US General Surgery Residents Readiness for Independent Practice

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“There’s increasing concern that U.S. general surgery residents are not ready to operate independently by the time they graduate.”

A study published in the April Issue of the Annals of Surgery found that in the final 6 months of training, 96% of residents were rated competent by their observers to perform a straightforward appendectomy on their own, but only 71% were rated the same for partial colectomy. 

In an article I published on this website in 2014, I commented on this lack of readiness in detail. Unfortunately, it appears that surgical training programs have made no progress since. It also appears that surgical skills training has been reduced to procedures that were once considered a  basic ability of a junior surgical resident:

Residents in this study were evaluated for five most frequently rated of 133 designated Core procedures that included laparoscopic cholecystectomy, laparoscopic appendectomy, open inguinal hernia repair, open ventral hernia repair, and exploratory laparotomy. 

Details below:

Objective
The American Board of Surgery has designated 133 procedures as being “Core” to the practice of General Surgery (GS). GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard.

Methods
Attendings in 14 General Surgery programs were trained to use a) the 5-level SIMPL Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (i.e. autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics.

Results
368 attending surgeons rated 393 categorical residents after 5861 procedures. The five most frequently rated Core procedures were laparoscopic cholecystectomy, laparoscopic appendectomy, open inguinal hernia repair, open ventral hernia repair, and exploratory laparotomy. From the first to the last year of training, the proportion of Performance ratings at “Practice Ready” or above for the top five Core procedures (n=1541) increased from 11.8% to 90.0% (p<0.001, 95% CI 7.4-18.1% and 86.2-92.9%, respectively) (Figure 1). For the most frequently rated procedure for residents in their final six months of training (laparoscopic cholecystectomy), the proportion of Performance ratings (n=161) at “Practice Ready” or above was 87.0% (95% CI 80.5-91.1%). For all procedures (n=5861), the proportion of Zwisch ratings indicating meaningful autonomy (“Passive Help” or “Supervision Only”) increased from 16.9% to 67.0% (p<0.001, 95% CI 14.4-19.7% and 64.4-69.5%, respectively) from the first to the last year of training. For the five most frequently rated Core procedures performed by residents in their final 6 months of training (n=342), the proportion of Zwisch ratings indicating near-independence (“Supervision Only”) was 49.1% (n=342, 95% CI 43.7-54.5%) (Figure 2).

Conclusions
US General Surgery residents are generally but not universally ready to independently perform the most common Core procedures by the time they complete residency training. Resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for independent practice.


Figure 1: The relationship between resident post-graduate year (PGY) and the distribution of operative Performance ratings. Ratings indicating readiness for independent practice (Pratice-Ready and Exceptional Performance) are plotted above the line in the top panel, with the percentage of ratings in those two top categories above each bar. The total number of ratings for each PGY is shown in the histogram below each distribution.


Figure 2: The distribution of faculty guidance (Zwisch) ratings for trainees in the last 6 months of their residency training while performing one of the five most frequently rated American Board of Surgery-defined “Core” procedures. Ratings indicating meaningful autonomy (Passive Help and Supervision Only) are plotted in the left panel. The total number of ratings for each procedure is shown in the histogram in the right panel.

PHILADELPHIA – The question of how prepared general surgery residents are to operate independently after their training is longstanding, but clear definitions of competency and readiness have been elusive. A consortium of general surgery residencies has developed a metric for assessing surgeon readiness, but what the metric revealed may be a cause for concern for the surgical profession.

1University of Michigan, Ann Arbor, MI; 2Massachusetts General Hospital, Boston, MA;3Indiana University, Indianapolis, IN;4Northwestern University, Chicago, IL;5SUNY Upstate, Syracuse, NY;6University of Washington, Seattle, WA;7Brigham and Women’s Hospital, Boston, MA;8University of Minnesota, Minneapolis, MN;9University of New Mexico, Albuquerque, NM;10Vanderbilt University, Nashville, TN;11Washington University, Saint Louis, MO;12University of Washington, Madison, WI;13University of Texas Southwestern, Dallas, TX;14University of Kentucky, Lexington, KY

 

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