Vascular surgery training in general surgery residency programs: the Canadian experience

TheCardiovascular Fellows Bootcamp

General surgery residents graduate with an inconsistent knowledge of cardiovascular disease and an inadequate skill set for the practice of vascular surgery. Vascular educators have proposed to overcome these challenges by incorporating standardized milestones and simulation curricula into vascular education, but at present, nonclinical vascular education remains nonstandardized. The first step in this direction is to lay a foundation of knowledge and skill for trainees nationwide, and regionalized courses have begun to be offered to address this need. Through the Methodist DeBakey Institute for Cardiovascular Education, we have developed our own course, The Cardiovascular Fellows Bootcamp. The principles behind The Cardiovascular Fellows Bootcamp are teach early, teach the basics, teach broadly, and teach multiple cardiovascular disciplines, and over a 3-day weekend of didactic lectures and skill training, we aim to lay a foundation for cardiovascular training that prepares the trainees for their fellowship. In this article, we describe the way in which our course is run and the thought process behind our approach. We also address some of the practical concerns that make hosting a course of this magnitude feasible and our plans for improving and expanding in the future.

Does operative experience during residency correlate with reported competency of recent general surgery graduates?

BACKGROUND

Identification of attributes of residency training that predict competency would improve surgical education. We hypothesized that case experience during residency would correlate with self-reported competency of recent graduates.

METHODS

Aggregate case log data of residents enrolled in 2 general surgery programs were collected over a 12-month period and stratified into Surgical Council on Resident Education (SCORE) categories. We surveyed recent (< 5 yr) residency graduates on procedural competency. Resident case volumes were correlated with survey responses by SCORE category.

RESULTS

In all, 75 residents performed 11 715 operations, which were distributed by SCORE category as follows: essential-common (EC) 9935 (84.8%), essential-uncommon (EU) 889 (7.6%) and complex 891 (7.6%). Alimentary tract procedures were the most commonly performed EC (2386, 24%) and EU (504, 56.7%) procedures. The least common EC procedure was plastic surgery (4, 0.04%), and the least common EU procedure was abdomen-spleen (1, 0.1%). The questionnaire response rate was 45%. For EC procedures, self-reported competency was highest in skin and soft tissue, thoracic and head and neck (each 100%) and lowest in vascular-venous (54%), whereas for EU procedures it was highest in abdomen-general (100%) and lowest in vascular-arterial (62%). The correlation between case volume and self-reported competency was poor (R = 0.2 for EC procedures).

CONCLUSION

Self-reported competency correlates poorly with operative case experience during residency. Other curriculum factors, including specific rotations and timing, balance between inpatient and outpatient surgical experience and competition for cases, may contribute to procedural competency acquisition during residency.

Competence in pediatric urology upon graduation from residency: perceptions of residents, program directors and pediatric urologists

OBJECTIVE

We aimed to clarify the scope of pediatric urological procedures that Canadian urology residents are perceived to be competent to perform upon graduation.

METHODS

We conducted a survey from April 2005 to June 2006 of urology residency program directors (UPDs), senior urology residents (SURs) and Pediatric Urologists of Canada (PUC) members from all 12 Canadian training programs. Questions focused on which of 23 pediatric urological procedures the 3 study groups perceived urology residents would be competent to perform upon completion of residency without further fellowship training. Procedures were based on the "A," "B" and "C" lists of procedures (least complex to most complex) as outlined in the Royal College of Physicians and Surgeons of Canada Objectives of Training in Urology.

RESULTS

Response rates were 12/12 (100%), 41/53 (77%) and 17/23 (74%) for UPDs, SURs and PUC members, respectively. Average exposure to pediatric urology during residency was 5.4 (range 3-9) months and considered sufficient by 75% of UPDs and 69% of SURs, but only 41% of PUC members (p = 0.05). Overall, the 3 groups disagreed on the level of competence for performing level "A" and "B" procedures, with significant disagreement between PUC members and UPDs as well as SURs (p < 0.005).

CONCLUSION

PUC members perceive Canadian urology residents' exposure to pediatric urology as insufficient and their competence for procedures of low to moderate complexity as inadequate. Further investigation regarding exposure to and competence in other emerging subspecialty spheres of urology may be warranted. Ongoing assessment of the objectives for training in pediatric urology is required.

Do new thoracic surgeons feel ready to operate? Self-reported comfort level of thoracic surgery trainees and junior thoracic surgeons with core thoracic surgery procedures

OBJECTIVE

To evaluate and compare self-reported surgical experience and comfort levels of Canadian thoracic surgery trainees and junior thoracic surgeons (<5 years in practice) with respect to core thoracic surgery procedures.

