Surgical caseload in army general surgery programs: a 10-year retrospective

PURPOSE: Over the past decade, the Army Medical Department (AMEDD) has been affected by a military-wide drawdown. The volume and acuity of patients appears to be declining, raising questions regarding quantity and quality in Army surgical training programs. The purpose of this study is to examine the caseloads of Army general surgery programs compared with national averages, and to compare the board examination performance of Army residents with national pass rates. METHODS: The program directors of all 6 Army training programs were requested to submit resident caseloads and performance on qualifying and certifying examinations from 1990 to 2000. The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Surgery (ABS) provided resident statistics summaries and board examination statistics, respectively, for the same period. Total caseloads, chief resident cases, performance in defined categories, and board pass rates of military residents were compared with national averages. RESULTS: Four of the 6 programs submitted the requested data. The average caseload for Army residents, both total and chief residents, has been lower than the national average over the past decade. Nationally, total case numbers have gradually increased while military changes have been variable. The number of chief resident cases has trended steadily downward in Army programs at a rate exceeding the national average. The volume of procedures in endoscopy, thoracic, and breast surgery in the Army generally exceeds those recorded outside of the military. Despite the decline in surgical cases in the military, the pass rates in both the certifying and qualifying examinations among Army graduates have been consistently higher than the national average. CONCLUSIONS: Residents who train in Army programs perform fewer operative cases than do their counterparts in civilian programs. The downward trend in the number of chief resident cases over the last 10 years is likely reflective of the changes in military medicine. Despite these trends, Army residency graduates continue to exceed national performance averages on the ABS qualifying and certifying examinations.     

The importance of vascular surgery training in a general surgery practice

The aim of this report was to document the practice of vascular surgery for graduates of 4 general surgery training programs.Graduating residents from 1991 to 1995 were surveyed by phone to document the number of reconstructive vascular and dialysis access procedures that they performed during the most recent 12 months. Those who pursued additional training beyond general surgery or who did not successfully complete the certifying examination of the American Board of Surgery (ABS) were excluded. In addition, the Resident Review Committee for Surgery (RRC-S) defined category report for these same general surgeons during their residency was examined.Fifty-five percent (26 of 47) of the board-certified general surgeons do either reconstructive or dialysis access vascular surgery. The average number of procedures in the RRC-S defined category for this cohort was 76. During the focused 12 months, 1986 vascular procedures were done by these 26 surgeons (76 cases per surgeon).In certain regions of this country, a significant volume of vascular surgery is done by general surgeons who have an ABS primary certificate alone. The technique of control and repair of major arteries and veins, the consequences of distal organ ischemia, reperfusion injury, thrombosis, and embolization are important anatomic and physiologic principles that must be taught in the curriculum to general surgeons, regardless of their future surgical careers. (Curr Surg 57:381-383. Copyright 2000 by the Association of Program Directors in Surgery.)     

The Remedial Year in the General Surgery Board Certification Process: How Effective Is It?

