General surgery resident rotations in surgical critical care, trauma, and burns: what is optimal for residency training?

BACKGROUND: There are no specific Accreditation Council for Graduate Medical Education General Surgery Residency Program Requirements for rotations in surgical critical care (SCC), trauma, and burn. We sought to determine the experience of general surgery residents in SCC, trauma, and burn rotations. METHODS: Data analysis of surgical rotations of American Board of Surgery general surgery resident applicants (n = 7,299) for the last 8 years (2006 to 2013, inclusive) was performed through electronic applications to the American Board of Surgery Qualifying Examination. Duration (months) spent in SCC, trauma, and burn rotations, and postgraduate year (PGY) level were examined. RESULTS: The total months in SCC, trauma and burn rotations was mean 10.2 and median 10.0 (SD 3.9 months), representing approximately 16.7% (10 of 60 months) of a general surgery resident's training. However, there was great variability (range 0 to 29 months). SCC rotation duration was mean 3.1 and median 3.0 months (SD 2, min to max: 0 to 15), trauma rotation duration was mean 6.3 and median 6.0 months (SD 3.5, min to max: 0 to 24), and burn rotation duration was mean 0.8 and median 1.0 months (SD 1.0, min to max: 0 to 6). Of the total mean 10.2 months duration, the longest exposure was 2 months as PGY-1, 3.4 months as PGY-2, 1.9 months as PGY-3, 2.2 months as PGY-4 and 1.1 months as PGY-5. PGY-5 residents spent a mean of 1 month in SCC, trauma, and burn rotations. PGY-4/5 residents spent the majority of this total time in trauma rotations, whereas junior residents (PGY-1 to 3) in SCC and trauma rotations. CONCLUSIONS: There is significant variability in total duration of SCC, trauma, and burn rotations and PGY level in US general surgery residency programs, which may result in significant variability in the fund of knowledge and clinical experience of the trainee completing general surgery residency training. As acute care surgery programs have begun to integrate emergency general surgery with SCC, trauma, and burn rotations, it is an ideal time to determine the optimal curriculum and duration of these important rotations for general surgery residency training.

Understanding the Operative Experience of the Practicing Pediatric Surgeon: Implications for Training and Maintaining Competency.

IMPORTANCE: The number of practicing pediatric surgeons has increased rapidly in the past 4 decades, without a significant increase in the incidence of rare diseases specific to the field. Maintenance of competency in the index procedures for these rare diseases is essential to the future of the profession. OBJECTIVE: To describe the demographic characteristics and operative experiences of practicing pediatric surgeons using Pediatric Surgery Board recertification case log data. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective review of 5 years of pediatric surgery certification renewal applications submitted to the Pediatric Surgery Board between 2009 and 2013. A surgeon's location was defined by population as urban, large rural, small rural, or isolated. Case log data were examined to determine case volume by category and type of procedures. Surgeons were categorized according to recertification at 10, 20, or 30 years. MAIN OUTCOME AND MEASURE: Number of index cases during the preceding year. RESULTS: Of 308 recertifying pediatric surgeons, 249 (80.8%) were men, and 143 (46.4%) were 46 to 55 years of age. Most of the pediatric surgeons (304 of 308 [98.7%]) practiced in urban areas (ie, with a population >50 000 people). All recertifying applicants were clinically active. An appendectomy was the most commonly performed procedure (with a mean [SD] number of 49.3 [35.0] procedures per year), nonoperative trauma management came in second (with 20.0 [33.0] procedures per year), and inguinal hernia repair for children younger than 6 months of age came in third (with 14.7 [13.8] procedures per year). In 6 of 10 "rare" pediatric surgery cases, the mean number of procedures was less than 2. Of 308 surgeons, 193 (62.7%) had performed a neuroblastoma resection, 170 (55.2%) a kidney tumor resection, and 123 (39.9%) an operation to treat biliary atresia or choledochal cyst in the preceding year. Laparoscopy was more frequently performed in the 10-year recertification group for Nissen fundoplication, appendectomy, splenectomy, gastrostomy/jejunostomy, orchidopexy, and cholecystectomy (P < .05) but not lung resection (P = .70). It was more frequently used by surgeons recertifying in the 10-year group (used in 11 375 of 14 456 procedures [78.7%]) than by surgeons recertifying in the 20-year (used in 6214 of 8712 procedures [71.3%]) or 30-year group (used in 2022 of 3805 procedures [53.1%]). CONCLUSIONS AND RELEVANCE: Practicing pediatric surgeons receive limited exposure to index cases after training. With regard to maintaining competency in an era in which health care outcomes have become increasingly important, these results are concerning.

