Changing Demographics of Residents Choosing Fellowships: Longterm Data from The American Board of Surgery

The general surgery job market: analysis of current demand for general surgeons and their specialized skills

BACKGROUND

The majority of general surgery residents pursue fellowships. However, the relative demand for general surgical skills vs more specialization is not understood. Our objective was to describe the current job market for general surgeons and compare the skills required by the market with those of graduating trainees.

STUDY DESIGN

Positions for board eligible/certified general surgeons in Oregon and Wisconsin from 2011 to 2012 were identified by review of job postings and telephone calls to hospitals, private practice groups, and physician recruiters. Data were gathered on each job to determine if fellowship training or specialized skills were required, preferred, or not requested. Information on resident pursuit of fellowship training was obtained from all residency programs within the represented states.

RESULTS

Of 71 general surgery positions available, 34% of positions required fellowship training. Rural positions made up 46% of available jobs. Thirty-five percent of positions were in nonacademic metropolitan settings and 17% were in academic metropolitan settings. Fellowship training was required or preferred for 18%, 28%, and 92% of rural, nonacademic, and academic metropolitan positions, respectively. From 2008 to 2012, 67% of general surgery residents pursued fellowship training.

CONCLUSIONS

Most general surgery residents pursue fellowship despite the fact that the majority of available jobs do not require fellowship training. The motivation for fellowship training is unclear, but residency programs should tailor training to the skills needed by the market with the goal of improving access to general surgical services.

General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors

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 directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains.

RESULTS

There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.

Trends in applications for thoracic fellowship in comparison with other subspecialties

BACKGROUND

Length of training (LOT), lifestyle, and decreasing reimbursement have been credited with contributing to the decline in applications to thoracic surgery (TS). Other surgical specialties share similarities in LOT and lifestyle; however, trends in applications for these specialties have not been compared. One cannot look at applications to TS without examining concurrent changes in the pool of residents finishing general surgery. To clarify the relative impact of LOT, lifestyle, applicant pool, and reimbursement on applications to TS, we analyzed these trends concurrently.

METHODS

National Resident Matching Program residency and fellowship match placement data (1997 to 2012) for general, TS, pediatric, transplant, and vascular surgery, including integrated TS and vascular surgery, were analyzed. Corresponding trends in reimbursement were analyzed from Medical Group Management Association data (1996 to 2010).

RESULTS

During the study period, percentage of medical students matching into general surgery has remained relatively constant (4.9% to 5.5%). Applications for TS have declined since 1997. Applications for pediatric and transplant surgery have increased. Vascular surgery has remained relatively constant, with an applicant to position ratio approximately 1:1. Integrated programs (thoracic and vascular) have been popular; 3 to 7.4 applicants per position and 2 to 3.47 applicants per position, respectively. Cardiovascular surgery median salaries have remained largely the same; salaries for general thoracic, pediatric, transplant, and vascular surgery have increased (1.95% to 7.13% per year) although cardiovascular surgeons continue to have the highest median salary.

CONCLUSIONS

Given the above data, it does not appear that LOT is the critical issue associated with the decline in fellowship applications for TS. The increased demand for integrated training programs may be reflective of other factors rather than LOT. The success of abbreviated programs in training competent thoracic surgeons has not yet been determined. Given that LOT does not appear to affect applications to surgical specialty, we may be able to maintain applications to the specialty without compromising LOT.

Specialization and the current practices of general surgeons

BACKGROUND

The impact of specialization on the practice of general surgery has not been characterized. Our goal was to assess general surgeons' operative practices to inform surgical education and workforce planning.

STUDY DESIGN

We examined the practices of general surgeons identified in the 2008 State Inpatient and Ambulatory Surgery Databases of the Healthcare Cost and Utilization Project for 3 US states. Operations were identified using ICD-9 and CPT codes linked to encrypted physician identifiers. For each surgeon, total operative volume and percentage of practice that made up their most common operation were calculated. Correlation was measured between general surgeons' case volume and the number of other specialists in a health service area.

RESULTS

There were 1,075 general surgeons who performed 240,510 operations in 2008. The mean operative volume for each surgeon was 224 annual procedures. General surgeons performed an average of 23 different types of operations. For the majority of general surgeons, their most common procedure constituted no more than 30% of total practice. The most common operations, ranked by the frequency they appeared as general surgeons' top procedure, included cholecystectomy, colonoscopy, endoscopy, and skin excision. The proportion of general surgery practice composed of endoscopic procedures inversely correlated with the number of gastroenterologists in the health service area (rho = -0.50; p = 0.005).

