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Transition to Surgical Residency

A Multi-Institutional Study of Perceived Intern Preparedness and the Effect of a Formal Residency Preparatory Course in the Fourth Year of Medical School

Minter, Rebecca M. MD; Amos, Keith D. MD; Bentz, Michael L. MD; Blair, Patrice Gabler MPH; Brandt, Christopher MD; D’Cunha, Jonathan MD, PhD; Davis, Elisabeth PhD; Delman, Keith A. MD; Deutsch, Ellen S. MD; Divino, Celia MD; Kingsley, Darra MD; Klingensmith, Mary MD; Meterissian, Sarkis MD; Sachdeva, Ajit K. MD; Terhune, Kyla MD; Termuhlen, Paula M. MD; Mullan, Patricia B. PhD

doi: 10.1097/ACM.0000000000000680
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Purpose To evaluate interns’ perceived preparedness for defined surgical residency responsibilities and to determine whether fourth-year medical school (M4) preparatory courses (“bootcamps”) facilitate transition to internship.

Method The authors conducted a multi-institutional, mixed-methods study (June 2009) evaluating interns from 11 U.S. and Canadian surgery residency programs. Interns completed structured surveys and answered open-ended reflective questions about their preparedness for their surgery internship. Analyses include t tests comparing ratings of interns who had and had not participated in formal internship preparation programs. The authors calculated Cohen d for effect size and used grounded theory to identify themes in the interns’ reflections.

Results Of 221 eligible interns, 158 (71.5%) participated. Interns self-reported only moderate preparation for most defined care responsibilities in the medical knowledge and patient care domains but, overall, felt well prepared in the professionalism, interpersonal communication, practice-based learning, and systems-based practice domains. Interns who participated in M4 preparatory curricula had higher self-assessed ratings of surgical technical skills, professionalism, interpersonal communication skills, and overall preparation, at statistically significant levels (P < .05) with medium effect sizes. Themes identified in interns’ characterizations of their greatest internship challenges included anxiety or lack of preparation related to performance of technical skills or procedures, managing simultaneous demands, being first responders for critically ill patients, clinical management of predictable postoperative conditions, and difficult communications.

Conclusions Entering surgical residency, interns report not feeling prepared to fulfill common clinical and professional responsibilities. As M4 curricula may enhance preparation, programs facilitating transition to residency should be developed and evaluated.

R.M. Minter is associate chair of education and associate program director, Department of Surgery, associate professor and chief, Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, and associate professor, Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan.

K.D. Amos was, at the time of this research, associate professor, Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina.

M.L. Bentz is professor and chairman, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin.

P. Gabler Blair is associate director, Division of Education, American College of Surgeons, Chicago, Illinois.

C. Brandt is the chair and Richard B. Fratianne MD Professor of Surgery, Department of Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio.

J. D’Cunha was, at the time of this research, associate program director, Division of Thoracic and Foregut Surgery, and assistant professor, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, and is now associate professor and associate director of lung transplantation, associate program director of thoracic surgery, and vice chairman, Academic Affairs, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.

E. Davis is education research associate, Division of Education, American College of Surgeons, Chicago, Illinois.

K.A. Delman is associate professor, Department of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia.

E.S. Deutsch is physician, Division of Pediatric Otolaryngology, Alfred I. duPont Hospital for Children, Wilmington, Delaware.

C. Divino is professor and chief, Division of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.

D. Kingsley is assistant professor, Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico.

M. Klingensmith is vice chair of education and Mary Culver Distinguished Professor, Department of General Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri.

S. Meterissian is associate dean, Postgraduate Medical Education, and program director, General Surgery, Department of Medicine, McGill University, Montreal, Québec, Canada.

A.K. Sachdeva is director, Division of Education, American College of Surgeons, Chicago, Illinois.

K. Terhune is assistant professor, Department of Surgery, and assistant professor of anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee.

P.M. Termuhlen is associate program director and professor, Department of Surgery, Boonshoft School of Medicine, Wright State University, Dayton, Ohio.

P.B. Mullan is professor, Department of Learning Health Sciences, University of Michigan School of Medicine, Ann Arbor, Michigan.

