It is of growing concern that residents are not prepared for independent practice upon completion of General Surgery training.1–6 Changes in duty hours and marked increased stringency in supervision standards has correlated with an increased failure rate on the certifying examination administered by the American Board of Surgery.7 When considering this current climate, Dr Frank R. Lewis, executive director of the American Board of Surgery, recently espoused a personal opinion that all residents should complete a fellowship following General Surgery residency to ensure that they are prepared for autonomous practice.6 Dr Lewis points to resident duty-hour restrictions as a major factor that has carved away approximately 2400 to 4800 hours of residency experiences, which equates to a loss of 6 to 12 months of training.6 In recognition of the issues of lost opportunities for graduated responsibility for surgical residents, the American Board of Surgery also recently added a requirement for a minimum of 25 teaching cases by graduating surgical residents as a proxy for some level of autonomy during training.
At the present time, greater than 80% of graduating residents already complete a subspecialty fellowship program,8 but fellowship directors have also expressed frustration with the lack of readiness on arrival to fellowship to focus on the subspecialty content of the fellowship.1 The American College of Surgeons recently developed a postgraduate apprenticeship model of additional training for General Surgeons; however, it is too soon to determine if these “finishing programs” will gain traction with the 15% to 20% of General Surgery residents not currently pursuing subspecialty training. Although fellowships and additional time in training are likely an essential consideration, as we work toward a solution to this critical problem, we need to be cautious that we do not assume that simply adding additional time to training will address this emerging deficiency, and we must carefully examine the true root causes that have led to a lack of preparation for independent practice.
It is certainly easy to point to the reduction of duty hours as a reason for the reduced experience and confidence of General Surgery residents upon graduation; however, we believe the problem is much more complex. Specifically, the degree of autonomy surgical residents experience in the operating room has significantly decreased over time due to many factors. These include, but are not limited to, duty-hour restrictions; increasing regulations that mandate more attending surgeon involvement and greater direct observation of residents; increased pressure on faculty surgeons to do more operations in less time; and more defined specialties within General Surgery—resulting in residents having exposure to numerous disciplines, but with little time to develop or demonstrate depth of ability with any 1 faculty surgeon.9 We believe it is the culmination of these factors that has led to a lack of readiness to operate independently upon completion of surgical residency.
Although the loss of 2400 to 4800 hours is significant, especially if substantive changes are not made in how we train General Surgeons, we argue that the increase in supervision requirements mandated by federal bodies such as the Center for Medicare Services and the Joint Commission have had a more deleterious impact on residency training. Although supervision is critical and appropriate, the failure to ensure progression to independence for surgical trainees during residency will result in the emergence of a surgical workforce which is not prepared to provide safe surgical care for patients. The stringency of the supervision requirements in and of themselves is not the greatest obstacle, but rather the faculty and institutional responses to them. These responses understandably stem from concerns regarding litigious consequences of an adverse outcome sustained in the setting of an unsupervised trainee. Unfortunately, however, appropriate progressive graduated responsibility with release of the learner as outlined by the Accreditation Council for Graduate Medical Education supervision policy has generally not occurred, and faculty and institutions have adopted a single model of rigid direct supervision regardless of the level of the learner and often well beyond what is required by the “written rules” of the Center for Medicare Services or the Joint Commission standards. Thus, the first time a young surgeon performs a given operation independently, they are often in a new environment with no immediately available safety net. Although this may be safer for institutions from a legal standpoint as these surgeons are now considered “Board-eligible” and thus deemed ready for independent practice, this model of training is not optimal for safe surgical care for patients.
Although the changes in surgical training in the United States in the last decade have been incredibly dynamic in terms of the expectations of our learners and the breadth of what they must learn, faculty development for the educators who are teaching and supervising in this period of rapid growth and transformation in surgical education has largely not occurred. As a result, our current apprenticeship models, which may be best described as “tea steeping” or “10,000 hours of practice,” are in danger of amounting to a lot of “weak tea” or 10,000 hours of doing something minimally well unless significant changes are made.10,11
As we transition to competency-based education, neither a time-based model nor a model that produces competent, sufficient, or good-enough surgeons at graduation is acceptable. The ultimate cost of such models is borne by patients. A new model must be anchored on progression through milestones, as well as entrustment and gradual release of the learner. A key feature of this framework is in understanding how faculty members make entrustment decisions when observing residents in the operating room, AND also explicitly building entrustment into the teaching and assessment framework. Entrustment of a resident to perform an operation or to care for a patient with a given condition equates to an implicit and explicit statement by the supervising faculty member that they trust this resident to perform this task independently.
