A new paradigm in surgical training

TY - JOUR

T1 - A new paradigm in surgical training

AU - Eberlein, Timothy J.

N1 - Funding Information: Presented at the Southern Surgical Association 125th Annual Meeting, Hot Springs, VA, December 2013. Timothy J. Eberlein MD, FACS ∗ Department of Surgery, Washington University School of Medicine, St Louis, MO Department of Surgery Washington University School of Medicine St Louis MO ∗ Correspondence address: Timothy J Eberlein, MD, FACS, Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave, Box 8109, St Louis, MO 63110-1110. First I would like to start by saying what an incredible privilege it has been to serve as your President during the past year. I joined this wonderful organization relatively late in my professional career and, therefore, serving as President has been more meaningful to me. One does not reach this podium, however, without tremendous help, and there are so many of you in this audience today who have given advice and guidance in my journey to this day. I cannot take the time to thank each of you at this moment, but will try to do so in the course of the meeting. Today, I want to speak about a topic that is timely, critical, and integral to all that we do. I believe that our most important role as surgeons, besides patient care, is the education of the next generation of surgeons. For all of us, that will truly be our legacy. I hope that I will convince you that the time for a new paradigm in surgical education is now, and that some of my suggestions will stimulate both debate and action. The story begins in the late 1800s when medical education in the United States was abysmal, but we will look at 2 institutions that had a major impact on surgical education. I will start with the story of Washington University. Washington University School of Medicine was the first medical school west of the Mississippi River and was formed from the merger of 2 institutions, the Missouri Medical College, started by Joseph Nash McDowell, and the St Louis Medical College, started by Charles Alexander Pope. However, there were no criteria for admission, no curriculum, and postgraduate training was an apprenticeship at best. In 1895, Robert S Brookings became President of the Washington University Corporation. Brookings recognized the need for change. He knew the President of the Carnegie Foundation, Henry S Pritchett, who was a former professor of mathematics and astronomy at Washington University. Pritchett is the person who hired Abraham Flexner to perform a comprehensive study of medical education in the United States and recommend constructive ways to improve the field. Flexner described Washington University School of Medicine as “in wretched condition” and entirely out of harmony with the rest of the institution. However, he recognized that Washington University had a unique opportunity and envisioned that it could become one of the greatest medical schools in the United States by linking medicine to the idea of a strong university for the entire “southwest” as that area of the country was then known. This vision was soon adopted as official policy by the Board of Trustees. Brookings, through the influence of William Welch, the legendary Chief of Pathology at Johns Hopkins, recognized the importance of linking medical education to hospital care of patients. Brookings forged a strong relationship with Robert Barnes, a wholesale grocer, who donated $100,000, which eventually served as the endowment to build Barnes Hospital, which opened in 1914 ( ). Washington University School of Medicine received the second grant from the Rockefeller Foundation to establish a full-time education model. The first grantee was Johns Hopkins University. The grant to Washington University was for $1 million, which required matching funds provided by citizens of St Louis. Not only was a full-time model established by Brookings, but the Executive Faculty governance structure was also put in place. Brookings fired the entire faculty (save for one anatomy professor) and hired a luminary group of department heads to run the medical school, one of whom, Joseph Erlanger, would go on to win the Nobel Prize. This emphasis on scholarly activity by full-time instructors and researchers has been continued over the years, and Washington University now boasts 17 Nobel Laureates on their faculty. Fig. 1 I would now like to move the story to Johns Hopkins Hospital in Baltimore. Before the appointment of William S Halsted as its surgeon-in-chief, surgeons were largely self-trained. They learned by apprenticeship and had very little exposure to patient care in a hospital setting. There were no standards for training, no curriculum, and no criteria for entrance into training or completion of training. Johns Hopkins Hospital was established in 1889 and, shortly thereafter, Dr Halsted was appointed Surgeon-in-Chief. In a speech to Yale faculty, Halsted emphasized the need for a new system of surgical training that would produce not only surgeons, but surgeons of “the highest type,” who would stimulate the finest youths of their country to study surgery and to devote their energies and