Review courses for the American Board of Surgery certifying examination do not provide an advantage.

PURPOSE: The purpose of this study was to evaluate whether participation in a commercially available board review course affected the likelihood of passing the general surgery certifying exam (CE) of the American Board of Surgery (ABS). METHODS: Candidates who took the ABS CE during the 2012-2013 academic year were surveyed electronically about their participation in commercial board review courses on the ABS website immediately before receiving their exam results. The primary outcome variable was passing the CE. Results were adjusted for background variables shown to correlate with CE pass rates using multilevel logistic regression. RESULTS: Of the 1,386 candidates who took the CE and had sufficient data for analysis, 974 of 1,064 first-time examinees (92%) and 272 of 322 repeat examinees (84%) completed the survey. Nearly 78% of survey respondents took a review course. Repeat examinees (85%) were more likely to attend a review course than first-time examinees (76%, P = .002). There were no significant differences in CE pass rates for first-time or repeat examinees who took a review course compared with those who did not (83.7% vs 80.7% for first-time examinees and 77.8% vs 69.0% for repeat examinees, P = .32 and P = .24, respectively). First-time examinee nonrespondents did not differ in their CE pass rates from those who responded to the survey (P = .113); however, repeat examinee nonrespondents had lesser CE pass rates than survey responders (P = .009). None of the review courses included had CE pass rates that differed significantly from the others after we controlled for program characteristics, ABS qualifying exam scores, medical school, and sex of the examinees. CONCLUSION: This study used a large, prospectively collected national sample with a high response rate to study the effect of board review courses on CE performance on the ABS examination. On the basis of this survey, there was no evidence that participating in a board review course provided a benefit to passing the CE of the ABS. These results should be considered when preparation for the CE is undertaken.

Resident Preparation for Careers in General Surgery: A Survey of Program Directors.

OBJECTIVE: The number of general surgery (GS) residency graduates who choose GS practice has diminished as the popularity of postresidency fellowships has dramatically increased over the past several decades. This study was designed to document current methods of GS preparation during surgery residency and to determine characteristics of programs that produce more graduates who pursue GS practice. DESIGN: An email survey was sent by the American Board of Surgery General Surgery Advisory Committee to program directors of all GS residencies. Program demographic information was procured from the American Board of Surgery database and linked to survey results. Multiple regression was used to predict postresidency choices of graduates. SETTING: Totally, 252 US allopathic surgical residencies. PARTICIPANTS: Totally, 171 residency program directors (68% response rate). RESULTS: The proportion of programs using an emergency/acute care surgery rotation at the main teaching hospital to teach GS increased from 63% in 2003 to 83% in 2014. An autonomous GS outpatient experience was offered in 38% of programs. Practice management curricula were offered in 28% of programs. Institutions with fewer postresidency fellowships (p < 0.003) and fewer surgical specialty residencies (p < 0.036) had a greater percentage of graduates who pursued GS practice. The addition of each fellowship at an institution was associated with a 2% decrease in the number of graduates pursuing GS practice. Residency size was not associated with predilection for fellowship selection and there was no difference between university and independent residencies vis-a-vis the proportion selecting fellowship vs GS practice. CONCLUSIONS: Practice management principles and autonomous GS outpatient clinic experiences are offered in a minority of programs. Graduates of programs in institutions with fewer surgery fellowships and residencies are more likely to pursue GS practice. Increased number of postresidency fellowships and specialty residencies may be associated with fewer GS rotations and fewer GS mentors. Further study of these relationships seems warranted.