Ten Cate has led the movement in applying the concept of entrustable professional activities (EPAs) in medical education as a framework to support progression to independence in residency.12 EPAs are tasks considered essential to the profession, identified as high-risk and error-prone activities, and responsibilities where a number of competency domains merge.12 On the basis of observable performance, a supervisor deems when a trainee can be entrusted to independently carry out the professional activity.7,9 For example, the concept of “Do I entrust this resident to independently obtain informed consent for a complex general surgical procedure?” is understandable and relatable to a faculty surgeon. This EPA touches many competencies, but the activity can be considered and assessed singularly. In keeping with teaching and assessing for entrustment, this would mean engaging in an individualized teaching relationship where the faculty surgeon makes a shift in the relationship with the learner and says “yes, unless” rather than “no, until,” but is also able to articulate resident performance outcomes that would limit entrustment.13,14 This model of surgical training—utilizing EPAs and Milestones—is also being adopted by the Royal College of Physicians and Surgeons in Canada, and it is presently in use in the Netherlands in graduate medical education in the field of Obstetrics and Gynecology.15,16 Successful transition to this model clearly requires significant faculty development as it is quite difficult for most faculty members to truly observe a resident in the operating room and not prematurely intervene or direct the operation—even when a resident is perfectly capable of leading the operation himself/herself. An investment of time and resources by departments and institutions, who are notably under increasing financial pressures, to implement this faculty development intervention will also be required to achieve this critical investment in the future surgical workforce.
We do not believe that simply adding additional time through fellowship training will ensure that all graduates are prepared for autonomous practice. Although training in the future may extend to 6 to 7 years to incorporate subspecialty training, we would argue that additional time must be added in a thoughtful way with an assurance that progressive responsibility is integrated in the final phases of training regardless of training pathway. If faculty do not allow their fellows to proceed to independence because of overly supervised operations and perioperative decision-making, then additional time will likely achieve the present result—just with an additional 1 to 2 years of training.
We must develop improved strategies for faculty development, which lead to more effective models of training and assessment within the constraints of the present supervision requirements. Although many surgical educators have pointed to the loss of the night, weekend, or veterans affairs experiences as those which have historically had less supervision and thus provided an opportunity for residents to gain confidence and independent operating skills, we would argue that from the patient viewpoint this could be perceived as a 2-tiered standard of care. Rather, a deliberate and transparent progressive autonomy model is a relevant and effective way of approaching faculty development, and this should apply to all settings of surgical patient care.
In the high-stakes environment of the operating room, faculty surgeons weigh minimizing risk to the patient with calculating risks to advance the expertise of trainees.17 Progressive autonomy is aligned with the ability of faculty surgeons to make these expert judgments by helping them identify critical intraoperative educational experiences, determining effective teaching methods to advance learners along those acute points, and establishing applicable assessment and feedback strategies. Residents would know explicitly from faculty how they benchmark, develop better skills to self-regulate learning, and work with faculty to address identified gaps as they progress toward autonomy.18 This ability to identify and acknowledge gaps in expertise, knowledge, and readiness to perform specific operations are critical lifelong skills for all expert surgeons and should be explicitly taught during residency.
Although this form of supervision is an improved approach of training for autonomy, it will also better serve future patients. This differentiated instruction is learner-centered in that it permits graduated release from supervision based on the individual resident's training trajectory, while also taking a patient-centered approach by being particularly attentive to the specific presentations of each patient for the best care and learning opportunities. This approach also fits nicely with the Flexibility in Surgical Training movement that allows for tailoring training during General Surgery to a trainee's future practice. This does not mean that we train a cadre of subspecialists; instead, we purposefully tailor the training for General Surgeons to provide them with more experiences oriented toward their future practice. This focused and tailored training approach allows for a progressive autonomy model that is simultaneously learner and patient centered—meeting the needs of our public as well as our trainees.
Fellowships following General Surgery residency should then ideally serve the original purpose for which they are intended—additional training in a specific field. As Mattar et al1 have outlined, this adjusted approach would allow residents to arrive ready to focus on their fellowship training and move to independence in this subspecialty as intended during their 1 to 2 years of additional training.
If we are to resolve the problem of residents who are unprepared for independent practice upon completion of training, an intentional shift to assess autonomy and independence must be consciously built into residency training. EPAs and progressive entrustment provide a rubric to do this and link nicely with the milestones. With the milestones initiative, the timing for implementing a new model of teaching and assessment is ideal. If we do not do this, we will continue to produce the same result—an unprepared surgical workforce. Completing a fellowship is by no means a guarantee that we will fix the problem of confidence or operative autonomy upon completion of training unless we are explicit about the needs for integration of progressive independence. In the absence of faculty development, it is unlikely that educators will substantially shift their interactions with trainees. If patient care, patient safety, and educating safe surgeons are core to our residency and fellowship educational models, we propose that EPAs and progressive entrustment are essential development initiatives for faculty surgeons.
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