their lives to raising the standards of surgical science ( ). Halsted then proceeded to enact this new paradigm. Residents had to be graduates of established medical schools. Training was university sponsored and hospital based. Training was intense, repetitive, and directly supervised. Dr Halsted emphasized both normal and pathologic anatomy and also stimulated change through work in the physiology laboratory. The final period of training featured near total independence and autonomous activity. Fig. 2 Figure 2 is a photograph of Dr Halsted. Under Dr Welch's encouragement, Halsted initially used the original Pathology building for an animal laboratory, where he helped teach residents technique and challenged the status quo. This eventuated into the Huntarian laboratory, where Halsted developed the important paradigm of practical training for both medical students and residents. Dr Halsted's innovative mind would contribute major advances in the field, such as popularizing radical mastectomy for the treatment of breast cancer, emphasizing meticulous dissection and gentle handling of tissue, obtaining complete hemostasis, and use of meticulous sterility. He introduced the concept of Latex gloves and used nonabsorbable suture for repair of inguinal hernias. He contributed a new methodology for secure anastomosis of intestines and, of course, did seminal work on local anesthesia, which unfortunately led to an addiction to cocaine throughout his professional career. Dr Halsted had a complex but paternal relationship with his residents. I am reminded of the story of Dr Mont Reid who, in his eighth year of training, mustered the confidence to ask Dr Halsted when he might be finishing his training and Dr Halsted's response being “Mont, what's the rush?” Dr Halsted's paradigm of surgical residency training has served us well for the last 100 years, with relatively minor modifications, and certainly has become one of his seminal contributions to the field of surgery, along with antisepsis and local anesthesia. What is the current state of affairs in surgical education? General surgery residents are by and large satisfied. They do have concerns about their lifestyle as well as income, especially when compared with subspecialists. Today, 80% or more of general surgery graduates pursue fellowship training. With the aging of the “baby-boomer” generation, there is a national shortage of general surgeons. De facto, the length of clinical training is at least 6 to 7 years. Resident graduates today voice a concern about their lack of preparedness for independence. This has resulted in increasing popularity of integrated training programs. There has been a change in the distribution of general surgeons. Work by Dr Tom Ricketts and his group at the University of North Carolina shows that the number of general surgeons has declined against population. In fact, the number of general surgeons has dropped more than 26% in the last 25 years. Rural America has been impacted more than urban America, and there is a crisis situation in many areas of the country. Almost half of the counties in the United States have no general surgeons. Superimposed on this maldistribution is a change in the surgical workforce. Again, work from Dr Ricketts shows the demographic change of the surgical workforce, both in terms of sex and age distribution, and the impact that this can have in meeting the workforce needs of the future. Other issues in general surgery residency training have impacted the nature of training. Benign peptic ulcer disease is now rarely a surgical disease due to pharmacologic intervention. Because of our gastroenterology colleagues, common bile duct exploration is infrequent. With the advent of endovascular technology, abdominal open vascular surgery is rare among general surgery trainees and an increasing amount of trauma is nonoperative; again, having a negative impact on the types and quantity of surgical procedures a trainee is able to perform. With the advent of laparoscopic surgery and the establishment of minimally invasive fellowships, we have taken cases out of junior resident hands and placed them in the domain of more senior trainees. Finally, what has been the impact of reduced duty hours? Before 2003, if we assume the average trainee worked 100 hours per week, with 48 weeks per year, that would equal 24,000 hours of potential training in 5 years. With the advent of an 80-hour work week and additional restrictions on internship training, it would appear superficially that we have made a 5-year program into a 4-year program in terms of hours of training. More importantly, the reduction in hours tends to impact resident training on nights and weekends, when urgent and emergent cases might in the past have been done by a somewhat less experienced trainee in a somewhat less closely supervised work environment, allowing for a greater degree of independence. Not long after the introduction of an 80-hour work week, there was an increase in the percent of residents failing the certifying examination of the American Board of Surgery (ABS). The subsequent sharp reduction in fail rate after 2012 coincides with a