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

OBJECTIVES: Vascular surgery is traditionally considered a component of general surgery. There is growing evidence of improved patient outcome related to surgeon volume and vascular certification status. The American Board of Surgery in the United States, as well as until recently the Royal College of Physicians and Surgeons in Canada, requires that vascular surgery be considered an essential content area of general surgery training. This requirement is controversial. The purpose of this study was to describe experience and perceived competence in common vascular surgery procedures during general surgery residency training in Canada. METHODS: This web-based survey was conducted between January and June 2002. General surgery program directors (GSPDs), vascular surgeons involved in general surgery training programs (VSs), and senior general surgery residents (SRs) from the 13 English-speaking general surgery programs in Canada were surveyed. Questions were asked regarding which vascular surgery procedures are appropriate for general surgeons to perform, which procedures SRs are trained to perform, and which procedures SR intend to perform. RESULTS: The response rate was 62% for GSPDs, 57% for VSs, and 45% for SRs. Overall, 49% of SRs did not intend to perform any vascular procedures after training. GSPDs, VSs, and SRs indicated that most SRs should be and are trained to perform varicose vein surgery, leg amputation, and femoral embolectomy (P >.05). In addition, GSPDs, VSs, and SRs indicated that SRs should not be and are not trained to perform infrainguinal bypass grafting, carotid endarterectomy, or abdominal aortic aneurysm (AAA) repair (P >.05). There were significant differences with respect to ruptured AAA repair: 49% of SRs, 25% of PDs, and only 12% of VSs believe that general surgeons should be trained to perform ruptured AAA repair (P <.05). Overall, 76% of VSs believe SRs receive too little vascular training. CONCLUSION: There is similarity between GSPDs, VSs, and SRs with respect to vascular surgery training in Canadian general surgery programs. Vascular surgery training cannot be considered a component of general surgery. More rotations or fellowship training is required to become competent in management of common vascular surgery procedures. Perhaps this level of competence should not be an objective of general surgery training.     

Gender trends in applicants to general surgery residency programs in Canada

BackgroundSurgical disciplines lag behind non-surgical disciplines in attracting female trainees. Female representation of Canadian General Surgeons has not been evaluated in recent years in the literature. The objectives of this study were to assess gender trends in applicants to Canadian General Surgery residency programs and practicing general surgeons and subspecialists.MethodsThis retrospective cross-sectional study analyzed gender data for residency applicants ranking General Surgery as their first-choice discipline from publicly-available annual Canadian Residency Matching Service (CaRMS) R-1 match reports from 1998 to 2021. Aggregate gender data for practicing female physicians in General Surgery and related subspecialties, including Pediatric Surgery, obtained from annual Canadian Medical Association (CMA) census from 2000 to 2019 was also analysed.ResultsThere was a significant increase in the proportion of female applicants from 34% in 1998 to 67% in 2021 (p < 0.001) and of successfully matched candidates from 39% to 68% (p = 0.002) from 1998 to 2021. Success rates between male and female candidates were significantly different in 1998 (p < 0.001), but not in 2021 (p = 0.29). The proportion of practicing female General Surgeons also significantly increased from 10.1% in 2000 to 27.9% in 2019 (p = 0.0013), with variable trends in subspecialties.ConclusionGender inequality in General Surgery residency matches has normalized since 1998. Despite females representing more than 40% of applicants and successfully matched candidates to General Surgery since 2008, a gender gap still exists amongst practicing General Surgeons and subspecialists. This suggests the need for further cultural and systemic change to mitigate gender disparities.Type of studyOriginal research article, clinical research.Level of evidenceLevel III (Retrospective cross-sectional study).     

Critical care education of surgical residents: a survey of general surgery residency programs

Critical care education may vary in general surgery residency programs because no specific guidelines for this type of training exist. In order to determine the current state of resident education in the ICU, a survey was sent to all general surgery program directors. Of the 217 programs responding, 90% had a dedicated ICU rotation. Surgical residents at the PGY-1 (27%) or PGY-2 (46%) level had a 1- (37%) or 2- (49%) month rotation in the ICU. Teaching formats included: bedside rounds (94% of programs), formal lectures (75%), patient problem-based reading (37%), assigned texts (34%), computers (20%), and videotapes (17%) or audiotapes (10%). Procedures were taught mainly by the senior house staff or faculty. Although the curriculum included a broad spectrum of critical care topics, ventilator management and respiratory failure were the only topics universally covered.Resident education in the ICU varies among general surgery programs. The data from this study establish a baseline for following the educational process as more uniform recommendations are developed and the use of novel educational techniques becomes more common.     

