LETTER TO THE EDITOR
The Greater Benefit on Comprehensive General Surgery Resident Education Through Implementation of a Pediatric Surgery Fellowship We read with interest the recent article, Impact of implementation of a pediatric surgery fellowship on general surgery resident operative volume, which evaluated one potential effect of initiating a surgical fellowship on the categorical general surgery (CGS) resident education.1 Although the reduction in operative volume at the “Surgeon Junior” level observed in this study appeared real, the founders of the pediatric surgery (PS) fellowship at the core of this analysis are concerned that the reader may come away with an incomplete understanding of the far more positive influence the fellowship has had on the examined CGS residency and institution at large. This letter is intended to gently redirect the reader toward the greater good that a carefully planned PS fellowship can impart on CGS resident education, academic training, and specialty choice. The authors have done a good job collecting and analyzing data regarding the operative volume of CGS residents experienced on the PS service during periods before and after the initiation of a PS fellowship, and this issue is important. From the study findings, the authors correctly recommended that consideration be given to the effect on CGS resident operative volume when implementing a new fellowship. Indeed, the fellowship founders thoughtfully deliberated over this issue before application submission and established methods to ensure continued compliance with the American Board of Surgery case volume requirements while concomitantly enhancing the overall academic training of the CGS resident. The slight but statistically significant difference in base numbers, however, does not necessarily constitute an overall negative effect on, and should not serve as the sole surrogate for, the educational quality of CGS residents experienced on the PS service. Importantly, PS is really general surgery with an emphasis on surgical disorders unique to newborns and young children. As John Morgan pointed out in 1765, “It is not only expedient but necessary that a physician should have a general and extensive knowledge of the whole art, and be acquainted with every branch of his profession.”2 This philosophy has been applied to surgical education and expanded over time by Benjamin Rush, Halsted, Zollinger, H.W. Scott, Longmire, and others.3 Thus, CGS education requires that trainees rotate through all surgical specialties, 2
and PS, because of its general nature, has progressively become highlighted in the core surgical residency curriculum, offering CGS residents a broad exposure to diverse surgical anatomy and diseases, including disorders of non– cardiac thoracic, abdominal, head and neck, oncologic, childhood gynecologic, and urologic organ systems. Although CGS residents are not expected to master all aspects of PS, hence the need for further accredited fellowship training, each should become competent in the total management of common surgical disorders of childhood, should the surgeon choose to work in rural areas or overseas sites. Establishing such standards and competence in PS for all general surgeons in training has been and remains the case at the institution the authors evaluated. With regard to the volume changes reported, certain contexts and resident qualifications should be considered. The number of PS cases performed by CGS residents as Surgeon Junior, though slightly fewer in the postfellowship era, remained 2.5 times the Accreditation Council for Graduate Medical Education (ACGME) requirements, and the scope of index cases was similar to prior levels. The split of operative cases reported in the study was 41% for the CGS residents and 59% for the 2 PS fellows. Before the fellowship, the CGS residents never performed all PS cases; at best it was 70% commensurate with resident experience, case complexity, and attending dogma. In the fellowship era, CGS residents averaged slightly more than 1 case a day as Surgeon Junior, in addition to the other cases in which they participated. The opportunity for CGS residents to join the operative team in the First Assistant role on index PS cases being performed by a fellow remains and continues to be encouraged at the evaluated institution. Importantly, the PS fellows serve as active teachers and role models to CGS residents on work rounds, in preparation of conferences and manuscripts, and in the operating room. For example, one benefit of the fellowship not evaluated in the study has been the opportunity for the PS fellow in the role of Teaching Assistant to perform procedures with the CGS resident as Surgeon Junior. To provide a few examples, invaluable fellow-resident interactions have occurred during resection of a newborn sacrococcygeal teratoma, correction of newborn duodenal atresia, and portoenterostomy for infant biliary atresia, which
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.05.010