change in the examination format. Whether this was causal is too early to tell. The change in work hours, the surgical environment, and new technologies have led to alternative training tracks. The early specialization program was started for vascular surgery in 2005 and for thoracic surgery in 2006. Unfortunately, only a handful of programs and, therefore residents, have participated. In fact, our department was the only program to offer both early specializations: 16 graduates finished in the vascular programs and 10 were certified, and 12 graduates finished in the thoracic program, of whom 9 were cardiothoracic certified. An important aspect of these training tracks is that graduates are eligible to take ABS General Surgery boards and all of these Early Specialization Program graduates to date have sought dual certification. Both of these specialties then developed more integrated training programs to allow trainees to enter their subspecialty right from medical school. There are now approximately 45 such programs in vascular and approximately 22 in cardiothoracic surgery. However, these integrated training programs are like a two-edge sword; if a trainee changes his or her mind, it is much more difficult to switch into a different track without the loss of years of training, and there is no option to seek ABS General Surgery certification, as they are not eligible. So, where does this leave surgical training at this point? Currently, environment and technology have changed operative experience. Duty-hour restrictions, while reducing in-hospital commitment, reduce ability to operate. The early specialization and integrated training tracks seem to be popular with resident applicants but have not necessarily improved the quality of surgical training. At least 80% of general surgery trainees do fellowships and since the initiation of the 80-hour work week, board-passage rates, especially among those taking the certifying examination, have demonstrated that many trainees lack judgment and confidence. Against this background, a restructuring committee was formed, composed of ABS Directors, Residency Review Committee (RRC) members, fellowship directors, general surgery program directors, and public members. The goals of this committee were to improve the training product. In other words, to “fix the five” and at the same time increase the attractiveness of general surgery, recognizing that matching to a specialty right out of medical school was becoming increasingly popular. From this restructuring committee came recommendations that were endorsed by the ABS to set individual yearly milestones for resident progression, establish objective measures of operative skill, and introduce flexibility in residency training, that is, to allow 12 months of focused training in the last 3 years of clinical training, with no more than 6 months in any 1 year. These recommendations were also approved by the RRC. At my home institution, we were also addressing the issue of surgical training through the formation of a task force composed of faculty committed to surgical education as well as residents, approximately 10 years ago. This group meets on a regular basis and is led by our Vice Chair for Education, Dr Mary Klingensmith. It includes our current Program Director, Dr Mike Awad and our 3 Associate Program Directors. It has involved 25 to 30 faculty over the years. The charge of the committee was to start with a green field, and to use our department's education program as a laboratory. We could test new approaches to surgical education, develop new strategies, and, in general, improve the methodology for surgical education with the goal of improving the product. The recommendations and strategies proposed by this task force needed to address the issues I have outlined as well as incorporate the current rules and guidelines of the ABS and the RRC. We were fortunate to be guided by 2 individuals with a passion for educating, Dr Klingensmith, who was appointed as head of the Surgical Council on Resident Education (SCORE) and eventually a Director of the ABS, and Dr Awad, whose efforts have continued to make our department's education program more efficient and effective. Based on national recommendations and the experience at Washington University, I would like to highlight 6 concrete steps that can improve surgery training: collaboration, minimization of noneducation workload, adherence to a curriculum, emphasizing simulation and virtual training, focusing on team training, and performance review. Our department task force committee addressed the fundamental issues impacting surgical training and has developed constructive solutions and stayed within the regulations of the ABS and RRC. During my presidential year of the American Surgical Association, that organization established a surgical education task force composed of a number of individuals who were focused on improving surgical education. LD Britt, Steve Stain, Chris Ellison, Frank Lewis, Jo Buyske, and Mary Klingensmith have played major roles in discussing alternatives, proposing constructive suggestions and proposing potential changes, and have benefitted