Career plans and perceptions in readiness to practice of graduating general surgery residents in Canada

Surgical confidence when operating among residents in surgery - a cross-sectional study (SCAR study)

BACKGROUND

Self-confidence, is one of the critical variables influencing surgical resident's abilities, and lack of confidence maybe a reason for not entering medical practice immediately. Measuring the level of confidence of senior surgical residents (SSRs) is a crucial step in assessing preparedness to practice. In this study, we aim to measure their confidence level and the factors that might contribute to it.

METHODS

Cross-sectional survey conducted at King Abdulaziz University Hospital on SSRs in Saudi Arabia (SA). We approached 142 SSRs, 127 responded. Statistical analysis was performed using RStudio v 3.6.2. Descriptive statistics were performed using counts and percentages for categorical variables and using mean ± standard deviation for continuous variables. Multivariate linear regression (t-statistics) was used to assess the factors associated with confidence in performing essential procedures, while the association between demographics and residency-related factor with the number of completed cases was tested using Chi-square. The level of significance was determined as 0.05.

RESULTS

Response rate was 89.4%. Among surveyed residents, 66% had completed < 750 cases as a primary surgeon. More than 90% of SSRs were confident in performing appendectomy, open inguinal hernia repair, laparoscopic cholecystectomy, and trauma laparotomy, while 88% were confident in being on-call in level-I trauma center. No difference was noted in confidence level in relation to the number of performed cases. Residents from the Ministry of Health accounted for 56.3% of the study population and showed a higher confidence level compared to others. 94% of SSRs plan to pursue fellowship training program.

CONCLUSION

The study showed that the confidence of SSRs in performing common general surgery procedures was as expected. However, it's important to recognize that confidence doesn't necessarily reflect competence. Considering the majority of SSRs planned to pursue fellowship training programs, it may be time to consider changing the structure of surgical training in SA to a modular format to allow earlier and more intensive exposure.

More than learning technical skills: The importance of mentorship and coaching during a brachytherapy fellowship

Brachytherapy exposure during residency varies between residency training programs. As a result, many graduating radiation oncology residents do not feel competent or confident in performing brachytherapy procedures. A brachytherapy fellowship encompasses hands-on procedural skills in addition to clinical decision-making, radiotherapy treatment planning, as well as post-treatment care. During this time, a fellow develops interpersonal relationships with their faculty supervisors in the form of mentorship, sponsorship, and coaching in addition to clinical teaching. The objective of this article is to review these important relationships focusing on brachytherapy fellowship training as an example.

Current status of pain medicine training in anesthesiology and pain medicine residency programs in university hospitals of Korea: a survey of residents’ opinions

Background

In Korea, anesthesiologists are expected to be mainstream pain medicine (PM) practitioners. However, anesthesiology and pain medicine (APM) residency programs mostly emphasize anesthesia learning, leading to insufficient PM learning. Therefore, this study evaluated the current status of PM training in APM residency programs in 10 Korean university hospitals.

Methods

Overall, 156 residents undergoing APM training participated anonymously in our survey, focusing on PM training. We assessed the aim, satisfaction status, duration, opinion on duration, desired duration, weaknesses of the training programs and plans of residents after graduating. We divided the residents into junior (first and second year) and senior (third and fourth year). Survey data were compared between groups.

Results

Senior showed significantly different level of satisfaction grade than did junior (p=0.026). Fifty-seven (81.4%) residents in junior and forty (46.5%) residents in senior underwent PM training for ≤2 months. Most (108; 69.2%) residents felt that the training period was too short for PM learning and 95 (60.9%) residents desired a training period of ≥6 months. The most commonly expressed weakness of the training was low interventional opportunity (29.7%), followed by short duration (26.6%). After residency, 80 (49.1%) residents planned to pursue a fellowship.

Conclusions

Dissatisfaction with PM training was probably due to a structural tendency of the current program towards anesthesia training and insufficient clinical experience, which needs to be rectified, with a change in PM curriculum.