CONCLUSIONS

Despite trends toward specialization, the current practices of general surgeons remain heterogeneous. This indicates a continued demand for broad-based surgical education to allow future surgeons to tailor their practices to their environment.

The ACGME case log: general surgery resident experience in pediatric surgery

BACKGROUND

General surgery (GS) residents in ACGME programs log cases performed during their residency. We reviewed designated pediatric surgery (PS) cases to assess for changes in performed cases over time.

METHODS

The ACGME case logs for graduating GS residents were reviewed from academic year (AY) 1989-1990 to 2010-2011 for designated pediatric cases. Overall and designated PS cases were analyzed. Data were combined into five blocks: Period I (AY1989-90 to AY1993-94), Period II (AY1994-95 to AY1998-99), Period III (AY1999-00 to AY2002-03), Period IV (AY2003-04 to AY2006-07), and Period V (AY2007-08 to AY2010-11). Periods IV and V were delineated by implementation of duty hour restrictions. Student t-tests compared averages among the time periods with significance at P < .05.

RESULTS

Overall GS case load remained relatively stable. Of total cases, PS cases accounted for 5.4% in Period I and 3.7% in Period V. Designated pediatric cases declined for each period from an average of 47.7 in Period I to 33.8 in Period V. These changes are due to a decline in hernia repairs, which account for half of cases. All other cases contributed only minimally to the pediatric cases. The only laparoscopic cases in the database were anti-reflux procedures, which increased over time.

CONCLUSIONS

GS residents perform a diminishing number of designated PS cases. This decline occurred before the onset of work-hour restrictions. These changes have implications on the capabilities of the current graduating workforce. However, the case log does not reflect all cases trainees may be exposed to, so revision of this list is recommended.

Review of influential articles in surgical education: 2002-2012

BACKGROUND

Exploring the trends in surgical education research offers insight into concerns, developments, and questions researchers are exploring that are relevant to teaching and learning in surgical specialties.

OBJECTIVE

We conducted a review of the surgical education literature published between 2002 and 2012. The purpose was 2-fold: to provide an overview of the most frequently cited articles in the field of surgical education during the last decade and to describe the study designs and themes featured in these articles.

METHODS

Articles were identified through Web of Science by using "surgical education" and "English language" as search terms. Using a feature in Web of Science, we tracked the number of citations of any publication. Of the 800 articles produced by the initial search, we initially selected 23 articles with 45 or more citations, and ultimately chose the 20 articles that were most frequently cited for our analysis.

RESULTS

Analysis of the most frequently cited articles published in US journals between the years 2002-2012 identified 7 research themes and presented them in order of frequency with which they appear: use of simulation, issues in student/resident assessment, specialty choice, patient safety, team training, clinical competence assessment, and teaching the clinical sciences, with surgical simulation being the central theme. Researchers primarily used descriptive methods.

CONCLUSIONS

Popular themes in surgical education research illuminate the information needs of surgical educators as well as topics of high interest to the surgical community.

Section for residents and fellows-in-training survey results

OBJECTIVES

(1) To present data from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Section for Residents and Fellows-in-Training (SRF) annual survey from 2002 to 2011. (2) To compare and analyze trends in resident demographics, residency experiences, and post-training career choices.

STUDY DESIGN

Review of cross-sectional survey data.

SETTING

Residents and Fellows registered as Members-in-Training through AAO-HNS.

METHODS

A review of data from surveys distributed between 2002 and 2011 was conducted. Respondent demographic data including age, postgraduate year, gender, and geographic distribution were analyzed. Responses about training experiences, fellowship selection, debt burden, and post-training practice choice were studied in order to elicit trends.

RESULTS

Respondents have consistently rated otolaryngology, anesthesia, and trauma/critical care as the most important intern rotations for otolaryngology residents. Each year, approximately 70% of respondents have reported interest in pursuing a fellowship. Pediatric otolaryngology fellowship is now the most popular fellowship among respondents. There has been a recent increase in the percentage of respondents who are interested in pursuing a career in academics. Location, family, and lifestyle have consistently been the most important factors in determining choice of practice. Respondents have reported increasing levels of educational debt.

CONCLUSION

The AAO-HNS SRF survey collects important data regarding resident/fellow training. Several factors limit the generalizability of these results. Despite its limitations, these unique data provide valuable information for continual evaluation and improvement of physician training in the specialty.