and learned from this collaboration. We do live in a complex world and making sure our proposed changes are not too radical, and that they are constructive and meaningful, has been the goal. Our institution, like each of yours, has made major investments in reducing the amount of “scut work” that our trainees perform. We have minimized the noneducation workload through the use of programs such a preoperative anesthesia assessment programs, a night-float system, investment of millions of dollars for physician extenders, and the use of information technologies. Our department work group emphasized the need to adhere to a curriculum. Again, with Dr Klingensmith's leadership, we very quickly integrated the SCORE curriculum, which has been continually updated. The SCORE curriculum is now the curriculum in more than 300 training programs, including all but 7 general surgery residencies in the United States, and is used by almost 10,000 residents. It fulfills all of the competency area requirements of the ABS and has topics organized into modules with defined learning objectives, open-ended questions, and opportunities for self-study. The SCORE curriculum has licensed textbook chapters and videos and, although this has been envisioned as a learning tool for residents, it has frequently become a “point of care” educational aid used by residents on the fly. During the last several years, our institution has made major investments in developing a first-class simulation center to serve as an adjunct to surgical training. It is gratifying to see how trainees, both medical students and surgical residents, can become proficient at various techniques when performed repetitively on a simulator. Similar to the repetitive learning proposed by Halsted, but using simulators instead of live patients, our program has developed the Recursive Expert Assessment of Cognitive and Technical Skills (REACTS) program. Instead of seeing one, doing one, and teaching one in a “one size fits all” mode involving actual patients, we now can use simulation and practice to perfect the technique. These opportunities can be customized to allow for remediation and provide verification of the trainees' progression toward expertise ( ). The REACTS program includes didactic classroom sessions and practical skills laboratories that are prospective and competency based. We are able to teach informed consent, plain film interpretation, common house officer calls, and technical skills, such as knot tying, suturing, and Foley catheter placement. These interventions are individualized and we can use a coaching model with individualized remediation. The results have led to identification of individual deficiencies and allowed for customized remediation with verified proficiency. This expert evaluation has resulted in polished cognitive and technical skills of our surgical residents. We have extended this coaching for surgical interns through the use of more senior laboratory residents, assigning 2 to 3 interns to each coach. Once again, practice and instruction are between coach and trainee, with individualized sessions for deficiencies identified during the REACTS program. This program has resulted in all interns reaching proficiencies in various technical skills, such as suturing and knot tying, as well as responding to common clinical scenarios. We are currently doing a longitudinal comparative study. This program has also permitted discussion of other important topics during the resident's training, such as transition to residency, clinical service advice, career advice, and living in a new city. Fig. 3 Our work group has now extended this training intervention into a formal program that we have called the Academy Model. It addresses the problem that goals and objectives for resident rotations have either been nonexistent, too lengthy, or barely acknowledged. There has really been a lack of outcomes-based evaluation of trainees, and we frequently have fallen into a rut of using a one-size-fits-all approach to training for our residents. The structure of the Academy model establishes goals and objectives at the beginning of a rotation, emphasizing what skills need to be acquired, the knowledge to be gained, and the expected behavior of the trainee. The objectives are tailored not only to past performance but also future career goals. The instructional methods ( ) include operative case loads on patients, clinic attendance, case conferences, SCORE module assignments, 4 to 5 seminal articles dealing with the topic at hand, Society of American Gastrointestinal and Endoscopic Surgeons, or other clinical guidelines, including videos and other audiovisual aids and coordinated skills laboratories under our coaching and REACTS program. The evaluation of each trainee is done in a formative feedback session at the midpoint of the rotation. Usually a faculty coordinator will solicit input from other individuals on the service, and progress toward the individualized goals set at the beginning of the rotation is assessed. The formal multidimensional competency-based assessment is then performed at the end of the rotation with a knowledge-based