Using the American Board of Surgery In-Training Examination to predict board certification: a cautionary study.

OBJECTIVE: Although designed as a low-stakes formative examination, the American Board of Surgery In-Training Examination (ABSITE) is often used in high-stakes decisions such as promotion, remediation, and retention owing to its perceived ability to predict the outcome of board certification. Because of the discrepancy between intent and use, the ability of ABSITE scores to predict passing the American Board of Surgery certification examinations was analyzed. METHODS: All first-time American Board of Surgery qualifying examination (QE) examinees between 2006 and 2012 were reviewed. Examinees' postgraduate year (PGY) 1 and PGY5 ABSITE standard scores were linked to QE scores and pass/fail outcomes (n = 6912 and 6846, respectively) as well as first-time certifying examination (CE) pass/fail results (n = 1329). Linear and logistic regression analyses were performed to evaluate the utility of ABSITE scores to predict board certification scores and pass/fail outcomes. RESULTS: PGY1 ABSITE scores accounted for 22% of the variance in QE scores (p < 0.001). PGY5 scores were a slightly better predictor, accounting for 30% of QE score variance (p < 0.001). Analyses showed that selecting a PGY5 ABSITE score that maximized overall decision accuracy for predicting QE pass/fail outcomes (86% accuracy) resulted in 98% sensitivity, 13% specificity, a positive predictive value of 87%, and a negative predictive value of 57%. ABSITE scores were not predictive of success on the CE. CONCLUSIONS: ABSITE scores are a useful predictor of QE scores and outcomes but do not predict passing the CE. Although scoring well on the ABSITE is highly predictive of QE success, using low ABSITE scores to predict QE failure results in frequent decision errors. Program directors and other evaluators should use additional sources of information when making high-stakes decisions about resident performance.

Subscription to the Surgical Council on Resident Education web portal and qualifying examination performance.

BACKGROUND: The Surgical Council on Resident Education (SCORE) curriculum for general surgery was developed to guide surgery residents in the acquisition of knowledge for patient care. We hypothesized that residents in programs that subscribed to the SCORE web portal would perform better on the American Board of Surgery (ABS) Surgery Qualifying Examination (QE). STUDY DESIGN: Scaled scores and the percent passing the 2011 ABS Surgery QE for individual residents and programs were compared between programs that subscribed to the SCORE portal in 2010 to 2011 and those that did not subscribe. Regression analyses were performed to control for program QE percent passing from 2004 to 2008 (baseline performance), as well as demographic factors known to affect examination results. RESULTS: There were 200 programs and 893 residents that subscribed to the SCORE web portal and 33 programs with 139 residents that did not subscribe. Regression analysis comparing predicted 2011 mean program QE scores based on 2004 to 2008 results showed that subscribing programs had a substantial increase in mean scaled scores of 1.4 points (adjusted means of 81.5 and 80.1, respectively), controlling for the percentage of international medical graduates and program size (p = 0.048). Residents from SCORE portal subscribing programs had a QE percent passing that was 1.6% higher than nonsubscribing residents, and the mean percent passing was higher for subscribing programs (86.4% vs 82.7%), but neither difference was statistically significant. The SCORE subscription status did not correlate with program size, percent of international medical graduates, or baseline scale scores. CONCLUSIONS: There was a considerable improvement in mean QE scaled scores for residents in programs that initially subscribed to the SCORE web portal. The percent passing the QE showed a trend toward improvement for subscribing programs and their residents. This association is promising and deserves additional investigation.

Operative experience of surgery residents: trends and challenges.