Are graduating residents sufficiently competent? Results of a national gap analysis survey of program directors and graduating residents in Japan

PURPOSE

To evaluate the self-assessed competency of graduating residents (GRs) in Japan upon completion of their residency and to identify the gap between their competency and the competency expected by their program directors (PDs).

METHOD

A list of 31 essential surgical procedures was compiled according to the consensus of surgical educators from around the country. A survey with this list was sent to all 909 GRs and their 611 PDs in 2016. The GRs rated their competency to perform these procedures and the PDs were asked to evaluate the expected competency of their GRs using the Zwisch Scale.

RESULT

The response rate was 56.3% for the GRs and 76.8% for the PDs. Fewer than half of the GRs who responded felt confident performing ten (32%) of the surgical procedures evaluated. For most procedures, the GRs' self-reported competency was lower than the expectation reported by their PDs. This gap was more than 10% for 13 of the procedures.

CONCLUSION

More than half of the GRs in Japan lacked the confidence in their skill to perform one-third of the surgical procedures selected for evaluation in this study. These findings should be used to update the surgical education curriculum in Japan.

The future of general surgery training: A Canadian resident nationwide Delphi consensus statement

BACKGROUND

Several models have been introduced to improve and restructure surgical training, but continued barriers exist. Residents are uniquely positioned to offer perspective on practical challenges and needs of reformatting surgical education. This study aimed to establish a nationwide, Delphi consensus statement on the perceptions of Canadian residents regarding the future of general surgery training.

METHODS

Canadian general surgery residents participated in a moderated focus group using the Nominal Group Technique to discuss early subspecialization, competency-based medical education, and transition to practice. Qualitative verbal data were transcribed, categorized into themes, and synthesized into recommendation statements. During an iterative Delphi survey, resident leaders ranked each statement on a 5-point Likert scale of agreement. The survey was terminated once consensus was achieved (≥2 survey rounds and Cronbach's α ≥ 0.80).

RESULTS

A total of 66 statements were synthesized by 16 members of the Canadian Association of General Surgeons Resident Committee. A total of 49 residents participated in the Delphi consensus, which was achieved after 2 voting rounds (Cronbach's α = 0.93). Participants agreed that (1) residency should focus on achieving standardized competencies and milestones based on resident ability to meet specific measurable metrics, (2) early streaming should be offered after "core" milestones and competencies have been achieved, and (3) an explicit period should allow transition-to-independent practice with tailored rotations, greater autonomy, and resident-run clinics. We identified 10 barriers to competency-based medical education implementation.

CONCLUSION

A nationwide consensus regarding the future of surgical training was established among current residents. These findings can inform and help implement guidelines and national curricula that meet the needs of the trainee and address the many challenges they face during their training.

Enhancing Confidence in Graduating General Surgery Residents: Establishing a Chief Surgery Resident Service at an Independent Academic Medical Center

OBJECTIVE

Providing opportunities for autonomy to enhance the development of independence and confidence during surgery residency remains among the greatest challenges of the current training paradigm. The objective of this study was to evaluate the implementation and outcomes of a chief resident service (CRS).

DESIGN

A CRS was designed with operative, call and office responsibilities. Supervision and evaluation were consistent with institutional guidelines. CRS operative logs from 2011 to 2014 were compared with logs from the participants' first year in practice. Select procedures were compared and evaluations were reviewed. Residency graduates' satisfaction with the CRS was evaluated.

SETTING

Independent academic medical center.

PARTICIPANTS

Nine general surgery residency graduates with one complete year in practice.