Symbiotic or parasitic? A review of the literature on the impact of fellowships on surgical residents

OBJECTIVE

We conducted a systematic review of published literature to gain a better understanding of the impact of advanced fellowships on surgical resident training and education.

BACKGROUND

As fellowship opportunities rise, resident training may be adversely impacted.

METHODS

PubMed, MEDLINE, Scopus, BIOSIS, Web of Science, and a manual search of article bibliographies. Of the 139 citations identified through the initial electronic search and screened for possible inclusion, 23 articles were retained and accepted for this review. Data were extracted regarding surgical specialty, methodology, sample population, outcomes measured, and results.

RESULTS

Eight studies retrospectively compared the eras before and after the introduction of a fellowship or trended data over time. Approximately half used data from a single institution, whereas the other half used some form of national data or survey. Only 3 studies used national case data. Fourteen studies looked at general surgery, 6 at obstetrics-gynecology, 2 at urology, and 1 at otolaryngology. Only one study concluded that fellowships have a generally positive impact on resident education, whereas 9 others found a negative impact. The remaining 13 studies found mixed results (n = 6) or minimal to no impact (n = 7).

CONCLUSIONS

The overall impact of advanced surgical fellowships on surgical resident education and training remains unclear, as most studies rely on limited data of questionable generalizability. A careful study of the national database of surgery resident case logs is essential to better understand how early surgical specialization and fellowships will impact the future of general surgery education.

General surgery vs fellowship: the role of the Independent Academic Medical Center

OBJECTIVES

To compare career choices of residency graduates from Independent Academic Medical Center (IAMC) and University Academic Medical Center (UAMC) programs and evaluate program directors' perceptions of residents' motivations for pursuing general surgery or fellowships.

DESIGN

From May to August 2011, an electronic survey collected information on program characteristics, graduates' career pursuits, and career motivations. Fisher's exact tests were calculated to compare responses by program type. Multivariate logistic regression was used to identify independent program characteristics associated with graduates pursuing general surgery.

SETTING

Data were collected on graduates over 3 years (2009-2011).

PARTICIPANTS

Surgery residency program directors.

RESULTS

Seventy-four program directors completed the survey; 42% represented IAMCs. IAMCs reported more graduates choosing general surgery. Over one-quarter of graduates pursued general surgery from 52% of IAMC vs 37% of UAMC programs (p = 0.243). Career choices varied significantly by region: over one-quarter of graduates pursue general surgery from 78% of Western, 60% of Midwestern, 40% of Southern, and 24% of Northeastern programs (p = 0.018). On multivariate analysis, IAMC programs were independently associated with more graduates choosing general surgery (p = 0.017), after adjustment for other program characteristics. Seventy-five percent of UAMC programs reported over three-fourths of graduates receive first choice fellowship, compared with only 52% of IAMC programs (p = 0.067). Fellowships were comparable among IAMC and UAMC programs, most commonly MIS/Bariatric (16%), Critical Care/Trauma (16%), and Vascular (14%). IAMC and UAMC program directors cite similar reasons for graduate career choices.

CONCLUSIONS

Most general surgery residents undergo fellowship training. Graduates from IAMC and UAMC programs pursue similar specialties, but UAMC programs report more first choice acceptance. IAMC programs may graduate proportionately more general surgeons. Further studies directly evaluating surgical residents' career choices are warranted to understand the influence of independent and university programs in shaping these choices and to develop strategies for reducing the general surgeon shortage.

Survey of hand surgeons regarding their perceived needs for an expanded upper extremity fellowship

PURPOSE

To survey practicing hand surgeons regarding their perceived need for an expanded upper extremity fellowship.

METHODS

Electronic surveys were sent to 248 surgeons who had completed a hand surgery fellowship between 2008 and 2010. The survey was structured to ascertain whether there was a need for expanded education encompassing the entire upper extremity. Four separate mailings were made. Of the 248 surgeons who were sent the survey, 131 (53%) responded. Of the respondents, 74% (97) were trained in orthopedics, 16% (21) in plastic surgery, and 10% (13) in general surgery.