BACKGROUND: The American Board of Surgery (ABS) intends to assure high standards for knowledge and experience in every graduate from an approved general surgery program. They have gone to great lengths to devise an optimal remediation process for every candidate failing to reach these standards. But what is the effectiveness of the remediation process? METHODS: ABS data outlined the history and development of the remediation process up to its current form. A core component of this process is a specifically structured additional year of training at selected institutions. Ten institutions, which were classified as outstanding by the ABS, received a standardized confidential questionnaire to collect data that included the institution's impetus to administer a remedial year (RY), organization of their RY, specific emphasis points, role of advisors, funding, and choice of RY candidates. Each institution was asked to mail a letter to their RY graduates, asking for their participation in a follow-up study aimed at characterizing the failing candidate. RESULTS: ABS data have been available since 1980. Pass rates for the qualifying written examination (QE) improved steadily from about 63% in 1985 to 78% in 2003. Pass rates for the certifying oral examination (CE) have been consistently around 75% since 1985 with improvement to just above 80% within the last 4 years. In 1995, a new ABS policy was announced requiring an additional year of structured training with specific elements. For the QE, the general pool pass rates continued their steady improvement. Although the results for RY candidates did reveal a 20% improved pass rate, they were still 30 percentage points lower when compared with the general pass rates. No improvement was noted in the CE results. In 2003, ABS enacted the latest policy change, which consists of an alternative pathway for QE. The initial experience for 2003 is disappointing. Less than 10 candidates have taken advantage of this alternative, and pass rates have not improved. The policy for CE was changed to allow 5 attempts (up from 3 attempts) in 5 years, and currently it is too early to determine the impact of this change. Nine of 10 institutions agreed to participate in our study. They identified the essential elements of a successful RY. They also emphasized that CE remediation has to go beyond correction of simple knowledge deficits. And they characterized the ideal candidate for remediation. No RY graduates agreed to participate in the planned follow-up study to characterize the failing candidate. CONCLUSION: The RY process seems to have a valid potential if specific conditions are met. We do believe that differentiation is needed between the QE and the CE remedial year programs. Because the CE incorporates rhetorical skills, an emphasis should be placed on public speaking and presentation skills in a remedial year for the CE. We recommend several possible avenues for consideration: identifying the resident at risk and intervening during residency, incorporating the RY process into the ongoing practice routine of the individual candidate, and actively recruiting participation of candidates in a needs assessment study.     

American board of vascular surgery: the first 7 years

The American Board of Vascular Surgery (ABVS) was incorporated in 1996 with a vision of improved training standards and certification of vascular surgeons. At that time, 91% of those holding American Board of Surgery Certificates of Added Qualifications in Vascular Surgery supported the formation of the ABVS. Subsequent events have led to a clear definition of specific educational issues important to the vascular surgery community. Unresolved issues relate to the need to complete a general surgery residency before beginning a vascular surgery fellowship, the continued inclusion of vascular surgery as a primary component of general surgery training, and the absence of a designated Residency Review Committee for Vascular Surgery. These issues have persisted since the inception of the ABVS. An application for the ABVS to become an American Board of Medical Specialties (ABMS) primary board was submitted in 2002 with a preliminary hearing before a liaison committee composed of American Medical Association and ABMS members. The American Board of Surgery (ABS) and a minority of the vascular surgery community vigorously opposed the application. The perceived divisiveness created by their actions contributed to the application's initial rejection and the necessity for an appeal. Certain ABS directors have recently stated that they would consider approving multiple track-type training that could allow single certification in vascular surgery, following 5 to 6 years of postgraduate training after medical school. The ABVS cautiously supports this action, recognizing that this radical change for the ABS may not be feasible given the broad-ranging interests of general surgery and restrictive ABMS guidelines for certifying medical specialists. The impact of not resolving the critical issues facing vascular surgery in a timely manner is that there will be inadequate numbers of competent vascular surgeons to provide for society's needs. An independent ABMS-approved ABVS provides a clear opportunity to resolve the recognized failings of the status quo.     

A history of the American Board of Surgery: vignettes from the certifying examination : The Edgar J. Poth Memorial Lecture

The American Board of Surgery was established in 1937 to certify surgeons who through training, experience, and examination meet the highest standards of surgical care. This lecture was given as the Edgar Poth lecture at the April 2015 meeting of the Southwestern Surgical Congress. Dr Poth was a surgical educator from the University of Texas Medical Branch, Galveston who was President of the Southwestern in 1963. The paper presents the history of the founding of the American Board of Surgery, with particular emphasis on the certifying examination—Part 2. Vignettes of occurrences associated with the “Oral” examination are given. The examination has changed substantially from a 2-day event involving an actual surgical procedure to the 90-minute quiz given today. The oral examinations remain an important part in the process of certification of surgeons of the highest quality.     

Surgical Resident Accuracy in Predicting Their ABSITE Score

Background:

The American Board of Surgery In-Training Examination (ABSITE) is given to all surgical residents as an assessment tool for residents and their programs in preparation for the American Board of Surgery qualifying and certifying examinations. Our objective was to ascertain how well surgical residents could predict their percentile score on the ABSITE using two predictor measures before and one immediately after the examination was completed.