Resident-as-teacher programs in general surgery residency – A review of published curricula

Introduction

The Liaison Committee on Medical Education (LCME) requires that residents are trained to fulfill their educational duties toward medical students. This study reviews the literature on resident-as-teacher programs (RATPs) aimed at surgical residents.

The status of ultrasonography training and use in general surgery residency programs

BACKGROUND: Effective use of ultrasonography (US) by surgeons was demonstrated a decade ago. Major surgical organizations now require its incorporation into surgical training and practice. But little information about the teaching of US to surgical residents exists. This study assesses the current status of US training in general surgery residency programs. STUDY DESIGN: A survey was mailed to the directors of 255 Accreditation Council for Graduate Medical Education-accredited general surgery residency programs. It questioned whether and how US was taught, who performed the examinations, and the types of US performed. Data were analyzed using chi-square tests comparing university versus community programs and training and practice in trauma US versus training in other US modalities. RESULTS: The response rate was 51% (130 of 255). Ninety-six percent of the programs responding taught US, with no differences between university- and community-based training programs in presence of training. Focused Assessment for the Sonography of Trauma (FAST) instruction was done by 79% (hands-on) and 68% (didactic) of programs that responded. Abdominal, laparoscopic, breast, endocrine, and vascular US were each taught less frequently (22% to 55%). Program directors at university programs reported that their attending surgeons performed FAST and abdominal US more often than their community counterparts (71% and 31% versus 47% and 14%). Program directors reported that university trainees performed laparoscopic, endocrine, and vascular US more often than community surgery residents (47%, 17%, 35% versus 29%, 3%, 19%). Program directors reported that surgery attendings or residents performed trauma and laparoscopic US more often than their radiology counterparts, and radiology attendings or residents performed more abdominal, breast, endocrine, and vascular US. CONCLUSIONS: The majority of general surgery residency programs whose directors responded to this survey are teaching US, but most of the training is in FAST. There is no difference in the reported presence of overall US training between university and community programs. But university programs report that their surgeons or residents performed more US in all areas (other than breast) than their community counterparts reported.     

High value care education in general surgery residency programs: A multi-institutional needs assessment

BackgroundThe ACGME mandates that residency programs provide training related to high value care (HVC). The purpose of this study was to explore HVC education in general surgery residency programs.MethodsAn electronic survey was distributed to general surgery residents in geographically diverse programs.ResultsThe response rate was 29% (181/619). Residents reported various HVC components in their curricula. Less than half felt HVC is very important for their future practice (44%) and only 15% felt confident they could lead a QI initiative in practice. Only 20% of residents reported participating in a root cause analysis and less than one-third of residents (30%) were frequently exposed to cost considerations.ConclusionFew residents feel prepared to lead quality improvement initiatives, have participated in patient safety processes, or are aware of patients’ costs of care. This underscores the need for improved scope and quality of HVC education and establishment of formal curricula.     

Medical students who enter general surgery residency programs: a follow-up between 1972 and 1986

Although a few surgical residents do leave the surgical field, little research has been done into the eventual whereabouts of all surgical residents. We undertook this follow-up to find out what proportion of them enter the surgical field and to identify changing patterns over the past 15 years. We compared 593 medical school graduates on demographics, academic credentials, and surgery program directors' rating of their performance in the first postgraduate year (PGY-1). Sixty percent remained in general surgery, and about 26% moved to another specialty within the surgical field. During the mid-1970s, those who remained within the surgical field had better academic credentials on average than those who switched out of the surgical field. However, more recently, the trend has reversed. There were no differences between the groups on age or sex. These results suggest that some good students are being recruited into surgical programs but are later lost in major career switches. Perhaps these changes are related to residents' preferences for specialties that offer more controllable lifestyles than the surgical field.     

Residency reform: anticipated effects of ACGME guidelines on general surgery and internal medicine residency programs

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) has recently amended guidelines for resident work environment. This study was conducted to evaluate opinions of program directors regarding the impact of the changes on residents and residency programs. METHODS: General surgery and internal medicine program directors were sent a 19-question survey. Questions were asked regarding anticipated effects on patient safety, resident well-being, education, medical errors, implementation costs, and methods needed for compliance. Data were analyzed using the chi-square test, the Mann-Whitney method, and the independent samples t-test where appropriate. RESULTS: Responses were received from 153 surgery program directors and 126 medicine program directors. Differences noted were hours worked (surgery 84.2 hours vs medicine 68.7 hours, p < 0.0005), current compliance (49% vs 73%, p < 0.0005), and allowance of internal (13% vs 54%, p < 0.0005) and external (24% vs 58%, p < 0.0005) moonlighting. CONCLUSIONS: Program directors anticipate improved resident safety and well-being. However, education, continuity of care, and board certification success are not expected to improve. Increased cost to institutions is anticipated. Surgery program directors feel medical errors will not decrease; medicine program directors are neutral. To facilitate compliance, surgery program directors anticipate employing physicians' assistants and technology, whereas medicine program directors may implement night float. Neither surgery nor medicine program directors expects increased quantity or quality of applicants. Program directors agree resident work hour reform is essential; however, varied methodology and outcomes are expected.     