RESULTS

Of the 131 respondents, 7% (9) felt that 1 year of specialty training was insufficient, 48% (63) had sought shoulder and elbow training in their fellowship, and 52% (68) did not have dedicated plastic surgery rotations. Microsurgical experience was variable: 8% (10) of respondents had not been exposed to replantation, 23% (30) had not been exposed to free flap surgery, 32% (42) had not participated in brachial plexus surgery, and 17% (22) had not done a vascularized bone graft. Fifty-six percent (73) of respondents had not had dedicated time for research during their fellowship. Eleven percent (15) had obtained additional training after their fellowship, including shoulder and elbow, microsurgery, pediatrics, and peripheral nerve surgery. When asked if they would have applied to a 2-year hand and upper extremity fellowship, 60% (79) of respondents would have applied.

CONCLUSIONS

Based on the results of this survey, 1 year of hand fellowship training has been perceived as inadequate by 7% (9) of respondents, with exposure insufficient in shoulder and elbow, microsurgery, pediatrics, and clinical research. Further critical review of hand fellowship education should be considered, with the availability of extended fellowship tracks for those requesting an increased breadth of upper extremity surgical training.

Impact of implementation of a pediatric surgery fellowship on general surgery resident operative volume

OBJECTIVE

The purpose of this study was to determine the impact of the initiation of a pediatric surgery fellowship on general surgery resident operative volume at 1 major academic institution.

DESIGN

Retrospective review of operative records obtained from the Accreditation Council for Graduate Medical Education (ACGME) general surgery resident and pediatric surgery fellow case logs. Data collected included number and type of pediatric index cases per year, number of total pediatric surgery cases per year, and number of total cases logged as primary surgeon to date.

SETTING

Vanderbilt University School of Medicine Department of Surgery, which has an accredited general surgery program, finishes 7 chief residents per year during the study period, and instituted a new pediatric surgery fellowship in 2007.

PARTICIPANTS

Case logs submitted by third and fourth year general surgery residents and first and second year pediatric surgery fellows were studied.

RESULTS

The number of pediatric attending surgeons, relative value units (RVUs), and hospital admissions increased from 2003 to 2011. The median number of pediatric index cases performed by a resident decreased after the onset of fellowship from 34 cases to 23.5 cases per year (p < 0.001). The median number of total cases that residents performed on the pediatric surgery rotation also decreased from 74 to 53 cases per year after onset of the fellowship (p < 0.001).

CONCLUSIONS

Even with an increase in the number of attending surgeons, RVUs, and admissions, the fellowship resulted in a decrease in general surgery resident index and overall case volume in pediatric surgery. Although operative volume is only 1 measure of surgical educational value, these findings suggest that the addition of surgical fellowships affects the educational experience of general surgery residents. We recommend that residency programs establish goals and calculate any potential impact on general surgery resident case volume before initiating a new surgical fellowship.

The Canadian general surgery resident: defining current challenges for surgical leadership

BACKGROUND

Surgery training programs in Canada and the United States have recognized the need to modify current models of training and education. The shifting demographic of surgery trainees, lifestyle issues and an increased trend toward subspecialization are the major influences. To guide these important educational initiatives, a contemporary profile of Canadian general surgery residents and their impressions of training in Canada is required.

METHODS

We developed and distributed a questionnaire to residents in each Canadian general surgery training program, and residents responded during dedicated teaching time.

RESULTS

In all, 186 surveys were returned for analysis (62% response rate). The average age of Canadian general surgery residents is 30 years, 38% are women, 41% are married, 18% have dependants younger than 18 years and 41% plan to add to or start a family during residency. Most (87%) residents plan to pursue postgraduate education. On completion of training, 74% of residents plan to stay in Canada and 49% want to practice in an academic setting. Almost half (42%) of residents identify a poor balance between work and personal life during residency. Forty-seven percent of respondents have appropriate access to mentorship, whereas 37% describe suitable access to career guidance and 40% identify the availability of appropriate social supports. Just over half (54%) believe the stress level during residency is manageable.

CONCLUSION

This survey provides a profile of contemporary Canadian general surgery residents. Important challenges within the residency system are identified. Program directors and chairs of surgery are encouraged to recognize these challenges and intervene where appropriate.

Teaching in the operating room: results of a national survey

BACKGROUND

With the institution of the work-hour restrictions in 2003, less time may be available for surgical residents to learn operative technique and judgment. While numerous studies have evaluated the use of surgical simulation training to enhance operative skills, little is known about the quality of teaching that takes place in the operating room (OR). The purpose of this study was to assess residents' perception of faculty teaching in the OR in order to target ways to improve operative education.

METHODS

A request for resident participation in an online survey was sent to the Program Coordinator at all 255 ACGME-accredited general surgery residency programs.