Funding/Support: The American College of Surgeons Division of Education has provided extensive support for this work and for the development and maintenance of the national preparatory curriculum.

Other disclosures: None reported.

Ethical approval: Exemption was obtained from the Loyola University institutional review board.

Previous presentations: Portions of these data have been presented at the following venues: American College of Surgeons Clinical Congress, San Francisco, California, October 2011; Accreditation Council for Graduate Medical Education Annual Educational Conference, Orlando, Florida, March 2, 2012; Association for Surgical Education Meeting, San Diego, California, March 22, 2012; Grand Rounds, Department of Surgery, University of New Mexico, Albuquerque, New Mexico, January 17–18, 2013; Association of Program Directors in Surgery Annual Meeting, Orlando, Florida, April 25, 2013; Grand Rounds, Department of Surgery, Southern Illinois University, Springfield, Illinois, May 15–16, 2013; American Board of Surgery Summit on Pre-Residency Instructional Program, Philadelphia, Pennsylvania, May 31, 2013; and Grand Rounds, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, January 14, 2014.

Correspondence should be addressed to Rebecca M. Minter, 2210A Taubman Center, 1500 E. Medical Center Dr. SPC 5343, Ann Arbor, MI 48109-5343; telephone: (734) 936-7944; e-mail: rminter@umich.edu.

Over the last two decades, medical educators have expressed caution that interns arriving for their surgical residency are not uniformly prepared to make the transition to physician and intern.1 Over the same time period, others in academic medicine have issued multiple calls for curricular reform in the fourth year of medical school (M4), particularly with respect to better preparation for the transition to internship; yet, widespread comprehensive curricular redesign has still not occurred.2–5 Factors contributing to variability and gaps include the fact that the majority of the M4 year often remains dominated by electives, subinternships providing variable experience, and “audition” rotations for residency.4 Specifically in surgery, clinical experiences gained during medical school vary widely. A surgeon’s practice, be it in either a university or community setting, tends to be quite focused. Although this specialization may be advantageous for patients, it limits the broad exposure to the field that students training in these practices need to prepare adequately for their transition to surgical internship. Additionally, medical schools vary in terms of students’ active participation in clinical decision making, assessment, and hands-on patient care activities. This variability places significant pressure on residency programs to determine where individual deficiencies exist and to tailor clinical assignments accordingly. The absence of standard assessments determining entering interns’ levels of preparation within expected competency domains further exacerbates this challenge.

Several institutions and departments of surgery have attempted to bridge the transition from medical school to surgical internship with special surgical preparatory courses, or “bootcamps,” delivered in the final months of medical school. These courses have been viewed very positively by course participants and seem to improve their confidence and technical skills performance.6–10 The course content varies by institution but commonly includes technical skills training, managing common clinical scenarios, responding to mock nursing pages, and evaluating acutely ill “patients” (through the use of human patient simulators). In most institutions, these courses occur as a one-month elective during the M4 spring semester.

Given both the success of these courses in a limited number of institutions and the need to ensure a more uniform medical school experience for preparing students to provide safe patient care under appropriate supervision, the American College of Surgeons (ACS) Division of Education, the Association of Program Directors in Surgery (APDS), and the Association for Surgical Education (ASE) convened a task force in July 2008 to explore the development of a national standardized preparatory surgical internship curriculum for M4 students. This task force reviewed an existing publication, which resulted from a prior collaboration of key surgical residency education stakeholders (e.g., members of the ACS Committee on Resident Education, the Surgery Residency Review Committee, and the APDS). This publication, entitled “Successfully Navigating the First Year of Surgical Residency: Essentials for Medical Students and PGY-1 Residents,” identifies competencies that surgical interns should possess at the beginning of the first year of residency education.11

The ACS/APDS/ASE Entering Surgery Resident Preparatory Task Force undertook the multi-institutional, mixed-methods needs assessment reported here to provide empirical guidance for the development of the aforementioned proposed national M4 preparatory curriculum. Our purpose was twofold: (1) to determine the scope and depth of current interns’ self-assessed preparedness for surgical internship, and (2) to compare the ratings of interns who completed a formal preparatory curriculum with those who had not so as to determine whether M4 preparatory courses (“bootcamps”) facilitate transition to internship. We augmented these structured survey methods by eliciting interns’ open-ended reflections on what they experienced as their greatest clinical care challenges.

