LETTER TO THE EDITOR General Surgery Residency Inadequately Prepares Trainees for Fellowship: Results of a Survey of Fellowship Program Directors To the Editor: he article by Mattar et al1 with the accompanying discussion is a fascinating exploration of the problems with surgical education today. Although many may disagree, and have disagreed, with the methodology or the seriousness of the problem, it seems that most of all would agree with Dr Lewis’s comments that there certainly is a problem, and it is multifactorial. As one who was intimately involved in residency education for 29 years and has been involved in rural surgery for the past 3 years, I believe I may have some unique perspectives on this problem. First class residency programs of the past provided residents with a broad and deep education that allowed them to practice a broad and deep variety of surgery. The combination of cultural changes in resident applicants, work hour reforms, and the growth of fellowship programs have made this impossible. Perhaps more importantly, the cultural changes and demands of hospitals have made it unnecessary to train the broad, deep general surgeon—there simply is no job for them. The large urban hospital wants specialists, and trust me, the rural hospital is simply unequipped to care for the complex patients that a superbly trained surgeon cares for. Thus, what we are left with now is how to provide a broad, shallow general surgeon for rural facilities, basic surgical education for specialists, and ideally a shorter period of training. The Transition to Practice program may well fill the short-term need, but in the long-term, how do we provide general surgeons while streamlining the educational process? First, we must recognize how we got into this situation. Drs Malangoni and Meyer allude to the fact that one cannot provide the same education to residents and fellows1 — this needs to be overtly recognized by all. In fact, one of the great weaknesses of this article’s methodology is that those who evaluated residents’ preparation for fellowship are those who were responsible for degrading the same residents’ preparation through the formation

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Disclosure: The author declares no conflicts of interest. C 2013 by Lippincott Williams & Wilkins Copyright  ISSN: 0003-4932/13/26101-e0006 DOI: 10.1097/SLA.0000000000000476

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of fellowships! I derived a certain schadenfreude in reading the article and comments, as this was my prediction of the effect of fellowships, and a major factor in my retirement from the educational process. But being in our current position, we must proceed in a way which will meet all our demands: decreasing length of training, providing education in general surgery, and providing preliminary education for specialty areas. It would seem this could be best met with a brief period (perhaps 2 years) of training to be followed by specialty training, the “general surgical” training being trauma and acute care surgery or a rural surgery tract. Sure, the pediatric surgeons will be unhappy, but one cannot always get what one wants. General Surgery is dead, we killed it, and now it is time to build its successor. Many “old school” surgeons, including me, may believe that this is NOT what is best for the public health, but given the demands of society, we have to compromise, and if I can, anyone can. It is time for the ACS, the ABS, and the RRC to quit talking and start acting. Charles M. Ferguson, MD Emory Clark-Holder Clinic Surgery, La Grange, GA [email protected]

REFERENCE 1. 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;258:440–449, discussion 447–449.

Reply: would like to thank Dr Ferguson for his insightful comments regarding our article. There is no doubt that General Surgery has suffered a significant identity crisis, and that there is poor alignment along the continuum of training with respect to the goals of training. Despite admirable attempts by the ABS Score Initiative to define the core of General Surgery, there remains a serious disconnect between the “common” and “uncommon essential” categories defined by the SCORE curriculum, and the case requirements that are dictated by the Residency Review Committee. As we move toward implementation of training milestones, it is important that all stakeholders and accrediting/certifying bodies are in sync with a realistic definition of what a well-trained General Surgeon should be able to do. The glaring reality is that more than 85% of residents are pursuing fellowships, and although

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Disclosure: The authors declare no conflicts of interest. DOI: 10.1097/SLA.0000000000000477

the data presented in this article are focused on readiness for transition to fellowship, the reasons residents pursue fellowship training are certainly multifactorial and are at least in part due to a feeling that they are not yet fully trained. Although our trainees have multiple interests, there continues to be primarily a “one size fits all” model of residency training despite the availability of a flexible rotation assignment in the final 3 years of training that might potentially offer an alternative to fellowship training. This lack of a significant change toward a more flexible General Surgery residency structure is likely due to the formidable logistical challenges that face a Residency Program Director who has to comply with an unpredictable rotation assignment that depends on residents’ varying interests. Thus, current residents have much more limited exposure to various areas, rather than a deeper experience in a more focused area of interest that may lead to greater autonomy by the completion of General Surgery training. Loss of autonomy is also a very important problem. Although this loss of autonomy is due to many factors, it is mainly related to strict supervision requirements imposed by several factors, including multiple external regulators, the public’s expectations, and the increased pressure for efficiency in clinical practice. In reality, the first time a resident performs an operation in an independent fashion is after completion of training. It is this lack of autonomy that most likely acts as the primary driving force that underpins the findings in this study—not duty hour restrictions or lack of commitment by our trainees, which was in fact noted to be very high in this study. Ideally, fellowship training should serve to provide focused training in a particular field of Surgery with the objective of achieving specialty expertise. In the current environment, fellowships serve as a key transitional experience for gaining autonomy and for accrual of the graduated independence that is currently missing in General Surgery training; as evidenced by our study and studies performed by others surveying recently graduated residents.1–3 With respect to the negative impact of fellowships on General Surgery residents’ experience, data from the ABS presented by Dr Borman and colleagues demonstrate that in those programs with residents and Accreditation Council for Graduate Medical Education-accredited specialty fellowships, General Surgery residents actually have a greater experience in these specialties.4 This observation is probably due to the existence of a programmatic effort that results in a larger portfolio of cases within these specialty domains. It is also important to note that most fellowship cases fall into the