RESULTS

A total of 148 programs (59%) participated in the survey, and anonymous responses were submitted by 998 of 4926 residents (20%). Most residents reported that attending surgeons verbalize their operative approach (55%), include residents in intraoperative decisions (61%), and offer technical advice (84%). However, few residents reported that faculty help to identify the resident's personal educational operative goals preoperatively (18%) or discuss areas of improvement with residents (37%). Of all cases scrubbed in the past year, most residents feel as though they only actually performed the procedure between 26% and 50% (29%) or between 51% and 75% (32%) of the time. However, more than half of all residents (51%) log these procedures for ACGME as primary surgeon 76%-100% of the time.

CONCLUSIONS

This study demonstrates that from the residents' perspective, a number of opportunities exist to improve teaching in the OR, such as guiding residents with preoperative preparation and providing them with constructive feedback. These findings also suggest that residents may be logging cases without feeling as though they actually perform the operations.

Nonverifiable research publications among applicants to an academic trauma and surgical critical care fellowship program

BACKGROUND

The purpose of this study was to determine the incidence and predictors of nonverifiable research publications among applicants to a trauma and surgical critical care fellowship program.

STUDY DESIGN

All complete applications submitted to our trauma and surgical critical care fellowship program were prospectively collected for 4 application cycles (2009 to 2012). All publications listed by applicants were tabulated and underwent verification using MEDLINE and direct journal search with verification by a team of professional health sciences librarians. Demographics and academic criteria were compared between applicants with nonverifiable and verifiable publications.

RESULTS

A total of 100 applicants reported 301 publications. Of those, 20 applicants (20%) listed 32 papers (11%) that could not be verified. These applicants comprised 30% of those with 1 or more peer-reviewed publications. There were no significant differences in sex (male, 55% nonverifiable vs 60% verifiable, p = 0.684) or age (34.3 ± 6.6 years vs 34.2 ± 5.0 years, p = 0.963). There were no differences with regard to citizenship status (foreign medical graduates, 20% nonverifiable vs 28% verifiable, p = 0.495). Applicants with nonverified publications were less likely to be in the military (0% vs 14%, p = 0.079), more likely to have presented their work at surgical meetings (80% vs 58%, p = 0.064), and to be individuals with 3 or more peer-reviewed publications (55% vs 25%, p = 0.009).

CONCLUSIONS

In this analysis of academic integrity, one-fifth of all applicants applying to a trauma and surgical critical care fellowship program and 30% of those with 1 or more peer-reviewed publications had nonverifiable publications listed in their curricula vitae. These applicants were less likely to be in the military, more likely to have presented their work at surgical meetings and to have 3 or more peer-reviewed publications.

Graduate medical education in trauma/critical care and acute care surgery: defining goals for a new workforce

The increasing need for skilled emergency surgical providers, coupled with decreasing experience in emergency surgery among trainees, has led to significant shortages in the availability of such surgeons. In response to this crisis, surgical leaders have developed a comprehensive curriculum and a set of professional standards to guide the training of a new specialist: the acute care surgeon. This article reviews the development and goals for Fellowship training of this new specialty.

Surgical fellowship training in Canada: what is its current status and is improvement required?

This paper examines current issues concerning surgical fellowship training in Canada. Other than information from a few studies of fellowship training in North America, there are scant data on this subject in the literature. Little is known about the demographic characteristics of those who pursue fellowship training in Canada, what the experiences and expectations are of fellows and their supervisors with respect to the strengths and weaknesses of this level of training, or how this level of education fits in with Canadian undergraduate and postgraduate medical training. We summarize current knowledge about fellowship training in Canada as it pertains to demographic characteristics, finances, work hours, residency training, preparation for clinical and research work and satisfaction with training. Most information on surgical fellowship training comes from the United States. As such, we used information from American studies to supplement the Canadian data. Because a surgical fellowship experience in Canada may be different from that in the United States, we propose that Canadian surgical fellows and their supervisors should be surveyed to gain an understanding of such information. This knowledge could be used to improve surgical fellowship training in Canada.

Trends in research time, fellowship training, and practice patterns among general surgery graduates

SUMMARY

A comparison of research experience, fellowship training, and ultimate practice patterns of general surgery graduates at a university-based surgical residency program. Research experience correlated with pursuing fellowship training and predicted an eventual academic career. More recently, graduates have been able to obtain fellowships without a dedicated research year, perhaps reflecting shifting fellowship training opportunities.

BACKGROUND

We hypothesized that the relationships among dedicated research experience during residency, fellowship training, and career choices is changing as research and fellowship opportunities evolve.