OBJECTIVE: To evaluate trends in operative experience and to determine the effect of establishing the Surgical Council on Resident Education (SCORE) operative classification system on changes in operative volume among graduating surgery residents. DESIGN: The general surgery operative logs of graduating surgery residents from 2005 were retrospectively compared with residents who completed training in 2010 and 2011. Nonparametric statistical analyses were used (Mann-Whitney and median test) with significance set at p<0.01. PARTICIPANTS: A total of 1022 residents completing residency in 2005 were compared with 1923 residents completing training in 2010-2011. RESULTS: Total operations reported increased from a median of 1023 to 1238 (21%) between 2005 and 2010-2011 (p<0.001). Cases increased in most SCORE categories. The median numbers of total, basic, and complex laparoscopic operations increased by 49%, 37%, and 82%, respectively, over the 5-year interval (p<0.001). Open cavitary (thoracic + abdominal) operations decreased by 5%, whereas other major operations increased by 35% (both p<0.001). The frequency of discrete operations done at least 10 times during residency did not change. The median number of SCORE essential-common operations performed ranged from 1 to 107, whereas essential-uncommon operations ranged from 0 to 4. Twenty-three of 67 SCORE essential-common operations (34%) had a median of less than 5 and 4 had a median of 0. CONCLUSIONS: The operative volume of graduating surgical residents has increased by 21% since 2005; however, the number of operations done 10 times or greater has not changed. Although open cavitary procedures continue to decline, there has been a large increase in endoscopy, complex laparoscopic, and other major operations. Some essential-common operations continue to be performed infrequently. These results suggest that education in the operating room must improve and alternate methods for teaching infrequently performed procedures are needed.

Evolving patterns of vascular surgery care in the United States: a report from the American Board of Surgery.

BACKGROUND: The purpose of this study was to analyze the distribution of major vascular procedures among general and vascular surgeons and to compare the evolution of vascular surgical practice of general and vascular surgeons at specific points in their careers. STUDY DESIGN: Case logs of surgeons seeking recertification in surgery from 2007 to 2009 were reviewed. Data from 3,362 physicians certified only in surgery (GS) were compared with 363 additionally certified in vascular surgery (VS). Independent variables were compared using factorial ANOVA. RESULTS: The mean numbers of major vascular procedures (±SD) were 10 ± 51 for GS and 192 ± 209 for VS (p < 0.001). Thirty-three percent of the total vascular procedures reported were performed by GS. Compared with VS, GS performed significantly fewer vascular procedures in all major procedure categories, and GS certifying at 10 years performed fewer vascular procedures (6.7 ± 47) than those recertifying at 20 years (11.5 ± 48) and 30 years (13.6 ± 59) (p < 0.01). In contrast, VS certifying at 10 years performed more vascular procedures (235 ± 237) compared with those recertifying at 20 years (157 ± 173) and 30 years (104 ± 115). The mean number of vascular procedures was not different for sex, geographic location, or practice type, after controlling for other variables in the study. CONCLUSIONS: The majority of GS currently do not perform any major vascular procedures, and younger GS are performing fewer such procedures than their older counterparts. The opposite is true for VS. These opposing trends indicate that vascular procedures are shifting from GS to VS in modern surgical practice, and this may have important implications for patient access to vascular surgery care, considering the limited capacity for VS to assume the excess case load.

Does success on the American Board of Surgery general surgery qualifying examination guarantee certifying examination success?

OBJECTIVE: The purpose of this study was to explore the relationship between qualifying examination (QE) and certifying examination (CE) results and to determine whether an appropriate cut-point on the QE would predict success on the CE. DESIGN: The scaled American Board of Surgery (ABS) QE scores of all first-time examinees from 2006 to 2010 were retrospectively matched to their first-time CE pass/fail decisions. Contingency tables illustrating the QE-CE relationship were constructed and appropriate correlational statistics were computed. A receiver operating characteristic (ROC) curve analysis was constructed, with sensitivity and 1-specificity calculated for each possible QE cut-point used to predicted CE pass/fail classifications. Additionally, the area under the curve (AUC) was calculated. PARTICIPANTS: All first-time American Board of Surgery examinees for the Surgery Qualifying Examination from 2006 to 2010. RESULTS: A total of 4385 surgeons were analyzed, with QE scores averaging 82.1 ± 5.8 (range, 58-99) and 82.8% of surgeons passing the CE on their first attempt. Contingency tables suggest a moderate relationship between QE and CE performance, although correlation indexes are low (phi = 0.13, point-biserial = 0.23). For the ROC analysis, the AUC = 0.674 (95% CI; 0.654-0.695) provides a better than chance pass/fail classification (p < 0.001), yet does not meet the minimum threshold for acceptability as a predictive test. No QE cut-point accurately predicted CE pass/fail decisions. CONCLUSIONS: While a moderate relationship between QE scores and CE performance is evident, correlations suggest that the 2 examinations measure different abilities. The low AUC value on the ROC analysis, along with poor predictability at all possible cut-points, show that no appropriate cut-point on the QE predicts success on the CE. These data add to the validity of both tests by providing evidence that distinct latent traits are being measured by both tests.