examination based on the SCORE question database. An oral examination with 2 faculty tests clinical judgment, and there is assessment of technical skills and operative planning through an intraoperative assessment of live surgery by an independent experienced surgeon, as well as the accomplishment of meeting certain levels of performance of index cases established for each rotation. There is also an outpatient performance assessment to evaluate the skills of the trainee in the clinic environment. Both the intraoperative assessment and the outpatient performance fulfill the new ABS requirements. In this way, each trainee receives a personalized report card. If criteria are met, the resident can be promoted. If promotion is not recommended, then remediation can be initiated with additional reading, skills laboratory, practice sessions, or ultimately, repetition of the rotation. The outcomes of this Academy model are clear expectations for the trainee and raising the bar for residency training in general. It facilitates the new ABS operative and clinical requirements and moves us closer to the holy grail of proficiency-based advancement. Fig. 4 Let me describe another innovative program that builds on the input of our American Surgical Association advisors and Dr Klingensmith's leadership, as well as the hard work of a number of Chairs and program directors. We call this new program, Flexibility in Surgical Training (FIST). The goals of the program are to keep comprehensive general surgery at the forefront and strengthen and define the specialty that will help meet workforce needs ( ). It provides for additional clinical experience in the area of the trainee's intended practice. It also allows for greater comfort with independent practice, enhancing quality surgical care with improved outcomes. Although not a short-term goal, we hope to eventually improve the focus of surgical training enough to perhaps even shorten training. Fig. 5 This FIST program is now a collaboration of 9 residency programs that are, in essence, fulfilling the Ashley rule of the ABS in providing early specialization in any area of general surgery as an offering to our trainees. The key to this consortium, however, is that all 9 programs have agreed to collect data prospectively and to share data so that we can evaluate objectively the progress and success of this program compared with standard trainees in each of the 9 programs. In this way, we hope to provide objective evidence of the success, or lack thereof, of this innovative program. shows the 9 programs that are participating in this novel consortium. Again, each of the program directors and chairs has played an important role in developing the program. Among the 9 programs, we have the capability to offer flexibility in training to any resident of these programs. We are then collecting performance data of FIST trainees and comparing their performance to the non-FIST trainees in the same institution. Recently, there were a number of other programs that applied for and were granted permission by the ABS to have flexible rotations for their senior residents. At last count, more than 20 residency programs are undertaking flexible training of some sort. The difference between these programs and FIST is that FIST is a prospective, multi-institutional study that is attempting to standardize the application of the flexibility rule to determine best practices in shortening and focusing surgical training. Table 1 I would like to highlight one particular trend in surgical training that has emerged during the past decade. Prior to 2003, much like the program popularized by Dr Halsted, one graduated from medical school, did an internship and a residency in surgical training, and went into practice. About 20% to 25% of graduates went on to fellowship training. Since 2003, the impact of duty-hour restrictions and resulting increased supervision, particularly among interns, has had a consequence of diminishing autonomy. This has resulted in residents desiring additional training to obtain confidence and maturity of judgment. This led to a dramatic rise in fellowships during the past decade, such that now more than 80% of our trainees perform fellowships. This change has functionally lengthened surgical training. How might we address this problem in a constructive way and recapture training and perhaps even shorten the length of training? Our department instituted a Capstone course in 2006, led by a devoted and committed Michael Brunt ( ). This course is offered during a 4-week period in the spring of the fourth year of medical school to all potential surgical residents. The course is divided into didactic sessions in the morning that emphasize topics such as time management, documentation, error avoidance, x-ray interpretation, and hand offs. The afternoon is devoted to skills training, with common issues likely to be seen by an intern such as airway management, central line placement, peripheral IV access, basic suturing and knot tying, and other procedural-based modalities. During the course of the day, nurse instructors page the trainee with likely common clinical questions. For