METHODS

A modified Delphi process was used to create a survey that was distributed electronically to all Canadian thoracic surgery residents and newly graduated thoracic surgeons. A descriptive summary, including calculation of frequencies, means, proportions, and standard deviations was conducted. Associations between reported experience and comfort level for residents and surgeons were explored separately using the Pearson product moment correlation. The differences between resident and junior surgeons' rating of experience and comfort for each procedure were explored using Fisher exact tests.

RESULTS

The response rates were 50% for residents and 85% for staff. Adequate or better experience was reported by residents for 9 of 18 core thoracic surgical procedures and by staff for 10 of 18 procedures. A significant difference in self-reported experience level was found between groups for only 1 of 18 procedures. Staff reported that they would confidently perform 7 of 18 procedures independently at the end of their training. The mean resident response did not reach this level of comfort for any of the 18 procedures. Eight of 16 staff had completed extra training, primarily for personal interest, whereas 4 of 6 residents were planning on further training because of job market factors.

DISCUSSION

The results of this study help to characterize the comfort levels of thoracic trainees and new attending thoracic surgeons with core thoracic procedures and might assist training programs in identifying and improving areas of weakness.

Thoracic surgery training in Canada according to the residents: the thoracic surgery resident survey, of the Canadian thoracic manpower and education study (T-Med)

OBJECTIVE

The resident component of the Canadian Thoracic Manpower and Education Study (T-MED) was conducted to understand the basic demographic of Canadian thoracic surgery residents, the factors influencing their selection of training programs, current work conditions, training and competencies, and opinions in regard to the manpower needs for the specialty.

DESIGN

A modified Delphi process was used to develop a survey applicable to thoracic surgery residents. In May and June 2009, residents completed the voluntary anonymous Internet-based survey. All Canadian residents participated in the survey, providing a 100% response rate.

RESULTS

Most respondents were male (11/12), and the average age was 34 years old with an anticipated debt greater than $50,000 on graduation. All residents worked more than 70 hours per week, with most doing 1 : 3 or 1 : 4 on-call. Two-thirds of respondents reported being satisfied or very satisfied with their training program. Rates of anticipated competence in performing various thoracic surgeries on graduation differed between residents and program directors. Two-thirds (8/12) of residents planned to practice thoracic surgery exclusively, and hoped to practice in an academic setting. Most residents (10/12) agreed or strongly agreed that not enough jobs are available in Canada for graduating trainees and that the number of residency positions should reflect the predicted availability of jobs.

CONCLUSIONS

This study has provided detailed information on thoracic surgery resident demographics and training programs. Most thoracic surgery residents are satisfied with their current training program but have concerns about their job prospects on graduation, and they believe that the number of training positions should reflect potential job opportunities. This survey represents the first attempt to characterize the current state of thoracic surgery training in Canada from the resident's perspective and may help in directing educational and manpower planning.

What impact might general surgery practice patterns of colon and rectal surgeons have on future training?

Currently, surgeons specialize in colon and rectal surgery after a complete residency and certification in general surgery. The American Board of Surgery is proposing reorganization of surgical training; only two to four years of general surgery would be required followed by two to three years of specialization. The general surgery practice patterns of colon and rectal surgeons are unknown. The purposes of this study were to evaluate the current practice patterns of colon and rectal surgeons and to quantify the frequency and type of general surgical procedures performed. Active candidates, members, and fellows of The American Society of Colon and Rectal Surgeons were asked to complete an online survey. Results collected from November 18 to 26, 2004 were included. Data were self-reported. A total of 772 surgeons were included in the analysis; 7 percent were candidates, 29 percent were members, and 64 percent were fellows. Sixty-three percent had been practicing for 20 years or less and 64 percent were younger 50 years of age. Colon and rectal practice consisted of 28 percent abdominal surgery, 14 percent laparoscopic surgery, 28 percent anorectal surgery, and 30 percent endoscopy. Fifty-six percent of colon and rectal surgeons reported performing general surgery procedures with an average of 25 percent of their practice being general surgery. The most common procedures were herniorrhaphy (87 percent), cholecystectomy (76 percent), and appendectomy (33 percent). The most common reasons for general surgery practice were practice (52 percent) and emergency room requirements (43 percent). Currently, colon and rectal surgeons perform general surgery procedures in clinical practice. If general surgery residency of future trainees is shortened, the types of procedures colon and rectal surgeons will be competent to perform may need to be redefined. This will have profound implications on training programs, certification requirements, and future practice patterns.