Annals of Surgery r Volume 261, Number 1, January 2015

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Annals of Surgery r Volume 261, Number 1, January 2015

category of “complex” cases as defined by SCORE and thus reside outside the scope of what has been defined as the core of General Surgery. We would posit that in an ideal world, the milestones assessment would be aligned with the core of General Surgery and once the resident is “certified”; on the basis of robust assessment in the management of diseases and procedures as defined by the SCORE curriculum (uncommon and common essential domains), they would then be credentialed in a progressive and transparent manner. Once verified as proficient within the domains defined as the core of General Surgery, they could then focus on developing skills directed toward their planned future practice. This could occur within the context of the 5 years of General Surgery training such that it would not impact current funding models for Graduate Medical Education, and would lead to both better trained General Surgeons upon completion of residency, and better prepared incoming fellows who are ready to maximally benefit from day 1. Samer G. Mattar, MD, FACS Department of Surgery Indiana University School of Medicine Indianapolis [email protected] Rebecca M. Minter, MD, FACS Department of Surgery University of Michigan Ann Arbor [email protected]

REFERENCES 1. 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: 440–449. 2. Bucholz EM, Sue GR, Yeo H, et al. Our trainees’ confidence: Results from a national survey of

4136 US General Surgery Residents. Arch Surg. 2011;146:907–914. 3. Fronza JS, Prystowski JP, DaRosa D, et al. Surgical residents’ perception and relevance of the clinical curriculum to future practice. J Surg Educ. 2012;69:792–797. 4. Hanks JB, Ashley SW, Mahvi DM, et al. Feast or famine? The variable impact of coexisting fellowships on General Surgery Resident Operative Volumes. Ann Surg. 2011;254:476–483.

Reply: r Ferguson has raised some vexing issues about the present paradigm for surgical training. Residency training by and large has not sufficiently adapted to the multiple changes in health care delivery that have occurred in the last half century. Patients are sicker, hospital care for most illnesses has contracted or vanished, and both knowledge and technology have advanced exponentially. Contact between residents and patients is often truncated, yet the complexities of care are more challenging. Duty hour regulations have tarnished the bond between residents and patients. Dr Ferguson correctly emphasizes that training residents for a variety of end points presents a dilemma. Some graduates will practice general surgery, others will become specialists and restrict their practice to a narrower field, and a third group will seek additional training but end up with a hybrid practice of broad-based general surgery with emphasis in a subspecialty area. All must have the basis to adapt to advances in care that inevitably occur regardless of the field of endeavor. Increasing specialization in medicine has resulted in major advances in care. Our patients expect and demand the best treatment and who can blame them? I don’t agree with some of Dr Ferguson’s comments. It is not “impossible”

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to train general surgeons. Some residencies have a remarkable record of doing so and many of their graduates pursue a broad-based practice. We need to learn from their successes if we hope to change the present situation. There are plenty of jobs in general surgery.1 Even tertiary medical centers have realized that they need general surgeons to care for patients with common diseases that do not require care by a subspecialist. General surgeons are anything but “shallow.” They are expected to provide the same high standard of care as subspecialists often in more diverse situations and frequently with less robust support systems to assist them and they regularly meet that challenge. Dissatisfaction with the state of surgical training is not new. There have been rumblings about this issue for decades. We cannot retrench to the past and we should not. As he states, this is a multifactorial problem. Like problems in most complex systems, solutions are not simple and require thoughtful planning, compromise, and revamping of the current training model. There are serious efforts underway by the American Board of Surgery and the American College of Surgeons to address this issue. The collective wisdom of the members of these and other organizations can identify the solution, but the real question is whether each of us is ready to change to achieve a better result. Mark A. Malangoni, MD American Board of Surgery Philadelphia, PA [email protected]

REFERENCE 1. Cofer JB, Burns RP. The developing crisis in the national general surgery workforce. J Am Coll Surg. 2008;206:790–797.

Disclosure: The authors declare no conflicts of interest. DOI: 10.1097/SLA.0000000000000478

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