concomitantly prepare the PS resident for future teaching positions without detracting from the CGS operative experience. Based on the study findings by Snyder et al., more of these fellow-resident educational opportunities, which were indeed highlighted in the original fellowship application but which may have diminished over time, are being reemphasized to ensure moving forward the optimal surgical exposure for all level CGS residents and PS fellows, commensurate with ability. Additional significant indicators of the beneficial effects of the fellowship not evaluated in the Snyder study but important to consider include in the 5 years preceding its inception, 2 CGS residents authored 3 publications with PS faculty, and 4 entered a PS fellowship (3 of these in 2007, coinciding with launch of the new fellowship). After initiation of the PS fellowship, 16 CGS residents authored 33 publications with PS faculty, and 7 entered the PS match. In the second era, 1 PS faculty was recognized as the best educator among all divisions of surgery, 1 PS fellow was inducted into Alpha Omega Alpha (AOA), and another fellow earned the prestigious Levi Watkins, Jr. Award for outstanding contributions to the medical school. Furthermore, no evidence exists that CGS residents are performing less well on the PS sections of American Board of Surgery exams, likely because of the more structured educational curriculum introduced with the fellowship program, the establishment of Surgical Council on Resident Education standards, the added conferences in pediatric radiology, pathology, trauma, oncology, neonatology, and fetal evaluation, and the exposure to augmented pediatric basic and clinical research programs. All in all, the global picture of PS surgical education for CGS residents at the authors' institution has been greatly enhanced since the fellowship was established. In summary, we agree that any proposal to establish a specialty fellowship should be vetted to ensure CGS resident education is not harmed but moreover enhanced. Assuring a positive effect on CGS resident education has been a
longtime ACGME requirement to receive and maintain accreditation, and we shared that concern when preparing the original proposal for the PS fellowship. The application indeed was presented to and approved by the institutional review committee before submission to the ACGME. We predicted that the increased PS volume realized through the opening of the new, nationally lauded children's hospital would provide ample operative exposure to both CGS and PS residents far exceeding the number requirements set by the ABS for both, which annually has proven to be the case. Along the way, the larger institution has added to its national educational profile (currently ranked among the top 14 medical schools, 11 of which have a PS fellowship) and has contributed significantly to expanding the PS workforce that the society needs. Harold N. Lovvorn III, MD James A. O’Neill Jr., MD Vanderbilt University School of Medicine, Nashville, Tennessee E-mail address: [email protected] (H.N. Lovvorn III)
REFERENCES 1. Snyder RA, Phillips SE, Terhune KP. Impact of
implementation of a pediatric surgery fellowship on general surgery resident operative volume. J Surg Educ. 2012;69(6):753-758. 2. Morgan JA. Discourse Upon the Institution of Medical
Schools in America. Philadelphia: W Bradford Press; 1765. 3. O’Neill JA Jr. Surgical education: foundations and
values. J Am Coll Surg. 2009;208:653-662.
Journal of Surgical Education Volume 71/Number 1 January/Febraury 2014
3
The Greater Benefit on Comprehensive General Surgery Resident Education Through Implementation of a Pediatric Surgery Fellowship We read with interest the recent article, Impact of implementation of a pediatric surgery fellowship on general surgery resident operative volume, which evaluated one potential effect of initiating a surgical fellowship on the categorical general surgery (CGS) resident education.1 Although the reduction in operative volume at the “Surgeon Junior” level observed in this study appeared real, the founders of the pediatric surgery (PS) fellowship at the core of this analysis are concerned that the reader may come away with an incomplete understanding of the far more positive influence the fellowship has had on the examined CGS residency and institution at large. This letter is intended to gently redirect the reader toward the greater good that a carefully planned PS fellowship can impart on CGS resident education, academic training, and specialty choice. The authors have done a good job collecting and analyzing data regarding the operative volume of CGS residents experienced on the PS service during periods before and after the initiation of a PS fellowship, and this issue is important. From the study findings, the authors correctly recommended that consideration be given to the effect on CGS resident operative volume when implementing a new fellowship. Indeed, the fellowship founders thoughtfully deliberated over this issue before application submission and established methods to ensure continued compliance with the American Board of Surgery case volume requirements while concomitantly enhancing the overall academic training of the CGS resident. The slight but statistically significant difference in base numbers, however, does not necessarily constitute an overall negative effect on, and should not serve as the sole surrogate for, the educational quality of CGS residents experienced on the PS service. Importantly, PS is really general surgery with an emphasis on surgical disorders unique to newborns and young children. As John Morgan pointed out in 1765, “It is not only expedient but necessary that a physician should have a general and extensive knowledge of the whole art, and be acquainted with every branch of his profession.”2 This philosophy has been applied to surgical education and expanded over time by Benjamin Rush, Halsted, Zollinger, H.W. Scott, Longmire, and others.3 Thus, CGS education requires that trainees rotate through all surgical specialties, 2