A survey of robotic surgery training curricula in general surgery residency programs: How close are we to a standardized curriculum?

Background

Robotic surgery is increasingly adopted into surgical practice, but it remains unclear what level of robotic training general surgery residents receive. The purpose of our study was to assess the variation in robotic surgery training amongst general surgery residency programs in the United States.

Characteristics of the applicant pool to vascular surgery residency programs

OBJECTIVE: Based on the significant number of unfilled vascular fellowship positions in the 2004 National Residency Matching Program (NRMP) and the perception of program directors that the quality of candidates is deteriorating, the Issues Committee of the Association of Program Directors in Vascular Surgery (APDVS) explored the characteristics and the trend of the applicant pool to develop recommendations for improvement. METHODS: The Electronic Residency Application Service (ERAS) database was queried for the total number of applicants, medical school, gender, and age, among other characteristics. The vascular surgery applicant pool was compared to the applicant pool for general surgery; the applicant pool for all fellowship positions, including a variety of medical subspecialties; the applicant pool for all residency positions; and the applicant pool for colorectal surgery, the only other surgical subspecialty participating in ERAS in 2004. NRMP data was used prior to 2004. The chi(2) test was used for statistical analysis, with significance set at P < .05. RESULTS: In the 2004 match for June 2005 positions, there were 100 applicants for 110 first-year vascular surgery positions in 90 programs. In 1989, there were 123 applicants for 56 positions in 49 programs. In 1989, 55% of vascular surgery applicants did not match; whereas in 2004, only 7% were unmatched. Although the overall number of vascular surgery applicants has remained relatively stable, the number of United States applicants has decreased from 89% in 1990 to 68% in 2004 (P < .01). There was a significant geographic variation: 34% of those in the applicant pool came from the state of New York, but 23 states did not contribute a single applicant to the pool. In addition, vascular surgery, like other fellowships, attracts fewer female applicants. CONCLUSIONS: The data from the ERAS database support the impression held by many in the vascular surgery education community that the size of the applicant pool for vascular surgery fellowship positions has remained stagnant, while the number of positions has significantly increased. Strategies to increase the size and quality of the applicant pool are needed.     

Standardizing vascular surgery residency: merger of two programs to create one model

The practice of vascular surgery has been transformed in the last decade. It is now necessary to change the way we train vascular surgeons, to keep pace with this rapidly evolving specialty.     

Prevalence of teaching sentinel lymph node biopsy for breast cancer in general surgery residency programs

PURPOSE: Sentinel lymphadenectomy (SLNB) for the evaluation of clinically negative lymph nodes in women with invasive breast cancer is rapidly gaining acceptance within the surgical community. The purpose of this study was to document the prevalence of teaching SLNB to residents in general surgery training programs in the United States. METHODS: The Fellowship and Residency Electronic Interactive Database (FREIDA) was searched for a listing of all general surgery residency programs. A short questionnaire was mailed to the program director of each residency program listed. The program directors were asked whether general surgery residents are taught the technique of performing SLNB for breast cancer, and how the procedure is performed at their institutions. RESULTS: Of the 255 surgical programs listed in FREIDA, 191 or 75% responded to the survey. Of responding programs, 92% are currently teaching surgical residents SLNB, whereas 4% plan on adding SLNB to the curriculum within the next academic year. A total of 74% of programs are performing SLNB as part of an organized hospital protocol, whereas 40% routinely follow SLNB with an axillary node dissection. A total of 89% of the programs use both sulfur colloid radioisotope and isosulfan blue dye, whereas 7% use dye alone, and 4% use only radioisotope. CONCLUSIONS: The practice of performing SLNB for the purpose of detecting occult nodal metastases in breast cancer is being taught at most surgery training programs in this country. In the less than 6 years since the modification of this technique for the treatment of breast disease, it has become the standard of care for treating women with invasive breast cancer with clinically negative axillary lymph nodes at training hospitals in the United States.