example, the postoperative patient who just had a major colectomy is now hypotensive or has reduced urine output. These pages need to be answered by the trainee, with the instructor providing constructive feedback to the trainee. This Capstone course has become the highest-rated offering of any course or clerkship in the fourth year of the medical school curriculum at Washington University. One hundred percent of the PGY1 residents agreed that they benefitted from this course during their internship. Students who completed the Capstone course performed better on objective structured assessment of technical skills (OSATS) and had consistently higher rated performance by their program directors compared with residents of the same program that did not participate in our Capstone course. In this fashion, we begin to take advantage of the fourth year and can easily see this Capstone course being expanded to include other rotations that fulfill the goals of the Academy model, such as doing acting internships in either surgery or medicine and other course requirements that would better prepare a medical student for eventual residency in surgery. In the past, junior surgical education was one size fits all. However, using our FIST model, and with the input of our surgical innovations faculty/resident work group, as well as the input of all of the program directors participating in FIST, we have developed a junior surgical education with early tracking ( ). All of the residents start with the boot camp, OSATS for assessment, and the REACTS program for remediation based on the OSATS results. The junior trainee is then allowed to diverge into 1 of 3 tracks, which are weighted based on the resident trainee's interest. Residents can still jump tracks without difficulty and all tracks remain General Surgery board−eligible. In the later years of surgical training, the FIST flexibility is demonstrated in the following hepatopancreatic biliary surgery example: a trainee might have 2 months of specialty training with endoscopy in the third clinical year, additional training with radiation and medical oncology in the fourth year, 6 months of hepatopancreatic biliary surgery in the fifth year, and instead of doing a “fellowship,” might become an instructor-level faculty member the entire year and have semi-autonomous practice with graded independence but available supervision and backup when needed. In fact, our program has recently produced several general surgeons who did trauma, acute care surgery, obtained their critical care boards, and then performed a year of semi-autonomous practice as an instructor in our institution and are now practicing general surgery in disadvantaged communities but with a much better degree of confidence in their independent management of patients. Fig. 6 Fig. 7 So what might the future of surgical training look like? ( ). With the onset of use of Capstone courses and boot camps and junior tracking and flexibility in surgical training, we can reverse the trend of extending surgical training. We can begin surgical training earlier in the fourth year of medical school, which will produce a more prepared surgical intern. We can blur the lines between residency and fellowship by creating a semi-autonomous practice in the last year or so of training using an instructor appointment, which permits autonomous practice but under supervision as needed. This model might result in shortening overall length of training as well as improve the confidence and independence of our surgical trainees. Fig. 8 In summary, we can follow many of the principles espoused by Dr Halsted. In fact, we really need objective standards that will produce not only surgeons, but surgeons of the highest type who will stimulate the very best medical students in the country to study surgery. These goals will be accomplished by setting a clear objective for every level of trainee and potential trainee, maximizing their time and experience, defining and updating the curriculum, and emphasizing use of technology, such as simulation and virtual training. I hope I have convinced you that we can improve the efficiency of learning, emphasize team training, and assure that residents receive performance review, and at the same time integrate technological solutions and improved assessment. Ladies and gentlemen, we have an opportunity to change the paradigm of surgical training. With thoughtful, creative, and measurable new standards, we will ensure competent and confident trainees who will enhance the future of our profession and our patients. The alternative is acknowledged by an admonition from Dr Halsted. Ladies and gentlemen, it has been my distinct honor to serve as your President, and I thank you for your kind attention this morning.

PY - 2014/4

Y1 - 2014/4

UR - http://www.scopus.com/inward/record.url?scp=84896451390&partnerID=8YFLogxK

U2 - 10.1016/j.jamcollsurg.2013.12.045

DO - 10.1016/j.jamcollsurg.2013.12.045

M3 - Article

C2 - 24655837

AN - SCOPUS:84896451390

SN - 1072-7515

VL - 218

SP - 511

EP - 518

JO - Journal of the American College of Surgeons

JF - Journal of the American College of Surgeons

IS - 4

ER -