Delay in taking the American Board of Surgery qualifying examination affects examination performance.

BACKGROUND: The American Board of Surgery (ABS) Qualifying Examination (QE) represents an important step along the pathway to board certification. We investigated whether candidates who delayed taking the QE had worse performance on the examination. METHODS: QE pass rates and equated scaled scores for all first-time examinees from 2006 to 2010 (n = 5,193) were reviewed. After eliminating examinees who could not be matched to final ABS In-Training Examination (ABSITE) scores, the remaining cohort (n = 4,909) was analyzed by comparing those who took the exam immediately after residency (Immediate, n = 4,488) to those who delayed for 1 or more years (Delay, n = 421). RESULTS: The Immediate group had a mean first-time QE pass rate of 87% compared to 57% for those who delayed 1 year and 48% for those who delayed 2 or more years (P < .001). Regression analysis demonstrated that delay in taking the QE remained a significant determinant of exam failure after controlling for ABSITE scores (odds ratio = 0.35; 95% CI, 0.29-0.43; P = .001). Undergraduate medical education and postresidency training did not affect the results. The Delay group had lower equated scaled scores, a greater ultimate failure rate on the QE, and was more likely to fail the ABS Certifying Examination on the first attempt. CONCLUSION: These results demonstrate that candidates who delayed taking the QE immediately are at extremely high risk for exam failure and failure to achieve board certification. These findings presumably are due to deterioration of knowledge over time, but they also may represent characteristics of the Delay group that are currently undefined.

Sleep, supervision, education, and service: views of junior and senior residents.

OBJECTIVES: To assess sleep time and views about faculty supervision and educational activities of residents training only under 2003 duty hours standards. DESIGN: A survey was delivered with the 2010 American Board of Surgery In-Training Examination (ABSITE). Twelve items explored sleep patterns, supervision, and educational activity times. Survey response relationships to gender, resident level, and program variables were explored through factorial analysis of variance and effect size testing. Alpha was set to <0.001, and effect size (omega-squared) significance was set at ≥1% of variance explained to limit statistically significant but practically unimportant results. Survey participation was voluntary, and responses were processed separately from ABSITE scoring. SETTING: General surgery residencies. PARTICIPANTS: A total of 6161 categorical surgery residents: 2545 first postgraduate year (PGY1) and second postgraduate year (PGY2) trainees took the junior examination (IJE), and 3616 third postgraduate year (PGY3) and above residents took the senior examination (ISE). RESULTS: Response rates were ≥95%. Sleep during extended call was significantly less for IJE residents, but IJE residents' sleep mirrored ISE residents' sleep on night float, day assignments, and days off. Faculty supervision was judged Adequate or better by more than 90% of both groups. IJE residents significantly more often rated operative caseloads and operating time as inadequate; caseloads and operating room (OR) time also linked significantly to program type. IJE residents reported significantly higher inpatient, but not outpatient, time. Most IJE and ISE residents agreed that care continuity opportunities were Adequate and judged workloads as Adequate or better. Although many IJE and ISE residents rated educational time as Adequate or better, 25% of each group scored it as Insufficient or worse. CONCLUSIONS: Resident discretionary time is not devoted primarily to sleep. Residents consider increased faculty supervision unnecessary. IJE residents believe their time could be better apportioned across educational settings. Decreased workloads and increased educational time are desired by substantial minorities of IJE and ISE residents, arguing for further interventions to preserve education over service.