RESULTS

Nine residents completed CRS rotations and submitted case logs. Median total case volume was 1101 (994-1311) during the 5-year residency, 92 (20-149) during CRS and 299 (99-784) during the first year in practice. Median case volumes for selected procedures for the entire 5-year residency, CRS, and first year of practice were: 93 (66-97), 7 (3-16), and 9 (1-26) laparoscopic appendectomies; 146 (120-157), 24 (3-32), and 34 (15-112) laparoscopic cholecystectomies; 81 (51-94), 1 (1-4), and 3 (0-8) ileocolectomies; 57 (35-86), 4 (0-9), and 8 (2-34) ventral/incisional hernia repairs; 102 (87-137), 12 (3-16), and 13 (3-86) inguinal hernia repairs. Graduates reported that the CRS experience was very beneficial to their current practice. Annual program reviews emphasized the CRS as a major strength of our residency.

CONCLUSIONS

Creation of a CRS to increase resident autonomy and provide continuity of patient care with appropriate faculty supervision was successful. Case mix and volumes provided an opportunity for independent operative and clinical experience during residency which realistically paralleled graduates' first year of practice.

Fellowship training: a qualitative study of scope and purpose across one department of medicine

BACKGROUND

Fellowship training follows certification in a primary specialty or subspecialty and focusses on distinct and advanced clinical and/or academic skills. This phase of medical education is growing in prevalence, but has been an "invisible phase of postgraduate training" lacking standards for education and accreditation, as well as funding. We aimed to explore fellowship programs and examine the reasons to host and participate in fellowship training, seeking to inform the future development of fellowship education.

METHODS

During the 2013-14 academic year, we conducted interviews and focus groups to examine the current status of fellowship training from the perspectives of division heads, fellowship directors and current fellows at the Department of Medicine, University of Ottawa, Canada. Descriptive statistics were used to depict the prevailing status of fellowship training. A process of data reduction, data analysis and conclusions/verifications was performed to analyse the quantitative data.

RESULTS

We interviewed 16 division heads (94%), 15 fellowship directors (63%) and 8 fellows (21%). We identified three distinct types of fellowships. Individualized fellowships focus on the career goals of the trainee and/or the recruitment goals of the division. Clinical fellowships focus on the attainment of clinical expertise over and above the competencies of residency. Research fellowships focus on research productivity. Participants identified a variety of reasons to offer fellowships: improve academic productivity; improve clinical productivity; share/develop enhanced clinical expertise; recruit future faculty members/attain an academic position; enhance the reputation of the division/department/trainee; and enhance the scholarly environment.

CONCLUSIONS

Fellowships serve a variety of purposes which benefit both individual trainees as well as the academic enterprise. Fellowships can be categorized within a distinct taxonomy: individualized; clinical; and research. Each type of fellowship may serve a variety of purposes, and each may need distinct support and resources. Further research is needed to catalogue the operational requirements for hosting and undertaking fellowship training, and establish recommendations for educational and administrative policy and processes in this new phase of postgraduate education.

Confidence Crisis Among General Surgery Residents: A Systematic Review and Qualitative Discourse Analysis

Importance

In the surgical community, there is concern that general surgery residents are choosing subspecialty training in large numbers because of a crisis in confidence at the end of training. Confidence is an essential quality of surgeons, and recent studies have attempted to quantify and measure it in graduating general surgery residents.

Objectives

To systematically review the quality of evidence provided and to critically analyze the language used to describe the findings using quantitative methods.

Evidence Review

A systematic review of the PubMed indexed literature on general surgery resident confidence was performed in March 2015. A summative table of each study's hypothesis, definition of confidence, quality using the Medical Education Research Study Quality Instrument, influence using Web of Science citations, results, and conclusions was created, and qualitative coding was applied to identify emerging themes. No date restrictions were used in the search.

Findings

Fifteen survey studies have been performed that measure confidence or readiness to practice. Although 5 studies had neutral or positive conclusions, most studies reported low confidence in general surgery graduates. There are conflicting data about definitions of confidence. The relationships between confidence, autonomy, and competence are varied and complex. Comparisons with the past are frequent.

