Annals of Surgery Journal Club

Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.

Friday, March 7, 2014

March, 2014 Journal Club
Moderator: Dr. Mark Malangoni
Featured Article: General Surgery Residency Inadequately Prepares Trainees for Fellowship: Results of a Survey of Fellowship Program Directors by SG Mattar etal. Ann Surg 258:440 - 449, 2013.

Mattar and coauthors have surveyed a select group of fellowship program directors (FPDs) regarding their opinions about the capabilities of those entering advanced training following completion of a general surgery residency.  Using a Likert scale to assess multiple domains, they report mixed results.  Their opinions of fellows in the domains of professionalism and clinical evaluation were very good with less than 5% of FPDs expressing significant concerns in these areas.  In contrast, more than 25% of FPDs felt that incoming fellows required more supervision than expected, including 18% who believed their fellow could not perform a laparoscopic cholecystectomy - the most common operation done in surgery residency - without supervision.  Concerns about basic and advanced minimally invasive skills were also prevalent and there was great concern about fellows’ interest and abilities in academic and scholarly pursuits.

These concerns are neither novel nor recent; however, this article emphasizes the ongoing unease about the preparedness of surgery residents to pursue further training (the focus of this report) or enter practice.  Proponents pile on with anecdotes reinforcing these findings while others blame duty hours requirements and the need to return to “the good old days,” alleging that these issues didn’t exist in decades past.  While time clouds all memories, most surgeons recognize that the majority of residency graduates, present or past, need some guidance and mentoring in the early years of practice.  If there was nothing further to learn during fellowship, why would these advanced training programs exist?  More importantly, Mattar et al ask an important question: can we do better in training surgery residents for their eventual careers, whether as specialist or sub-specialist surgeons?

This article presents the opinions of one group, the FPDs.  The results and conclusions should give us pause to reexamine the current training paradigm for surgery and use the collective will to provide the best possible training.


1.      Do you believe that graduated residents should be capable of unsupervised practice either when entering additional training or going into clinical practice?  Is ongoing mentoring a necessity that should be acknowledged and supported?

2.      Do you agree with the opinions of the fellowship program directors that a large percentage of residents lack appropriate minimally invasive skills at the completion of training?  If you agree, what needs to change to remedy this problem?

3.      Does the presence of a minimally invasive surgery fellowship program interfere with the training of surgery residents?

4.      Would rotations where residents perform a large volume of operations (e.g., in community hospitals) improve training? 

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.