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Method

Intern survey

The majority of our questionnaire’s content drew on the Agency for Health Research and Quality–supported ACS publication “Successfully Navigating the First Year of Surgical Residency: Essentials for Medical Students and PGY-1 Residents.”11 Most of the questions (n = 7) focused on defined surgery internship competencies, but a few (n = 4) asked participants about M4 electives they had taken and about the nature of their internship (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A274). An iterative revision process by the complete ACS/APDS/ASE Entering Surgery Resident Preparatory Curriculum Task Force refined the questionnaire content to include skills that task force members considered essential for safe patient care at the beginning of internship, as well as technical skills commonly performed by interns. The questionnaire authors (a subset of the task force) categorized each item into Accreditation Council for Graduate Medical Education (ACGME) competency domains.12 The response scale used a Likert-type format, anchored at 1 (“Not prepared at all”) and 5 (“Well prepared”). An open-ended reflective question at the conclusion of the survey asked interns:

Reflecting back on your first year of Surgery residency, what was the most challenging clinical care scenario you faced, and why did you find it challenging? Specifically, did you feel you lacked some skill or preparation that would have aided you in addressing it?

We pilot-tested the questionnaire in paper form at Icahn School of Medicine at Mount Sinai and the University of Minnesota to assess clarity and to determine the amount of time needed to complete the survey (12–15 minutes). No changes to the survey were required, and it was converted to a Web-based format and administered through the ACS Division of Education to participating institutions.

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Intern participants

All surgical interns (categorical and designated/undesignated preliminary postgraduate year [PGY] 1 residents) participating in the general surgery residency training program in June of 2009 at Case Western Reserve University, Emory University School of Medicine, McGill University, Icahn School of Medicine at Mount Sinai, University of Michigan, University of Minnesota, University of New Mexico, University of North Carolina, University of Wisconsin, Washington University School of Medicine in St. Louis, and Boonshoft School of Medicine of Wright State University were eligible to participate (n = 196). We invited institutions to participate via a call for volunteers disseminated through the APDS and ASE listserves. We then selected a convenience sample among the institutions that responded based on their geographic diversity and the presence of a local investigator willing to complete the site-specific tasks necessary for intern participation.

Next, we identified additional interns who had completed a focused bootcamp elective for surgical residency during their M4 spring semester (February–April 2008). Participating site investigators who sponsored an M4 bootcamp curriculum and had contact information for medical students from the prior year who had matriculated into surgical internships at institutions outside of the 11 participating study sites provided the names of additional interns (n = 77). Of these, 25 interns who had attended Emory University, University of Minnesota, University of Michigan, and Washington University School of Medicine in St. Louis for medical school agreed to participate. We purposefully oversampled interns completing a bootcamp. The total number of eligible interns in the study (n = 221), which includes the few from McGill University, represented 12% of the matched PGY1 categorical and preliminary surgery positions in the United States in 2009.13

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Data collection

Surgical interns received a letter via e-mail from the local site investigator (June 2009) informing them about the study and providing a link to the electronic questionnaire. Participation was voluntary, responses were confidential, data were anonymized, and we offered no incentives for participating. The local site investigator sent two follow-up e-mails over the subsequent six weeks. The interns who had completed a surgery bootcamp the previous year but were now interns at institutions not participating in the study received the e-mail with the letter and link to the questionnaire directly from the ACS Division of Education.