Methods:

A survey was given to surgical residents in postgraduate year(s) (PGY) 2 through 5 as well as to research residents in November and December 2011, and immediately after the examination in January 2012, to ascertain their predicted ABSITE scores. Thirty-one general surgery residents were measured consisting of PGY-2 (22%), PGY-3 (19.4%), PGY-4 (19.4%), and PGY-5 (12.9%), and research residents 25.8%.

Results:

Mean prediction scores were consistently higher than actual examination scores for both junior and senior examination takers, with senior examination predictions exhibiting the highest proportion of variation on the actual examination score. Stratified linear regression analysis showed little predictive significance of all 3 examination predictions and actual score, except for the senior examination predictions in November 2011 (t test = 2.521, P = .027). We found no statistically significant difference in the proportion of residents overestimating or underestimating their predicted score. Secondary analysis using a linear regression model shows that 2011 scores were a statistically significant predictor of 2012 scores (overall F = 13.258, P = .001, R² = 0.31) for both junior and senior examinations.

Conclusion:

General surgery residents were not able to accurately predict their ABSITE score; however, the previous year''s actual scores were found to have the most predictive value of the next year''s actual scores.     

Surgical council on resident education: a new organization devoted to graduate surgical education

The Surgical Council on Resident Education (SCORE) is a voluntary consortium of six organizations with responsibility for resident education in surgery and an interest in improving the training of surgeons. The founding organizations are the American Board of Surgery (ABS), the American College of Surgeons (ACS), the American Surgical Association (ASA), the Association of Program Directors in Surgery (APDS), the Association for Surgical Education (ASE), and the Residency Review Committee for Surgery of the Accreditation Council on Graduate Medical Education (RRC-S). SCORE emerged from a concerted desire to strengthen the graduate education of surgeons and to assure the competence of surgical trainees in the US. SCORE has a unique ability to foster change in resident education because it brings together the major regulatory organizations (ABS and RRC-S), the major professional organization in surgery (ACS), the senior academic organization in surgery (ASA), and the major surgical education organizations (APDS and ASE). SCORE envisions an ambitious agenda. At its meeting in Philadelphia on November 20, 2006, it began developing a standardized curriculum in general surgery to span the period from medical school to practice, and it defined the scope of the curriculum. It approved continued work of building a national Web site to deliver educational content to general surgery residents and to assist program directors. It endorsed continued development of a basic surgery curriculum for all first-year surgery residents and development of a comprehensive technical skills curriculum for all levels of general surgery training, both of which have been initiated by the ACS. In the future, SCORE plans to examine issues such as the assessment of technical competency, the role of simulation in surgical education, the teaching and assessment of professional behaviors, the practicing surgeon's view of the adequacy of residency training, faculty development, and the attrition of residents from surgery residencies. Members of SCORE intend to investigate best practices in surgical education in other countries. SCORE hopes to take a leadership position in improving the quality of surgical education and surgery in the US.     

Educational deficiencies in musculoskeletal medicine

BACKGROUND: We previously reported the results of a study in which a basic competency examination in musculoskeletal medicine was administered to a group of recent medical school graduates. This examination was validated by 124 orthopaedic program directors, and a passing grade of 73.1% was established. According to that criterion, 82% of the examinees failed to demonstrate basic competency in musculoskeletal medicine. It was suggested that perhaps a different passing grade would have been set by program directors of internal medicine departments. To test that hypothesis, and to determine whether the importance of the individual questions would be rated similarly, the validation process was repeated with program directors of internal medicine residency departments as subjects. METHODS: Our basic competency examination was sent to all 417 program directors of internal medicine departments in the United States. Each recipient was mailed a letter of introduction explaining the purpose of the study, a copy of the examination, and our answer key and scoring guide. There was no mention of the results of the first study. The subjects were requested to rate the importance of each question on the same visual analog scale, ranging from "not important" to "very important," as had been used by the orthopaedic program directors. These ratings were converted into numerical scores. The program directors were also asked to suggest a passing score for the examination, and this score was used to assess the examinees' performance on the examination. The results on the basis of the internal medicine program directors' responses and those according to the orthopaedic program directors' responses were compared. RESULTS: Two hundred and forty (58%) of the 417 program directors of internal medicine residency departments responded. They suggested a mean passing score (and standard deviation) of 70.0% +/- 9.9%. As reported previously, the mean test score of the eighty-five examinees was 59.6%. Sixty-six (78%) of them failed to demonstrate basic competency on the examination according to the criterion set by the internal medicine program directors. The internal medicine program directors assigned a mean importance score of 7.4 (of 10) to the questions on the examination compared with a mean score of 7.0 assigned by the orthopaedic program directors. The internal medicine program directors gave twenty-four of the twenty-five questions an importance score of at least 5 and seventeen of the twenty-five questions an importance score of at least 6.6. CONCLUSIONS: According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination. It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.     