Conclusions and Relevance

Confidence is difficult to define and measure. Despite limitations, survey studies are used to shape discourse and influence policies. Social and cultural factors influence self-efficacy, and focusing on operative volume and autonomy alone may not address all of the reasons that some residents express concerns about readiness to practice.

For Love, Not Money: The Financial Implications of Surgical Fellowship Training

Surgical residents cite “increased income potential” as a motivation for pursuing fellowship training, despite little evidence supporting this perception. Thus, our goal is to quantify the financial impact of surgical fellowship training on financial career value. By using Medical Group Management Association and Association of American Medical Colleges physician income data, and accounting for resident salary, student debt, a progressive tax structure, and forgone wages associated with prolonged training, we generated a net present value (NPV) for both generalist and subspecialist surgeons. By comparing generalist and subspecialist career values, we determined that cardiovascular (ANPV = $698,931), pediatric ($430,964), thoracic ($239,189), bariatric ($166,493), vascular ($96,071), and transplant ($46,669) fellowships improve career value. Alternatively, trauma (-$11,374), colorectal (-$44,622), surgical oncology (-$203,021), and breast surgery (-$326,465) fellowships all reduce career value. In orthopedic surgery, spine ($505,198), trauma ($123,250), hip and joint ($60,372), and sport medicine ($56,167) fellowships improve career value, whereas shoulder and elbow (-$4,539), foot and ankle (-$173,766), hand (-$366,300), and pediatric (-$489,683) fellowships reduce career NPV. In obstetrics and gynecology, reproductive endocrinology ($352,854), and maternal and fetal medicine ($322,511) fellowships improve career value, whereas gynecology oncology (-$28,101) and urogynecology (-$206,171) fellowships reduce career value. These data indicate that the financial return of fellowship is highly variable.

Declining Operative Experience for Junior-Level Residents: Is This an Unintended Consequence of Minimally Invasive Surgery?

INTRODUCTION

Our group has previously demonstrated an upward shift from junior to senior resident participation in common general surgery operations, traditionally performed by junior-level residents. The objective of this study was to evaluate if this trend would correct over time. We hypothesized that junior resident case volume would improve.

METHODS

A sample of essential laparoscopic and open general surgery procedures (appendectomy, inguinal herniorrhaphy, cholecystectomy, and partial colectomy) was chosen for analysis. The American College of Surgeons National Surgical Quality Improvement Program Participant Use Files were queried for these procedures between 2005 and 2012. Cases were stratified by participating resident post-graduate year with "junior resident" defined as post-graduate year1-3. Logistic regression was performed to determine change in junior resident participation for each type of procedure over time.

RESULTS

A total of 185,335 cases were included in the study. For 3 of the operations we considered, the prevalence of laparoscopic surgery increased from 2005-2012 (all p < 0.001). Cholecystectomy was an exception, which showed an unchanged proportion of cases performed laparoscopically across the study period (p = 0.119). Junior resident participation decreased by 4.5%/y (p < 0.001) for laparoscopic procedures and by 6.2%/y (p < 0.001) for open procedures. The proportion of laparoscopic surgeries performed by junior-level residents decreased for appendectomy by 2.6%/y (p < 0.001) and cholecystectomy by 6.1%/y (p < 0.001), whereas it was unchanged for inguinal herniorrhaphy (p = 0.75) and increased for partial colectomy by 3.9%/y (p = 0.003). A decline in junior resident participation was seen for all open surgeries, with appendectomy decreasing by 9.4%/y (p < 0.001), cholecystectomy by 4.1%/y (p < 0.002), inguinal herniorrhaphy by 10%/y (p < 0.001) and partial colectomy by 2.9%/y (p < 0.004).

CONCLUSIONS

Along with the proliferation of laparoscopy for common general surgical procedures there has been a concomitant reduction in the participation of junior-level residents. As previously thought, familiarity with laparoscopy has not translated to redistribution of basic operations from senior to junior residents. This trend has significant implications for general surgery resident education.