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Data analysis

We calculated descriptive summary statistics to characterize the demographics of the intern study sample as well as their perceived degree of preparedness for each clinical or professional skill. We limited item-level statistics to summaries of the frequency distribution of residents’ self-reported degree of preparedness. To compare bootcamp-prepared interns with their nonbootcamp colleagues on overall ACGME domain levels, we applied independent t tests to the sum of items contained in each domain, setting significance at P < .05. We calculated associated effect sizes using Cohen d. In accordance with Cohen’s convention, we used thresholds of 0.2, 0.5, and 0.8 to describe, respectively, “small,” “medium,” and “large” effects.14

We reviewed the qualitative written responses to the questionnaire’s open-ended reflective question to identify themes. We followed the tradition of grounded theory,15 a qualitative research approach in which themes are discerned from participants’ responses, rather than from predefined constructs or categories. Two of us (R.M.M. and P.B.M.) reviewed the responses (n = 147), using the constant comparison method15 to identify themes and illustrative intern quotations. Five additional surgeon reviewers (S.M., K.T., J.D’C., E.S.D., and C.D.) independently reviewed all of the narrative responses, further clarifying and modifying the themes, and assigning the narrative responses to the identified themes. These five reviewers additionally designated whether or not they thought the nature of the challenging experience described by the intern would have been amenable to training or, rather, if it entailed something that a clinician would simply have to learn from direct experience. The responses from all five surgeon reviewers for each scenario were summated to determine an overall value of how often the scenarios described were likely to be amenable to training. For those scenarios for which the surgeon reviewers disagreed about whether the situation described was amenable to training, the majority response was recorded as the final designation. We used Krippendorff alpha to determine the reliability (reproducibility) of quotes assigned to themes. Krippendorff alpha ranges from 0.0 to 1.0, with higher values indicating greater agreement.

The Loyola University institutional review board (IRB) granted this study an exemption, with the requirement that all data collected remain anonymous and participants could not be identified by medical school or current institution.

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Results

Intern self-assessed preparedness

Of the eligible 221 interns, 158 (71.5%) completed the survey. Table 1 provides a summary of the characteristics of all responders, and Table 2 displays the distribution of perceived degree of preparedness as assessed by a five-point ordinal scale. Interns reported feeling only moderately prepared at the outset of their intern year to perform most of the common intern-level clinical responsibilities in the domains of medical knowledge and patient care. Particularly their responses to prescribing common perioperative drugs (e.g., narcotic pain medication, antibiotics, antihypertensives) and to performing some surgical technical skills and procedures (e.g., needle thoracostomy, central line placement) reflected a perceived lack of preparation. In contrast, they perceived that they were well prepared for clinical responsibilities in the domains of professionalism, interpersonal and communication skills, practice-based learning, and systems-based practice.

Table 1

Table 1

Table 2

Table 2

Compared with the interns who did not attend bootcamp (n = 122), the interns who completed a bootcamp curriculum during their M4 spring semester (n = 36) reported greater preparedness as follows:

  • surgical technical skills: t(156) = 2.7 [P = .008, d = 0.51],
  • professionalism: t(156) = 2.5 [P = .012, d = 0.48],
  • interpersonal communication skills: t(156) = 2.5 [P = .014, d = 0.47], and
  • overall preparation: t(156) = 2.6 [P = .011, d = 0.49].

See also Figure 1.

P

P

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Themes identified in interns’ characterizations of their most challenging clinical scenarios

As illustrated in Table 3, themes identified in the interns’ responses to the question regarding the most challenging clinical care situation they faced during their internship included anxiety or lack of preparation related to (1) performance of a technical skill or procedure, (2) managing and/or prioritizing multiple simultaneous demands, (3) being first responders for critically ill or unstable patients, (4) clinical management of (predictable) postoperative conditions, and (5) “difficult communications” (e.g., with families, superiors, peers, or other health care professionals). The value of Krippendorff alpha, calculated as a measure of the reliability (reproducibility) of theme categorization, was 0.68. The percentage of interns contributing statements represented in each theme is included in Table 3. Of note, despite the confidence in the domains of professionalism and interpersonal and communication skills reported in the structured survey, 22 (15%) of the 148 intern responders cited difficult professional interactions or interpersonal communications as the most challenging clinical scenario they confronted in their intern year.

Table 3

Table 3

The five independent surgeon reviewers who deemed the interns’ clinical scenarios as amenable (or not amenable) to training characterized 122 (83%) of the scenarios as “yes, amenable to training.”