Initial assessment of a new preparatory tool for board certification in urology

OBJECTIVES: To establish a Canadian national examination simulating the qualifying Urology examinations of the Royal College of Physicians and Surgeons of Canada (RCPSC) and to survey candidate perceptions regarding the mock examination's utility as a preparatory tool for the RCPSC examinations and the adequacy of examination preparation provided by their residency training program. METHODS: From January 1997 to February 1999, the Queen's Urology Examination Skills Training (QUEST) program was established, consisting of a short answer question component and an objective structured clinical examination. All participants and residency program directors received detailed feedback regarding candidate performance. RESULTS: All 11 Canadian training programs were represented, for a total of 64 participants. The 56 final-year candidates participating in QUEST and the RCPSC examinations in the same calendar year represented 66% of Canadian residents attempting the RCPSC examinations during that period. QUEST participants were surveyed immediately after the RCPSC examinations (response rate 84%). Of the respondents, 96% believed that QUEST was representative of the RCPSC examinations, and 100% said they would recommend it to future residents. Most respondents (92%) believed that the QUEST program improved their performance on the RCPSC examinations. Regarding the examination preparation received, 32 (68%) of 47 believed their program provided inadequate preparation for the RCPSC examinations. CONCLUSIONS: Support is strong among Canadian urology residents for a preparatory examination such as the QUEST program. A significant majority of residents believed that they received inadequate preparation for the RCPSC examinations from their residency training program.     

Critical care education in general surgery residencies

Surgical critical care (SCC) was recently identified as an essential component of general surgery by the American Board of Surgery (ABS). Previous studies have found limited attention to critical care education in general surgery programs. This survey was developed to determine the changes in critical care education, following the emphasis by the ABS. The survey determined the format for SCC education, the time and resources committed, and the views of the program directors toward SCC. Program directors of all 296 approved general surgery residencies were surveyed, with a 79% response. Most program directors (91%) agree that SCC is an essential component of general surgery, and 72% believe a separate intensive care unit (ICU) rotation should be used in SCC education. Education in SCC was provided by a separate ICU service in 110 (47%) of the programs. The remaining 53% used care of patients in the ICU during traditional services as their educational experience. The average ICU rotation for surgery residents was 9 weeks and usually occurred in the second year of training. In 97% of the 110 programs with an ICU service, lectures and conferences were conducted regularly. Seventeen programs sponsored critical care fellowships, and 25 additional programs were considering them. Ninety percent of surgical ICU services had faculty that consisted exclusively of surgeons or surgeons and other specialists. Only 53% of surgeons attending on an ICU service had a reduction in their other responsibilities. Despite overwhelming agreement that critical care is an essential component of general surgery, less than half of the training programs have an ICU service to coordinate resident education in SCC. If surgeons are to continue to provide total care to their patients, there needs to be increased commitment to SCC education.     

Improved continuity of care in a community teaching hospital model.