METHODS

Comparison of research experience, fellowship training, and ultimate practice patterns of general surgery graduates for 2 decades (1990-1999, n = 82; 2000-2009, n = 98) at a university-based residency program. Main outcome measures were number of years and area of research, fellowship training, and practice setting.

RESULTS

Compared by decade, graduates became increasingly fellowship-trained (51.2% vs 67.3%; p < 0.05) and pursuit of fellowship training increased for both research and nonresearch participating graduates. The number of residents completing more than 1 year of research doubled (9.8% vs 22.4%, p < 0.05). By decade, the percentage of female graduates increased significantly (22% vs 41%, p = 0.005), with more women participating in dedicated research (17% vs 51%, p < 0.001) and seeking fellowships. The number of graduates going into specialty practice and academic/clinical faculty positions increased over time.

CONCLUSIONS

Surgical residents have completed more dedicated research years and became increasingly fellowship-trained over time. The proportion of female graduates has increased with similar increases in research time and fellowship training in this subgroup. In the earlier decade, dedicated research experiences during surgical residency correlated with pursuing fellowship training, and predicted an eventual academic career. More recently, graduates have obtained fellowships and academic positions without dedicated research time, perhaps reflecting shifting fellowship opportunities.

Civilian and Military Trauma: Does Civilian Training Prepare Surgeons for the Battlefield?

The management of trauma patients continues to be a major focus of resident training. The purpose of this review is to compare the mechanism and distribution of injuries in civilian and military trauma and to ascertain whether we are optimally preparing surgeons for the injuries seen on the battlefield. We performed a retrospective 5-year review of all trauma admissions to our urban trauma center (TC). We then compared this data with that recently acquired from Operation Iraqi Freedom (OIF). There were 7732 trauma patients seen during that time at our TC with 9.8 per cent sustaining gunshot wounds. Of those, 26 per cent sustained a gunshot wound to the thorax, and injuries to the abdomen and pelvis were sustained in 28.5 per cent. In total, truncal trauma accounted for 55 per cent of the injuries. Extremity injuries occurred in just 31 per cent. Data from OIF show the mechanism and distribution of injuries to be quite different. Improvised explosive devices accounted for greater than 50 per cent of the injuries in OIF. Truncal injuries accounted for just 14 per cent of the injuries seen and extremity injuries accounted for, a significant, 56 per cent of all the injuries observed. The civilian experience with gunshot wounds often focuses on truncal trauma, yet the military data show a need for knowledge of devastating injuries to the extremity. This divergent experience may be even more salient in the future as the battlefield is brought closer to home through domestic terrorism and the line is blurred between military and civilian trauma.

Tracking Residents Through Multiple Residency Programs: A Different Approach for Measuring Residents' Rates of Continuing Graduate Medical Education in ACGME-Accredited Programs

BACKGROUND

Increased focus on the number and type of physicians delivering health care in the United States necessitates a better understanding of changes in graduate medical education (GME). Data collected by the Accreditation Council for Graduate Medical Education (ACGME) allow longitudinal tracking of residents, revealing the number and type of residents who continue GME following completion of an initial residency. We examined trends in the percent of graduates pursuing additional clinical education following graduation from ACGME-accredited pipeline specialty programs (specialties leading to initial board certification).

METHODS

Using data collected annually by the ACGME, we tracked residents graduating from ACGME-accredited pipeline specialty programs between academic year (AY) 2002-2003 and AY 2006-2007 and those pursuing additional ACGME-accredited training within 2 years. We examined changes in the number of graduates and the percent of graduates continuing GME by specialty, by type of medical school, and overall.

RESULTS

The number of pipeline specialty graduates increased by 1171 (5.3%) between AY 2002-2003 and AY 2006-2007. During the same period, the number of graduates pursuing additional GME increased by 1059 (16.7%). The overall rate of continuing GME increased each year, from 28.5% (6331/22229) in AY 2002-2003 to 31.6% (7390/23400) in AY 2006-2007. Rates differed by specialty and for US medical school graduates (26.4% [3896/14752] in AY 2002-2003 to 31.6% [4718/14941] in AY 2006-2007) versus international medical graduates (35.2% [2118/6023] to 33.8% [2246/6647]).

CONCLUSION

The number of graduates and the rate of continuing GME increased from AY 2002-2003 to AY 2006-2007. Our findings show a recent increase in the rate of continued training for US medical school graduates compared to international medical graduates. Our results differ from previously reported rates of subspecialization in the literature. Tracking individual residents through residency and fellowship programs provides a better understanding of residents' pathways to practice.