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Discussion and Conclusions

The present study has provided insight into the preparation of current surgical interns, and it has identified challenges interns face that at least generate tension or (at worst) create patient care hazards as medical school graduates transition to their surgery internships. Specifically, we have assessed interns’ self-reported perceived degree of preparation to perform a defined set of clinical and professional skills—all of which are expected of incoming surgical interns as formulated by medical education content experts. The finding that current surgical interns feel only moderately prepared to respond to common surgical clinical care scenarios is concerning. The additional insight and data gleaned from the qualitative analysis of interns’ reflections about their greatest challenges provide further evidence that the challenges interns face in the clinical environment are rarely part of the knowledge and skills they obtain through the formal curriculum during medical school.

We recognize that our study has several limitations. We used self-assessment, which remains vulnerable to both social desirability (i.e., the tendency of respondents to characterize one’s self favorably) and to deficits in calibrating one’s competency (e.g., the Dunning–Kruger paradox effect, in which “one doesn’t know what one doesn’t know”). The Dunning–Kruger paradox effect can potentially lead both to inflated judgments about one’s competency and to a lack of appreciation of one’s true skill, the latter of which can in turn lead to overly critical self-assessments.16 Although we felt that the vulnerability presented by self-report would be potentially mitigated by framing questions in terms of how well their training had prepared the intern respondents for defined responsibilities, our own study uncovered a seeming contradiction: The domains in which most interns characterized themselves as competent on the ordinal questionnaire were the very same domains that emerged as the sources of their most memorable challenges during their intern year.

A further limitation of this study was our use of a volunteer, convenience sample of interns. Given the general low response rate achieved with surveys disseminated via a central source with no clear stakeholder connection to the respondents, we elected to ask site investigators to introduce the study and disseminate the link to the interns at their institutions. Though the results from this convenience sample of about 12% of the surgical intern population in the United States may not be reflective of the entire U.S. or Canadian surgery intern population, we believe this approach contributed to our high response rate. In addition, if our findings are biased, they are likely biased in a favorable direction. Our data likely depict preparation for surgical internships more favorably than is the reality across all programs because the institutions whose directors volunteered for the study are greatly engaged in resident education.

Another limitation is that because some of the bootcamp responders were drawn from institutions outside of the participating 11 institutions, we could not conduct a head-to-head comparison of the nonbootcamp interns at those institutions. Lastly, because of the IRB requirement for complete anonymization of the respondents’ identities, we could neither calculate separate response rates for those interns in the full cohort completing a bootcamp versus those who had not, nor could we further characterize the interns in terms of gender, age, exam scores, grades, rotations completed, or other potential predictors of performance. This IRB limitation likewise precluded our evaluation of the nonresponder characteristics.

Development of an M4 bootcamp curriculum with a focus on hands-on management of skills that an intern is commonly called upon to perform may help to bridge some of the perceived gaps in training that emerged through this study. Our finding—that interns who participated in M4 surgery bootcamps self-reported greater perceived preparedness for their internship responsibilities—offers encouraging support for proposed educational reform. This finding is consistent with those of others who have examined pre- and postcourse confidence and technical skills performance and found significant improvement following the course.6–8,10 The narratives that the interns have provided demonstrate considerable variability in terms of experiences and preparation. Some interns report feeling quite prepared to handle complex emergent clinical care situations, while others report struggling or feeling ill prepared to perform common intern duties (e.g., prescribing medications or responding to postoperative complications that should be anticipated). Although variability in individual ability will always exist, multiple accrediting bodies and professional associations have identified a need for improved coordination across the continuum of medical education, particularly at critical transitions such as the transition from medical school to residency. The Carnegie Foundation’s recent call for reform of medical education specifically proposes that “Accrediting, certifying, and licensing bodies together develop a coherent framework for the continuum of medical education and establish effective mechanisms to coordinate standards.”17