HYPOTHESIS: We created an ambulatory resident clinic in a community teaching hospital to improve the continuity of care in a surgery residency program. DESIGN: A retrospective chart review analysis. SETTING: A community hospital, general surgery residency training program, and its ambulatory practice. INTERVENTIONS: Providence Hospital, Southfield, Mich, has established a new model, the Surgical Associates of Michigan, which is an association comprising private practice physicians serving as full-time faculty in the Department of Surgery. In addition to clarification of teaching requirements and reimbursement for educational activities, the most dramatic feature is the relocation of private practice offices and the staff surgical office to one central location within the hospital. The proximity of the staff and private surgical offices facilitates closer interaction of attending physicians, residents, and patients. MAIN OUTCOME MEASURES: Compliance rates of continuity of patient care provided by the same resident, as presented by the Surgery Residency Review Committee, including confirmation of diagnosis, provision of preoperative care, discussion with attending physician, selection and provision of intervention, direction of postoperative care, and postdischarge follow-up. RESULTS: Since the inception of this arrangement at our institution, surgical residents have seen 229 staff patients and 465 private patients in the offices under supervision. Compliance rate of continuity of care was defined as patient follow-up with the same senior surgical resident who performed an operation or evaluated the patient on initial presentation to the emergency department or offices. We achieved a compliance rate of 92.8% (169/182) in the staff surgical clinics. A compliance rate of 63.5% (205/323) for private general surgical patients and 70.4% (100/142) for vascular surgical patients was obtained. With the establishment of the teaching faculty group and the relocation of offices, we were able to achieve a dramatic improvement in continuity of care. CONCLUSIONS: In addition to fulfilling the Surgery Residency Review Committee requirements, we believe our model facilitates broader education of surgical residents and improves risk management. We recommend further similar studies, greater involvement of primary care specialties in recruiting staff surgical referrals, and implementation of a specialized computer program to continue to improve continuity of care in surgery residency programs.     

Residency program directors' perceptions about the impact of the American Board of Anesthesiology's Objective Structured Clinical Examination

Study objectiveTo describe how the introduction of an Objective Structured Clinical Examination (OSCE) by the American Board of Anesthesiology (ABA) to its initial certification impacted anesthesiology residencies in the United States.Design and settingA sequential mixed-methods design with focus groups and online survey among program directors of Accreditation Council for Graduate Medical Education-accredited anesthesiology residencies.PatientsNo patients were included.InterventionNone.MeasurementsA convenience sample of 34 program directors were interviewed to understand their perceptions of the ABA OSCE. Subsequently, an online survey, based on major themes identified from the focus groups, was sent to all 156 program directors.Main resultsSeveral themes emerged from the focus group discussions: (1) a mock OSCE was most common for preparing residents for the ABA OSCE; 2) the ABA OSCE led to changes in residency curriculum; 3) the ABA OSCE assessed communication and professionalism skills well, and how well it assessed technical skills was less agreed on. Survey results from 87 program directors (response rate = 56%) were mostly consistent with the themes generated by the focus groups. Eight-one out of 87 programs (93%) specifically prepared their residents for the ABA OSCE. Fifty-two out of 81 program directors (64%) reported the introduction of the ABA OSCE led to curricular changes. Out of 79 program directors, 45 (57%) agreed the ABA OSCE assesses skills essential to anesthesiology practice, and 40 (51%) considered it added value to board certification.ConclusionsThe introduction of the OSCE by the ABA for board certification has affected the curriculum of many residencies. Approximately 3 in 5 program directors perceived the ABA OSCE measures skills essential to anesthesiologists' practice. Future studies should assess residency graduates' perspective on the usefulness of both mock OSCE preparation and the ABA OSCE, and whether the ABA OSCE performance predicts future clinical practice.     

An analysis of vascular surgical manpower requirements and vascular surgical rates in the United States

Inherent in any analysis of vascular surgical manpower must be accurate data on surgical rates and numbers of surgeons who perform vascular operations. For in-depth analysis of age-sex standardized vascular operative rates from 1979 to 1984 and a determination of current manpower levels, data from the National Center for Health Statistics (NCHS) and the American Board of Surgery (ABS) were reviewed. During 1979 to 1984, total vascular surgical procedures increased 50%. In 1983 such operations comprised 11% of all general surgical procedures and 3% of all operations performed in this country. In 1983, 95,000 carotid endarterectomies, 74,000 peripheral bypasses, were performed. Through November 1984, among approximately 1600 surgeons who had applied to take the General Vascular Surgery Examination, 676 took the examination and 545 passed. What percentage of all vascular surgeons these 1600 represent is unknown. Consequently, what percentage of the total vascular operative load their own experiences represent is uncertain. As of May 1985, the Residency Review Committee for General Surgery had approved 42 fellowship positions in 29 vascular training programs. How these training figures will change to meet optimal manpower requirements remains undefined. Although data concerning operative rates have become more precise, forecasting manpower needs will be met with skepticism because of unknown current and future numbers of vascular surgeons and their average caseloads. Regardless of these uncertainties, vascular surgeons, program directors, and health analysts should be aware of such information because until we know how many vascular surgeons are necessary to provide optimal care, training and certification can not rationally evolve.     

