How to Change General Surgery Residency Training
The training of general surgeons in the United States can trace its roots back to the system introduced by William Stewart Halsted at the Johns Hopkins Hospital, and many of the unique components persist today [1]. The training was hospital based, university sponsored, with the expectation that residents would gain knowledge and understanding of the scientific basis of surgical principles, ultimately resulting in increased responsibility over several years of training [2]. This training culminated in a final period of near-total independence and autonomy. The results of this training under Halsted were quite remarkable, and those who completed the Halsted training went on to direct departments of surgery at the leading institutions of the day [3].
General surgery residency training has been largely unchanged for the last 100 years. The most substantive change to the structure of training was the abandonment of the pyramidal system (where many medical school graduates entered surgical residency, but only one ascended to be the chief resident) and the adoption of the rectangular surgical residency program. This program was introduced in 1939 by Edward D. Churchill at the Massachusetts General Hospital [4]. Churchill initiated the current system we have where all entering trainees are expected to finish training at the hospital they began.
In the 1990s, general surgery became more separated into its own component subspecialties, as both training and practice became more focused. Surgeons (especially in academic centers) desired a more limited practice, and patients sought care by physicians with special expertise and training. Although many trainees went on to practice general surgery, an increasing number of residency graduates opted for fellowship training after completion of general surgery residency. A few of fellowships were distinct from general surgery (plastic surgery, cardiothoracic surgery, pediatric surgery) and for the most part, these surgeons no longer practice general surgery. Several subspecialties remain closely linked to the practice of general surgery. Most have training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME); but non–ACGME-approved fellowships (transplant, surgical oncology, minimally invasive surgery, bariatric surgery, endocrine surgery, breast surgery, hepatopancreatobiliary surgery, trauma, acute care surgery) have developed for a multitude of reasons, including the lack of graduate medical education funding, the ability to bill for the services of non-ACGME fellows, and not wanting ACGME oversight for work hours. Most importantly, however, may be the realization that additional training and focused practice results in better patient outcomes [5–7]. For those interested in an academic career, narrowing of one’s practice allows special expertise that may enhance academic productivity and increase patient referrals to tertiary centers.
Two technical advancements of the 1990s fundamentally changed general surgery: the introduction of laparoscopic cholecystectomy and the advent of endovascular techniques. Laparoscopic cholecystectomy was first performed by Philippe Mouret and Francois Dubois in France. When a video was presented at the 1987 Society of American Gastrointestinal Endoscopic Surgeons video session by Jacques Perissat, it revolutionized general surgery [8]. Other procedures followed and laparoscopic adrenalectomy, appendectomy, and colectomy have become the preferred technique for many patients. The inadequacy of minimally invasive surgical training in general surgery residency led to an explosion (more than 100) non–ACGME-approved minimally invasive and bariatric surgery fellowships. Some think that laparoscopic training is a fad and will eventually be encompassed into general surgery residency training. Until this happens, minimally invasive surgery fellowships, which have become one of the most popular choices of general surgery residency graduates, has the potential to remain a separate discipline from general surgery. Up until the mid-1990s, many general surgeons were able to perform both general and vascular surgery in their practice. The advent of endovascular treatment of abdominal aortic aneurysmal disease and subsequent extension of infrainguinal occlusive disease has separated the field of vascular surgery from general surgery. To practice modern vascular surgery, a surgeon must have endovascular skills, and the American Board of Surgery (ABS) now recognizes that although general surgeons do need to have some familiarity with vascular surgery, vascular surgery is now a unique discipline, and promotes that the path to proficiency in vascular surgery requires completion of a vascular surgery residency.
In the last two decades, there have been significant changes to graduate medical education that have influenced the ability of residency graduates to feel confident about independent practice. The Centers for Medicare and Medicaid Services (the primary funder of graduate medical education) implemented more stringent rules surrounding the supervision of residents performing operations in 1996 [9,10]. The teaching physician was required to be present for the key portion of any operation and any clinic or hospital visit they are going to bill for. Although these changes should be commended for ensuring adequate supervision, they may have had the unintended consequence of residents going into practice feeling less than secure in their abilities to make independent operative decisions. In 2003, the ACGME instituted duty hour restrictions that limited a resident to an 80-hour workweek [11]. Most recently, the ACGME amended their standards to limit the interns (PGY-1) to 16 hours per day [12]. The new regulations recommend that interns should have 10 hours (and must have at least 8 hours) free of duty between scheduled duty periods. For these reasons, and several others, more than 80% of general surgery residency graduates enter fellowships. Because many of those who complete fellowships narrow their practices, there remains a shortage of general surgeons capable and interested in practicing broad-based general surgery [13–15]. There is an acknowledged need to provide general surgeons for rural communities, but there is an equivalent obligation to provide qualified general surgeons to care for patients in community hospitals (where most patients are cared for), including managing common conditions, taking emergency room calls, and performing emergency operations.
The challenge of redesigning general surgery residency training is to simultaneously meet these two seemingly competing objectives: to provide general surgeons competent to be independent practitioners and (for most residents) to optimally prepare them for fellowship training. The most common procedures done by general surgeons in practice are listed in Table 1
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