Ideally, interns should graduate from medical school ready for their internship with greater specialty-specific hands-on training and practical skills. The ACGME Milestones Initiative18 lends itself to establishing well-defined performance metrics for each level of training. A national preparatory curriculum for each specialty could serve to define the first level of skills required for entry into residency—or the “first milestones” within the competency domains for that specialty. Specifically, within the field of surgery, calls to develop new training paradigms that more cohesively track trainees from medical school into independent practice were proposed in 200419; however, little progress has been made. More recently, the ACS, APDS, and ASE have begun to develop transitional curricular offerings for M4 for students entering a surgical field. The present work provides critical insight and will serve as a multidimensional needs assessment for developing such a curriculum. Careful consideration by the ACS/APDS/ASE Entering Surgery Resident Curriculum Task Force has led to the recommendation that the best timing for preparatory curricula is during the M4 year, which immediately follows the broad, foundational medical education provided across all fields of medicine, in an environment comfortable for and familiar to the learner.

The ACS Division of Education, in concert with the now formalized ACS/APDS/ASE Surgery Resident Prep Curriculum Committee, hopes to provide resources to medical schools and surgery departments willing to develop and evaluate such curricula, by providing a common set of goals and objectives with well-developed curricular modules and associated assessment tools. Support for this approach and this specific curriculum have recently been garnered by the American Board of Surgery and other stakeholders in surgical education. These groups have recently issued a joint statement20–25 recommending the national preparatory curriculum; the statement reads in part that “it is essential that all matriculants to surgery residency complete a preparatory course of blended learning that specifically addresses essential components of quality care and patient safety before the start of their training.”20,21,23,25

Colleagues in the fields of internal medicine,26 family medicine,27 and emergency medicine28 have undertaken similar initiatives, defining what specific skills and experiences are needed during the M4 year for students entering their respective fields. Although flexibility for both learners and medical schools will be critical moving forward, it seems both prudent and consistent with our promise to deliver safe patient care that we look ahead to setting common standards that all entering interns in a given field should be able to demonstrate. Setting common standards will require significant cooperation between medical schools and their various departments to identify training that may be best delivered in a transition or capstone course that cuts across and integrates disciplines4 (e.g., communicating with patients, families, and other professionals), and those that are more specialty specific and should be captured within a discipline-specific preparatory course or bootcamp (e.g., managing postoperative complications). Recent work by an Association of American Medical Colleges–convened task force to define core entrustable professional activities for entering residency29 may provide a framework for those skills all medical students should accomplish; specialty-specific curricula could then be built on this foundation.

Although the ultimate benefactors of students completing specialty preparatory courses are the patients treated in the receiving residency programs, we believe that such training could also alleviate the angst these young doctors may feel, given the challenges they described fulfilling clinical responsibilities for which they did not feel their training had adequately prepared them. Although a focused bootcamp course can by no means replace the clinical knowledge and skills students obtain through the more traditional medical school coursework and clinical rotations, it may provide an additional practical, skills-intensive curricular experience that better prepares them for the most anxiety-provoking and difficult clinical situations they will face in their PGY1 year. In the words of one of our intern study participants,

We need better preparation for all aspects of direct patient care, from the routine pre-op assessment to running a code. Too much of our medical school training is directed towards broad medical knowledge without a step-by step, nuts-and-bolts guide to actually taking care of someone.

We believe that this multi-institutional, mixed-methods needs assessment has helped inform the development of a robust preparatory curriculum for transition to surgical residency that has the potential to be adopted in the senior year of all U.S. and Canadian medical schools. A dedicated preparatory course or bootcamp is a model that can be implemented across all specialties, potentially allowing for a smoother and safer transition from medical school to residency, and to the development of necessary bridges to support a more cohesive framework across the continuum of medical education as called for in the Carnegie Foundation report.17

Dedication: The authors would like to recognize the contributions of their friend and colleague, Dr. Keith D. Amos, who passed away unexpectedly in the midst of this work. Dr. Amos was a talented young surgeon who had much to contribute to the field of surgery and surgical education. His premature death is a tremendous loss to all of us.

Acknowledgments: Kimberly Echert and Cherylnn Sherman of the American College of Surgeons Division of Education provided significant support in the development and dissemination of this survey and in the organization of the senior resident focus group at the American College of Surgeons Clinical Congress.

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