and PS, because of its general nature, has progressively become highlighted in the core surgical residency curriculum, offering CGS residents a broad exposure to diverse surgical anatomy and diseases, including disorders of non– cardiac thoracic, abdominal, head and neck, oncologic, childhood gynecologic, and urologic organ systems. Although CGS residents are not expected to master all aspects of PS, hence the need for further accredited fellowship training, each should become competent in the total management of common surgical disorders of childhood, should the surgeon choose to work in rural areas or overseas sites. Establishing such standards and competence in PS for all general surgeons in training has been and remains the case at the institution the authors evaluated. With regard to the volume changes reported, certain contexts and resident qualifications should be considered. The number of PS cases performed by CGS residents as Surgeon Junior, though slightly fewer in the postfellowship era, remained 2.5 times the Accreditation Council for Graduate Medical Education (ACGME) requirements, and the scope of index cases was similar to prior levels. The split of operative cases reported in the study was 41% for the CGS residents and 59% for the 2 PS fellows. Before the fellowship, the CGS residents never performed all PS cases; at best it was 70% commensurate with resident experience, case complexity, and attending dogma. In the fellowship era, CGS residents averaged slightly more than 1 case a day as Surgeon Junior, in addition to the other cases in which they participated. The opportunity for CGS residents to join the operative team in the First Assistant role on index PS cases being performed by a fellow remains and continues to be encouraged at the evaluated institution. Importantly, the PS fellows serve as active teachers and role models to CGS residents on work rounds, in preparation of conferences and manuscripts, and in the operating room. For example, one benefit of the fellowship not evaluated in the study has been the opportunity for the PS fellow in the role of Teaching Assistant to perform procedures with the CGS resident as Surgeon Junior. To provide a few examples, invaluable fellow-resident interactions have occurred during resection of a newborn sacrococcygeal teratoma, correction of newborn duodenal atresia, and portoenterostomy for infant biliary atresia, which
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.05.010
concomitantly prepare the PS resident for future teaching positions without detracting from the CGS operative experience. Based on the study findings by Snyder et al., more of these fellow-resident educational opportunities, which were indeed highlighted in the original fellowship application but which may have diminished over time, are being reemphasized to ensure moving forward the optimal surgical exposure for all level CGS residents and PS fellows, commensurate with ability. Additional significant indicators of the beneficial effects of the fellowship not evaluated in the Snyder study but important to consider include in the 5 years preceding its inception, 2 CGS residents authored 3 publications with PS faculty, and 4 entered a PS fellowship (3 of these in 2007, coinciding with launch of the new fellowship). After initiation of the PS fellowship, 16 CGS residents authored 33 publications with PS faculty, and 7 entered the PS match. In the second era, 1 PS faculty was recognized as the best educator among all divisions of surgery, 1 PS fellow was inducted into Alpha Omega Alpha (AOA), and another fellow earned the prestigious Levi Watkins, Jr. Award for outstanding contributions to the medical school. Furthermore, no evidence exists that CGS residents are performing less well on the PS sections of American Board of Surgery exams, likely because of the more structured educational curriculum introduced with the fellowship program, the establishment of Surgical Council on Resident Education standards, the added conferences in pediatric radiology, pathology, trauma, oncology, neonatology, and fetal evaluation, and the exposure to augmented pediatric basic and clinical research programs. All in all, the global picture of PS surgical education for CGS residents at the authors' institution has been greatly enhanced since the fellowship was established. In summary, we agree that any proposal to establish a specialty fellowship should be vetted to ensure CGS resident education is not harmed but moreover enhanced. Assuring a positive effect on CGS resident education has been a
longtime ACGME requirement to receive and maintain accreditation, and we shared that concern when preparing the original proposal for the PS fellowship. The application indeed was presented to and approved by the institutional review committee before submission to the ACGME. We predicted that the increased PS volume realized through the opening of the new, nationally lauded children's hospital would provide ample operative exposure to both CGS and PS residents far exceeding the number requirements set by the ABS for both, which annually has proven to be the case. Along the way, the larger institution has added to its national educational profile (currently ranked among the top 14 medical schools, 11 of which have a PS fellowship) and has contributed significantly to expanding the PS workforce that the society needs. Harold N. Lovvorn III, MD James A. O’Neill Jr., MD Vanderbilt University School of Medicine, Nashville, Tennessee E-mail address: [email protected] (H.N. Lovvorn III)
REFERENCES 1. Snyder RA, Phillips SE, Terhune KP. Impact of
implementation of a pediatric surgery fellowship on general surgery resident operative volume. J Surg Educ. 2012;69(6):753-758. 2. Morgan JA. Discourse Upon the Institution of Medical
Schools in America. Philadelphia: W Bradford Press; 1765. 3. O’Neill JA Jr. Surgical education: foundations and
values. J Am Coll Surg. 2009;208:653-662.
Journal of Surgical Education Volume 71/Number 1 January/Febraury 2014
3