Motivation of French medical students to pursue surgical careers: results of national survey of 1742 students

OBJECTIVES

Analyze the aspirations and personal motivations behind the choice of surgical specialties in a large sample of students in their 6th year of medical school.

MATERIAL AND METHODS

In December 2008, 2588 students participated in a nation-wide mock exam, before taking the National Ranking Exam. When they looked for their grades on the web, the students were prompted to answer a questionnaire containing socio-demographic questions concerning their choice and motivation to pursue a career in a surgical specialty. The survey called also for listing the three main factors (out of a list of 11) motivating their choice.

RESULTS

Students originated from 39 medical schools. Of the 2588 students, 1427 (55%) were women. The response rate to the questionnaire was 1742/2588=67%. Two hundred and twenty students (13%) did not express any specific professional orientation. Of the 1522 responses obtained, 522 students wanted to become surgeons. Gender was a determining factor as 44% of male students (n=252) versus 29% of female students wanted to become a surgeon; P<0.0001. The three most selected surgical subspecialties were gynecology (n=137), orthopedics (n=91) and ophthalmology (n=57). Once again gender played a role in the choice: 82% who chose gynecology were women while 73% of future urologists were men (P<0.0001). Special interest in specific diseases (n=356, 23%), the possibility of private practice (n=280, 18%) and life style (n=175, 11%) were the motivations most often cited to back their choice.

CONCLUSION

One third of medical students want to become surgeons. Feminization, life style and income are the principal factors influencing the choice of the type of surgical subspecialization.

Career choices of medical students: a national survey of 1780 students

OBJECTIVES Many factors influence the career specialty decisions made by medical students. The aim of this study was to broaden consideration of the determinants of specialty choice in a large population of medical students in their sixth year of study. METHODS A total of 2588 students distributed across all of the 39 medical schools in France participated in a National Practice Examination in December 2008, after which an electronic questionnaire was administered. Study criteria were: population characteristics; demographics, and motivation for and drawbacks to medical specialty choice. RESULTS A total of 1780 students (1111 women, 62%) responded to the questionnaire (69% response rate). The mean age of respondents was 23.8 years (22-35 years). Of these, 1555 students (87%) stated their preferred medical specialty. Surgical and medical specialties were the two specialties selected most frequently by students (n = 729, 47%). General practice was chosen by 20%. Gender influenced the choice of specialty: 88% of future paediatricians, 82% of gynaecologists and 77% of general practitioners (GPs) were women (p < 0.05). Main motivating factors included interesting diseases, opportunities for private practice and patient contact. Main drawbacks limiting the choice of other specialties were poor quality of life, an exclusively hospital-based career and loss of patient contact. Gender was the criterion most associated with significant differences in factors of motivation for or discouragement from a career. Patient contact and opportunities for private practice were significantly highlighted by future GPs compared with students opting for the medical or surgical specialties (p < 0.0001). CONCLUSIONS Students' career choices regarding specialties or general practice result from the interplay among several factors. Career interest in general practice is particularly low. Initiatives to address the factors affecting student career choices regarding less favoured specialties and to deal with the growing feminisation of the profession, which will lead to irreversible changes in clinical practice, are required.

Colorectal procedures: what proportion is performed by American board of colon and rectal surgery-certified surgeons?

PURPOSE

The surgical workforce within the United States is moving rapidly toward increasing subspecialization. We hypothesized that over time an increasing proportion of colorectal procedures is performed by subspecialty-trained colorectal surgeons.

METHODS

We used data from the Surveillance, Epidemiology, and End Results-Medicare program to examine the treatment of patients who underwent a colorectal surgical procedure between 1992 and 2002. We established whether the surgeon responsible for the patient's initial care was a board-certified colorectal surgeon based on a linkage with 2 overlapping data sources: 1) historical data from the American Board of Colon and Rectal Surgery and 2) the American Medical Association Physician Masterfile.

RESULTS

We examined a total of 104,636 procedures; overall, 30.6% of anorectal procedures, 22.0% of proctectomies, 14.0% of ostomy-related procedures, and 11.5% of colectomies were performed by board-certified colorectal surgeons. Procedures in regions with lower population density or during urgent/emergent hospitalizations were more likely to be performed by a noncolorectal surgeon. Operations for cancer and those performed on an elective basis were more likely to be performed by a board-certified colorectal surgeon. Over time, the proportion of each of these types of cases performed by a colorectal surgeon increased. This increase was fastest for anorectal procedures.

