General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors.
TL;DR: Assessment of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.
Abstract: Objective:To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America.Methods:A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program director
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TL;DR: Recent RDH changes are not consistently associated with improvements in resident well-being, and have negative impacts on patient outcomes and performance on certification examinations.
Abstract: After the tragic death of a young woman named Libby Zion in a New York Hospital, resident duty hour (RDH) restrictions were introduced in this state. An investigation ruled that lack of supervision, the resident's lack of familiarity with this woman's complex diagnosis and resident fatigue were contributing factors in the tragic outcome. In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated an 80-hour duty limit on residents, averaged over a 4-week period. In 2011, the ACGME mandated 16-hour duty periods for first year residents whereas the province of Quebec instituted 16-hour periods for all in-house residents in 2012. The stated goals of duty hour limitations were to improve patient safety, resident well-being, and education.1 Surgical disciplines have expressed concern with the contraction of duty hours stating that the impact on training time could have a negative effect on educational and patient outcomes.2 Specifically, the American College of Surgeons, Division of Education, has stated that mastery in surgery requires extensive and immersive experiences.3 A “one-size fits all” approach to RDHs may not be appropriate given the variation in training needs, diversity of practice patterns, and various competencies required among disciplines.4,5
In March 2012, the Royal College of Physicians and Surgeons of Canada undertook a project to develop a pan-Canadian consensus on issues related to RDH. A national steering committee was struck and this committee further created 6 expert working groups. Recognizing that surgical training is unique in many aspects and that there have been significant obstacles related to the implementation of RDH in surgery, a specific working group entitled Special Considerations for Procedural and Surgical Disciplines was created. The National Steering Committee's full report is published elsewhere (www.residentdutyhours.ca).5 As part of this process, the Procedural/Surgical discipline working group performed a systematic review and meta-analysis to evaluate the association between RDH and clinical and educational outcomes in surgery.
394 citations
Cites background from "General surgery residency inadequat..."
...Country Study design United States 121 (90) Survey 61 (46) Canada 7 (5) Interventional (≥2 groups) 52 (39) Europe 6 (4) Observational 8 (6) New Zealand 1 (1) Systematic review 6 (4) Type of center Other 5 (4) Academic 86 (64) Program evaluation 2 (1) Community 20 (15) Randomized controlled trial 1 (1) Multicentre 71 (53) Surgical subspecialty Study objectives General surgery 67 (50) Education 101 (75) Orthopedic 15 (11) Patient safety 79 (59) Gynecology 13 (10) Wellness 48 (36) Multi-specialty (including surgery) 12 (9) Heterogeneity 9 (7) All surgical specialties 12 (9) Study quality∗ Trauma 10 (7) High 21 (15) Other† 10 (7) Moderate 36 (27) ENT 8 (6) Low 51 (38) Pediatrics 8 (6) Very low 27 (20) Cardiac 8 (6) Type of surgery Neurosurgery 6 (4) Emergency 95 (70) Vascular 5 (4) Elective 88 (65) Thoracic 5 (4) Not described 38 (28) Urology 3 (2) Plastic 3 (2) Not described 12 (9)...
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TL;DR: Flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality.
Abstract: In an analysis of data from 138,691 patients, flexible, less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P = 0.92; unadjusted odds ratio for the flexible-policy group, 0.96; 92% confidence interval, 0.87 to 1.06; P = 0.44; noninferiority criteria satisfied) or of any secondary postoperative outcomes studied. Among 4330 residents, those in programs assigned to flexible policies did not report significantly greater dissatisfaction with overall education quality (11.0% in the flexiblepolicy group and 10.7% in the standard-policy group, P = 0.86) or well-being (14.9% and 12.0%, respectively; P = 0.10). Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education but were more likely to perceive negative effects on personal activities. There were no sig nificant differences between study groups in resident-reported perception of the effect of fatigue on personal or patient safety. Residents in the flexible-policy group were less likely than those in the standard-policy group to report leaving during an operation (7.0% vs. 13.2%, P<0.001) or handing off active patient issues (32.0% vs. 46.3%, P<0.001). CONCLUSIONS As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents’ satisfaction with overall well-being and education quality. (FIRST ClinicalTrials.gov number, NCT02050789.) abstr act
332 citations
TL;DR: The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor.
Abstract: The decision to trust a medical trainee with the critical responsibility to care for a patient is fundamental to clinical training. When carefully and deliberately made, such decisions can serve as significant stimuli for learning and also shape the assessment of trainees. Holding back entrustment decisions too much may hamper the trainee's development toward unsupervised practice. When carelessly made, however, they jeopardize patient safety. Entrustment decision-making processes, therefore, deserve careful analysis.Members (including the authors) of the International Competency-Based Medical Education Collaborative conducted a content analysis of the entrustment decision-making process in health care training during a two-day summit in September 2013 and subsequently reviewed the pertinent literature to arrive at a description of the critical features of this process, which informs this article.The authors discuss theoretical backgrounds and terminology of trust and entrustment in the clinical workplace. The competency-based movement and the introduction of entrustable professional activities force educators to rethink the grounds for assessment in the workplace. Anticipating a decision to grant autonomy at a designated level of supervision appears to align better with health care practice than do most current assessment practices. The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor. The authors' aim in this article is to lay a theoretical foundation for a new approach to workplace training and assessment.