General surgery workloads and practice patterns in the United States, 2007 to 2009: a 10-year update from the American Board of Surgery.

OBJECTIVE: To assess changes in general surgery workloads and practice patterns in the past decade. BACKGROUND: Nearly 80% of graduating general surgery residents pursue additional training in a surgical subspecialty. This has resulted in a shortage of general surgeons, especially in rural areas. The purpose of this study is to characterize the workloads and practice patterns of general surgeons versus certified surgical subspecialists and to compare these data with those from a previous decade. METHODS: The surgical operative logs of 4968 individuals recertifying in surgery 2007 to 2009 were reviewed. Data from 3362 (68%) certified only in Surgery (GS) were compared with 1606 (32%) with additional American Board of Medical Specialties certificates (GS+). Data from GS surgeons were also compared with data from GS surgeons recertifying 1995 to 1997. Independent variables were compared using factorial ANOVA. RESULTS: GS surgeons performed a mean of 533 ± 365 procedures annually. Women GS performed far more breast operations and fewer abdomen, alimentary tract and laparoscopic procedures compared to men GS (P < 0.001). GS surgeons recertifying at 10 years performed more abdominal, alimentary tract and laparoscopic procedures compared to those recertifying at 20 or 30 years (P < 0.001). Rural GS surgeons performed far more endoscopic procedures and fewer abdominal, alimentary tract, and laparoscopic procedures than urban counterparts (P < 0.001). The United States medical school graduates had similar workloads and distribution of operations to international medical graduates. Compared to 1995 to 1997, GS surgeons from 2007 to 2009 performed more procedures, especially endoscopic and laparoscopic. GS+ surgeons performed 15% to 33% of all general surgery procedures. CONCLUSIONS: GS practice patterns are heterogeneous; gender, age, and practice setting significantly affect operative caseloads. A substantial portion of general surgery procedures currently are performed by GS+ surgeons, whereas GS surgeons continue to perform considerable numbers of specialty operations. Reduced general surgery operative experience in GS+ residencies may negatively impact access to general surgical care. Similarly, narrowing GS residency operative experience may impair specialty operation access.

Feast or famine? The variable impact of coexisting fellowships on general surgery resident operative volumes.

OBJECTIVES: Nearly 80% of general surgery residents (GSR) pursue Fellowship training. We hypothesized that fellowships coexisting with general surgery residencies do not negatively impact GSR case volumes and that fellowship-bound residents (FBR) preferentially seek out cases in their chosen specialty ("early tracking"). METHODS: To test our hypotheses, we analyzed the Accreditation Council for Graduate Medical Education Surgical Operative Log data from 2009 American Board of Surgery qualifying examination applicants (N = 976). General surgery programs coexisted with 35 colorectal (CR), 97 vascular (Vasc), 80 minimally invasive (MIS), and 12 Endocrine (Endo) fellowships. We analyzed (1) operative cases for general surgery residency programs with and without coexisting Fellowships, comparing caseloads for FBR and all GSR and (2) operative cases of FBR in their chosen specialties compared to all other GSR. Group means were compared using ANOVA with significance set at P < 0.01. RESULTS: Coexisting fellowships had minimal impact on GSR caseloads. Endocrine fellowships actually enhanced case volumes for all residents. CR impact was neutral while MIS and vascular fellowships resulted in small declines. Endo, CR, and Vasc but not MIS FBR performed significantly more cases in their future specialties than their GSR counterparts, consistent with self-directed, prefellowship tracking. Tracking seems to be additive and FBR do not sacrifice other GSR cases. CONCLUSIONS: Our data establish that the impact of Fellowships on GSR caseloads is minimal. Our data confirm that FBR seek out cases in their future specialties ("early tracking").

Early tracking would improve the operative experience of general surgery residents.

