Surgical fellowship directors: General surgery trainees arrive ill prepared

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Training, not time, is the concern

No one should be surprised by the Fellowship Council survey results. During the past decade, the failure rate on the American Board of Surgery’s oral exam has climbed steadily from 16% to 28%. At present, the percentage of examinees who fail either the oral or written American Board of Surgery exam the first time around is in the mid-30s. That’s arguably an absurd failure rate for a 5-year training program in a group of people who should have mastered the subject.

The 80-hour work limit has effectively subtracted 6-12 months from the general surgery residency, yet I do not believe this emotional and contentious issue is the explanation.

At present, the average number of operations done by a first-year resident is less than two per week, while second-year residents average two to three per week. Our residents are spending 80 hours a week while doing two or three operations per week, which arguably could be done in half a day. It would be hard to imagine a less efficient educational process.

Dr. Frank R. Lewis is executive director of the American Board of Surgery. He was an invited discussant of the presentation.



INDIANAPOLIS – The nation’s elite surgical educators are up in arms over reported widespread deficiencies in the skill set and judgment of recent graduates of 5-year general surgery residencies.

Many trainees arrive at surgical subspecialty fellowships unprepared in their basic skills, according to a detailed new survey of the nation’s subspecialty fellowship program directors. The underlying theme of the responses is that many fellows are pursuing fellowship positions to make up for inadequacies in their general surgery residency rather than to push their skills to the next level, according to Dr. Samer Mattar.

Courtesy Dr. Samer Mattar

Dr. Samer Mattar

About 80% of graduating general surgery residents now seek fellowships to obtain advanced training in bariatric, colorectal, thoracic, hepatobiliary, or other surgical specialty areas.

"Many new fellows must gain basic and fundamental skills at the beginning of their fellowship before they can commence to benefit from the advanced skills that they originally came to obtain. The current high demand for fellowship training and the lack of readiness upon completion of general surgery residencies should be a call to action for all stakeholders in surgical training," Dr. Mattar said in presenting the survey results at the annual meeting of the American Surgical Association.

Constructive changes are afoot, according to Dr. Mattar of Indiana University, Indianapolis. Plans are well underway to change the fourth year of medical school so that students interested in a career in surgery can begin preparing for it. And there are also efforts to custom tailor the final year of general surgery residency so residents can focus on their planned fellowship year. Toward that end, the Fellowship Council has moved the fellowship match date up to June so residents who know they are fellowship-bound can put their fifth year to the best use.

The survey was conducted by the Fellowship Council, an umbrella organization in charge of standardizing curricula, accrediting programs, and matching residents to fellowships. The group distributed the surveys to all 145 subspecialty fellowship program directors and drew a 63% response rate. That’s considered high for such a lengthy survey, said Dr. Mattar, and is an indication of the importance educators place on the subject.

The survey assessed five key educational domains: professionalism, independent practice, psychomotor skills, expertise in their chosen disease state, and scholarly focus.

"Incoming fellows exhibited high levels of professionalism, but there were deficiencies in autonomy and independence, psychomotor abilities, and – most profoundly – in academics and scholarship," Dr. Mattar said.

Among the key survey findings:

• Incoming fellows were unable to independently perform half an hour of a major procedure, according to 43% of program directors.

• Of incoming fellows, 30% couldn’t independently perform basic operations such as laparoscopic cholecystectomy.

• Of incoming fellows, 56% were able to laparoscopically suture and tie knots properly; 26% couldn’t recognize anatomic planes through the laparoscope.

• One-quarter was deemed unable to recognize early signs of complications.

In other findings, nearly 40% of program directors said new fellows display a lack of "patient ownership." "We promote patient ownership in our programs. We are somewhat disappointed and dismayed that the fellows feel that the patient is part of a service and not their own," Dr. Mattar commented. Half of the program directors indicated their incoming fellows demonstrated independence in the operating room and on call, although they reported the fellows showed marked improvement in these areas as the year went on.

A large majority of program directors felt their fellows were disinterested in research and in advancing the field, even though, as Dr. Mattar noted, "This is a mandate in our curriculum."

He reported having no financial conflicts.

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