326 citations
TL;DR: Deployed on an automated smartphone-based system, the Zwisch scale can be used to make reliable and valid measurements of faculty guidance and resident autonomy and is suggested to infer resident operative performance.
234 citations
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TL;DR: The American Council of Graduate Medical Education is moving from accrediting residency programs every 5 years to a new system for the annual evaluation of trends in measures of performance.
Abstract: The American Council of Graduate Medical Education is moving from accrediting residency programs every 5 years to a new system for the annual evaluation of trends in measures of performance.
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TL;DR: Proposed modifications in the current requirements for medical residency training programs, including in the limits on resident hours, are explained and input on the new requirements is invited.
Abstract: A task force of the Accreditation Council for Graduate Medical Education (ACGME) has proposed modifications in the current requirements for medical residency training programs, including in the limits on resident hours. This article explains the proposed changes and the rationale for them and invites input on the new requirements, which are scheduled for implementation in 2011.
549 citations
"General surgery residency inadequat..." refers background in this paper
...The quantitative responses are reported by the frequency distribution of responses within a given response category, for example, (1) strongly disagree, (2) disagree, (3) neither disagree nor agree, (4) agree, and (5) strongly agree....
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TL;DR: The Blue Ribbon Committee on Surgical Education was charged with examining the multitude of forces impacting health care and making recommendations regarding the changes needed in surgical education to enhance the training of surgeons to serve all the surgical needs of the nation, and to keep training and research in surgery at the cutting edge in the 21st Century.
Abstract: American surgical education has a rich heritage, and its programs produce some of the best trained and most competent surgeons. Although surgery residency training has changed little since its formulation by Halsted at the beginning of the last century, surgery residency and fellowship programs continue to maintain high standards because they are highly structured, monitored, evaluated, and credentialed.
At the dawn of the 21st Century, however, numerous forces for change are impacting medical education in general and surgical training in particular. On the one hand, the explosion of knowledge from the advances of science, systems, and information technology provide new opportunities to improve our training programs. On the other hand, as the public has become increasingly better informed about its healthcare needs and safety, its expectation has shifted and now increasingly demands advanced and specialized care. Contrary to earlier predictions of excess physicians by 2010, we appear to be on the threshold of a shortage in physician workforce. This impending shortage should be viewed in the context of Association of American Medical Colleges (AAMC) data, which show that the number of applicants to medical schools in the United States has declined by 25% since 1996. Now, nearly 50% of students entering medical school are women. The average U.S. medical student now graduates with a debt in excess of $100,000. Students of both genders are increasingly selecting specialties with more controllable lifestyles than general surgery. Furthermore, general surgery residencies experience an attrition rate of nearly 20%, primarily because of lifestyle concerns of residents. Major changes have occurred and more are foreseen in the practice of surgery. Much clinical care has moved from the inpatient hospital setting to the outpatient, and the length of stay for inpatients has significantly decreased. These shifts have resulted in a significant impact on both undergraduate and graduate medical/surgical education. Surgical care is moving from discipline-based to disease-based practice in which surgeons will increasingly practice within a team of experts. How do we train surgeons to be leaders of such multidisciplinary teams?
Recognizing the multitude of changes taking place, and spearheaded by the Presidential Address at the 2002 annual meeting of the American Surgical Association (ASA), the ASA Council in partnership with the American College of Surgeons (ACS), the American Board of Surgery (ABS), and the Resident Review Committee for Surgery (RRC-S), established a Blue Ribbon Committee on Surgical Education in June 2002. The Committee was charged with examining the multitude of forces impacting health care and making recommendations regarding the changes needed in surgical education to enhance the training of surgeons to serve all the surgical needs of the nation, and to keep training and research in surgery at the cutting edge in the 21st Century.
This report is based on the work done and consultations obtained by the ASA Blue Ribbon Committee over a 2-year period. The Committee quickly recognized the complexity of its tasks and how any major recommendation for change could provoke controversy among many stakeholders, including members of the committee itself. Gradually, however, the committee was able to arrive at a consensus. On a separate track, the ABS has come to similar conclusions on how to restructure the surgery training program. The Committee recognizes that its recommendations are just recommendations, but sincerely hopes that they will serve as an impetus for a concerted effort by the ACS, ABS, and the RRC to further refine and implement them.
What is being recommended here is no less than a new surgical education system but one that takes place in the context of patient care. This will require major redesign of surgery residency training and allocation of sufficient resources to achieve the desired outcomes. Given that such an education system is essential not only for producing the next generation of highly trained surgeons, but also for enhancing the quality of the most advanced patient care in the nation's teaching hospitals and clinics, appropriate strategies need to be developed at the national level to implement the recommendations. The report is presented under the following headings:
Surgical/Medical workforce
Medical student education in surgery
Resident workhours and lifestyle in surgery
Residency education in surgery
The structure of surgical training
Education support and faculty development
Training in surgical research
Continuous professional development
The Executive Summary highlights the conclusions and recommendations of the Committee.
295 citations