CONCLUSIONS

During the 11-year period of our study, there was a significant increase in the proportion of colorectal surgical procedures performed by board-certified colorectal surgeons.

Incorporating an HPB fellowship does not diminish surgical residents' HPB experience in a high-volume training centre

BACKGROUND

Surgical residency training is evolving, and trainees who wish to practice hepato-pancreato-biliary (HPB) surgery in the future will be required to obtain advanced training. As this paradigm evolves, it is crucial that HPB fellowship incorporation into an established surgical residency programme does not diminish surgical residents' exposure to complex HPB procedures. We hypothesized that incorporation of a HPB fellowship in a high-volume clinical training programme would not detract from residents' HPB experience.

METHODS

Resident operative case logs and HPB fellow case logs were reviewed. Resident exposure to complex HPB procedures for 3 years prior to and 3 years after fellowship incorporation were compared.

RESULTS

No significant changes in surgical resident exposure to liver and pancreatic resection were seen between the two time periods. Surgical resident exposure to complex biliary procedures decreased in the 3 years after HPB fellowship incorporation (P= 0.003); however, exceeded the national average in each year except 2006. Graduating residents' overall HPB experience was unchanged in the 3 years prior to and after incorporating an HPB fellow. Expansion of HPB volume was a critical part of successful HPB fellowship implementation.

DISCUSSION

An HPB fellowship programme can be incorporated into a high-volume clinical training programme without detracting from resident HPB experience. Individual training programmes should carefully assess their capability to provide an adequate clinical experience for fellows without diminishing resident exposure to complex HPB procedures.

Transition from Chief Residency to Specialty Training: Issues and Solutions

Three fourths of chief residents in general surgery receive further specialty training. The end to start-of-year transition can create administrative conflicts between the residency and the specialty training program. An Internet-based questionnaire surveyed general surgery and surgical specialty program directors to define issues and possible solutions associated with end to start-of-year transitions using a Likert scale. There was an overall response rate of 17.5 per cent, 19.6 per cent among general surgery directors, and 15.8 per cent among specialty directors. Program directors in general surgery felt strongly that the transition is an administrative problem ( P < 0.001). They opposed extra days off at the end of the chief resident year or ending in mid-June, which specialty directors favored ( P < 0.001). Directors of specialty programs opposed starting the year 1 or 2 weeks after July 1, a solution that general surgery directors favored ( P < 0.001). More agreement was reached on whether chief residents should take vacation week(s) at the end of the academic year, having all general surgery levels start in mid-June, and orientation programs in July for specialty trainees. Program directors acknowledge that year-end scheduling transitions create administrative and patient care problems. Advancing the start of the training year in mid-June for all general surgery levels is a potential solution.

The eighty-hour workweek: surgical attendings' perspectives

OBJECTIVE

The year 2008 was a sentinel year in resident education; this was the first graduating general surgery class trained entirely under the 80-hour workweek. The purpose of this study was to evaluate attending surgeon perceptions of surgical resident attitudes and performance before and after duty-hour restrictions.

DESIGN

An electronic survey was sent to all surgical teaching institutions in North Carolina. Both surgeon and hospital characteristics were documented. The survey consisted of questions designed to assess residents' attitudes/performance before and after the implementation of the work-hour restriction.

RESULTS

In all, 77 surveys were returned (33% response rate). The survey demonstrated that 92% of educators who responded to the survey recognized a difference between the restricted residents (RRs) and the nonrestricted residents (NRRs), and most respondents (67%) attributed this to both the work-hour restrictions and the work ethic of current residents. Most attending surgeons reported no difference between the RRs and the NRRs in most categories; however, they identified a negative change in the areas of work ethic, technical skills development, decision-making/critical-thinking skills, and patient ownership among the RR group. Most surgeons expressed less trust (55%) with patient care and less confidence (68%) in residents' ability to operate independently in the RR group. Eighty-nine percent indicated that additional decreases in work hours would continue to hamper the mission of timely and comprehensive resident education.

CONCLUSIONS

The perception of surgical educators was that RRs are clearly different from the NRRs and that the primary difference is in work ethic and duty-hour restrictions. Although similar in most attributes, RRs are perceived as having a lower baseline work ethic and a less developed technical skill set, decision-making ability, and sense of patient ownership. Subsequent study is needed to evaluate these concerns.