OBJECTIVE(S): High surgical complexity and individual career goals has led most general surgery (GS) residents to pursue fellowship training, resulting in a shortage of surgeons who practice broad-based general surgery. We hypothesize that early tracking of residents would improve operative experience of residents planning to be general surgeons, and could foster greater interest and confidence in this career path. METHODS: Surgical Operative Log data from GS and fellowship bound residents (FB) applying for the 2008 American Board of Surgery Qualifying Examination (QE) were used to construct a hypothetical training model with 6 months of early specialization (ESP) for FB residents in 4 specialties (cardiac, vascular, colorectal, pediatric); and presumed these cases would be available to GS residents within the same program. RESULTS: A total of 142 training programs had both FB residents (n = 237) and GS residents (n = 402), and represented 70% of all 2008 QE applicants. The mean numbers of operations by FB and GS residents were 1131 and 1091, respectively. There were a mean of 252 cases by FB residents in the chief year, theoretically making 126 cases available for each GS resident. In 9 defined categories, the hypothetical model would result in an increase in the 5-year operative experience of GS residents (mastectomy 6.5%; colectomy 22.8%; gastrectomy 23.4%; antireflux procedures 23.4%; pancreatic resection 37.4%; liver resection 29.3%; endocrine procedures 19.6%; trauma operations 13.3%; GI endoscopy 6.5%). CONCLUSIONS: The ESP model improves operative experience of GS residents, particularly for complex gastrointestinal procedures. The expansion of subspecialty ESP should be considered.

Motivations to pursue fellowships are gender neutral.

OBJECTIVE: To determine the importance of factors in decision making by general surgery chief residents to pursue fellowships and to relate factor importance to gender and residency characteristics. DESIGN: Prospective, voluntary, national survey conducted April through May, 2008, in which finishing chief residents rated the importance of 12 factors in their decision making to pursue fellowships. SETTING: General surgery chief residents who applied for admission to the American Board of Surgery Qualifying Examination process. PARTICIPANTS: All 1034 first-time applicants. MAIN OUTCOME MEASURES: chi(2) tests and 1-way analyses of variance were used to correlate gender and residency type, size, and location with summed values and scaled mean scores for ratings of the importance of 12 potential factors in fellowship decision making. RESULTS: The fellowship rate was 77% and correlated with residency size and location. Women were dispersed asymmetrically across residencies overall but future female fellows were distributed similarly to male ones. Survey item response rates for future fellows were 96% to 98%. Clinical mastery and specialty activities were valued most highly by more than 90% of men and women. Men placed more value on income potential and spousal influence. Lifestyle factors reached only midrange importance for both genders. Program size had more significant relationships to decision-making factors than did gender. CONCLUSIONS: The ability to master an area of clinical practice and the clinical activities of a specialty are the most important factors for chief residents in fellowship decision making, regardless of gender. Lifestyle factors are of midrange importance. Program size is as influential as is gender.

Operative experience of residents in US general surgery programs: a gap between expectation and experience.

OBJECTIVE: The purpose of the study was to identify a group of operations which general surgery residency program directors believed residents should be competent to perform by the end of 5 years of training and then ascertain actual resident experience with these procedures during their training. SUMMARY BACKGROUND DATA: There is concern about the adequacy of training of general surgeons in the United States. The American Board of Surgery and the Association of Program Directors in Surgery undertook a study to determine what operative procedures residency program directors consider to be essential to the practice of general surgery and then we measured the actual operative experience of graduating residents in those procedures, as reported to the Residency Review Committee for Surgery (RRC). METHODS: An electronic survey was sent to residency program directors at the 254 general surgery programs in the US accredited by the RRC as of spring 2006. The program directors were presented with a list of 300 types of operations. Program directors graded the 300 procedures "A," "B," or "C" using the following criteria: A--graduating general surgery residents should be competent to perform the procedure independently; B--graduating residents should be familiar with the procedure, but not necessarily competent to perform it; and C--graduating residents neither need to be familiar with nor competent to perform the procedure. After ballots were tallied, the actual resident operative experience reported to the RRC by all residents finishing general surgery training in June 2005 was reviewed. RESULTS: One hundred twenty-one of the 300 operations were considered A level procedures by a majority of program directors (PDs). Graduating 2005 US residents (n = 1022) performed only 18 of the 121 A procedures, an average of more than 10 times during residency; 83 of 121 procedures were performed on an average less than 5 times and 31 procedures less than once. For 63 of the 121 procedures, the mode (most commonly reported) experience was 0. In addition, there was significant variation between residents in operative experience for specific procedures. In virtually all cases, the mean reported experience exceeded the mode, suggesting that the mean is a poor measure of typical experience. CONCLUSIONS: These data pose important problems for surgical educators. Methods will have to be developed to allow surgeons to reach a basic level of competence in procedures which they are likely to experience only rarely during residency. Even for more commonly performed procedures, the numbers of repetitions are not very robust, stressing the need to determine objectively whether residents are actually achieving basic competency in these operations. Finally, the large variations in experience between individuals in our residency system need to be explored, understood, and remedied.

Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery.

BACKGROUND: After completing general surgery residency, surgeons may seek focused additional education or fellowships. Longterm data describing the characteristics of residents selecting fellowships are lacking. Credible data could inform decisions about surgical education paradigms and workforce planning. STUDY DESIGN: From 1993 to 2005, residents taking the American Board of Surgery In-Training Examination were queried about fellowship plans. Individual and residency program data were collected: gender, postgraduate year level (PGY), medical school location (US/international), residency type (academic/community), residency size, and residency location (Northeast, Southeast, Midwest, Southwest, West). The data were examined for changes in the numbers and characteristics of residents seeking fellowships. RESULTS: Responses from 11,080 postgraduate year level-5 residents were analyzed. The number of women nearly doubled and the number of international medical graduates (IMG) almost tripled. Residency program demographics were static. The percentage choosing fellowships increased from 67% to 77%. Patterns of change from "No Fellowship" to "Any Fellowship" were spread heterogeneously across individual and residency subsets. Increases were greatest for Midwest, Southeast, women, community, small program, and US medical graduates. Temporal patterns of change were also heterogeneous. Specialty top choice patterns varied, leading to disproportionate demographic subgroup representation within some specialties. CONCLUSIONS: More general surgery residents are pursuing fellowships. The increase has originated disproportionately from resident and residency demographic subsets and has varied temporally across subgroups. The heterogeneity of change suggests a multifactorial etiology. Future directions in surgical education and workforce planning should reflect these findings.

Graduate medical education in surgery in the United States.

Each year, approximately 1000 graduating medical students enter 5-year residency programs in general surgery. Their salaries are funded by the federal government. Following 5 years of general surgery training, approximately 70% of graduates enroll in a specialty fellowship. Surgery training currently faces a number of challenges, including the diminishing attractiveness of surgery as a career, attrition from residency programs, mandated work hour limits, extensive service requirements in the hospital environment, increasing specialization, and changing patient expectations about the role of residents in their care, among others. In the face of these challenges, the profession is beginning to respond to the need for positive change in the process of training surgeons.

Certification and maintenance of certification in surgery.

The processes that lead to certification by the American Board of Surgery (ABS) emphasize surgeons' training and qualifications. Moreover, the need for periodic recertification appears to provide strong motivation for surgeons to remain current. Such certification is regarded as having great value among patients, but concerns about quality and safety have increased pressure to assess what surgeons actually do in practice. As a result, the American Board of Medical Specialties (ABMS) member boards have recently initiated Maintenance of Certification (MOC) programs that add a requirement for assessment of practice performance to the elements of traditional certification. This article describes the current ABS certification process and the ABS MOC program in greater detail.

Assessing surgical knowledge: a primer on the examination policies of the American Board of Surgery.

Specialty board certification is very important to both physicians and patients. Although certification does not imply or assess competence per se, it does positively correlate with other quality measures. The assessment of knowledge is a critical part of certification by the American Board of Surgery (ABS) because knowledge is fundamental to understanding, judgment, and clinical decision making in surgery. The relationship between knowledge and performance is underscored by advances in the field of cognitive psychology. Given the importance of certification, ABS examination development and scoring processes use widely accepted psychometric principles to ensure a high degree of validity and reliability. The ABS also closely monitors the examinations to maintain the integrity of the examination process. This article details some processes the ABS uses to achieve these ends.