to identify career plans and perceptions of competence among graduating general surgery residents on a national level. It is of relevance to both current graduates seeking fellowships and employment and residency training programs. Expectations for residents in terms of competencies and future practices should be established and encouraged throughout residency training.

7. Drake FT, Horvath KD, Goldin AB, Gow KW. The

general surgery chief resident operative experience: 23 years of national ACGME case logs. JAMA Surg. 2013;148(9):841-847. 8. Canadian Association of General Surgeons. 2011 needs

assessment. Ottawa. Available at: 〈http://www.cags-accg. ca/userfiles/english%20summer2009%20final.pdf〉; 2009.

9. Royal College of Physicians and Surgeons of Canada.

Objectives of training in the specialty of general surgery. Available at: 〈http://www.royalcollege.ca/cs/groups/pub lic/documents/document/y2vk/mdaw/ edisp/tztest3rcp sced000902.pdf〉; 2010. 10. The American Board of Surgery. Specialty of general

surgery defined. Available at: 〈http://www.absurgery. org/default.jsp?aboutsurgerydefined〉; 2013.

11. Gillman LM, Vergis A. General surgery graduates may

be ill prepared to enter rural or community surgical practice. Am J Surg. 2013;205(6):752-757. 12. Friedell ML, VanderMeer TJ, Cheatham ML, et al.

Perceptions of graduating general surgery chief residents: are they confident in their training? J Am Coll Surg. 2014;218(4):695-703. 13. Accreditation Council for Graduate Medical Education.

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16. Royal College of Physicians and Surgeons of Canada. The

Draft CanMEDS 2015 Milestones Guide. Available at: 〈http://www.royalcollege.ca/portal/page/portal/rc/ common/documents/canmeds/framework/canmeds2015_ draft_milestones_e.pdf〉; 2014. 17. Accreditation Council for Graduate Medical Education.

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Datta I. What’s Really Behind Canada’s Unemployed Specialists? Too Many, Too Few Doctors? Findings From the Royal College’s Employment Study. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2013.

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Career plans and perceptions in readiness to practice of graduating general surgery residents in Canada.

Overall, 25% of American general surgery residents identified as not feeling confident operating independently at graduation, which may contribute to ...
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