The effect of improving communication competency on the certifying examination of the American Board of Surgery

BACKGROUND: Since 1991 the authors have offered a course that identifies content deficits, but only provides instruction directed at improving verbal and nonverbal behaviors. We report the outcome of this 10-year effort as success on the certifying examination of the American Board of Surgery between 1991 and 2001. METHODS: Sixteen 5-day courses were scheduled over 10 years. Participants included those who had not taken the oral examination or had failed at least once and invited senior faculty (n = 26). Sites were chosen to replicate the actual examination setting. RESULTS: There were 122 participants, with follow-up data available on 88. Success in the certifying examination after completing the course is 96 percent. CONCLUSIONS: Evaluation of communication deficits and training to improve them is strongly associated with success. Clearly, this course is effective at identifying communication behaviors that are interfering with success on the certifying examination of the American Board of Surgery.     

General surgery resident attrition and the 80-hour workweek

BACKGROUND: This study examines the effect of implementation of the resident duty-hour regulations on the attrition rate of general surgery residents. METHODS: A 7-part survey encompassing the 2001 to 2004 academic years was sent to program directors of general surgery residency programs in the United States. RESULTS: One hundred twenty-four of 252 programs (49%) responded, reporting a loss of 338 categorical residents. The total attrition rate increased from .6 residents lost/program/y to .8 residents/program/y (P = .0013). Lifestyle concerns were the most commonly reported reason for residents leaving during surgical training. The majority (56%) of those who left surgery entered other fields of medicine (ie, Anesthesia and Family Medicine most commonly). CONCLUSIONS: More residents are leaving general surgery training since the institution of the 80-hour workweek. Despite improvements in work hours and lifestyle during surgical training, residents migrate to specialties that are conducive to a more controllable lifestyle after experiencing surgery residency.     

The unkindest cut of all: are international medical school graduates subjected to discrimination by general surgery residency programs?

PURPOSE: International medical school graduates (IMGs) have been part of the United States residency applicant pool for several years. There has been increasing discussion of an overproduction of doctors in the United States, and mention of limiting IMG quotas. The purpose of this study was to find out if measurable discrimination existed real or perceived, against IMGs. METHODS: A survey was performed to assess whether program directors of surgery residencies perceive the performance, dedication, and abilities of IMGs as being equal to United States medical school graduates (USMGs), and whether program directors believe that a preference toward USMGs exists. Surveys with 30 tailored questions were mailed to all members of the Association of Program Directors in Surgery. One hundred twenty-five surveys were returned out of 283 mailed, and 112 were included in the data analysis. Besides those relating to demographics, questions on the survey included two series of queries. One set was designed to assess whether the respondent reported that IMGs possessed similar skills and abilities as USMGs, whereas the other addressed whether respondents perceived a tendency in their programs to focus recruitment toward USMGs. Still others were inserted to confirm results of these series, and to assess whether program directors perceived discrimination toward IMGs in general. RESULTS: Survey results indicate the perception that IMGs are similar in skill and ability to USMGs, regardless of program size. However, a perception existed among program directors that USMGs were favored in the recruitment process, with more than 70% of respondents indicating that they believed IMGs were discriminated against. Furthermore, nearly 20% reported that they had been pressured to rank a less-qualified USMG higher than a more qualified IMG, and 22% reported that they had ranked a USMG higher than an IMG to avoid a reduced compliment of USMGs. CONCLUSIONS: There is a significant belief and perception that IMGs are indeed discriminated against, despite program directors seeing no clear differences in surgical skills between IMGs and USMGs.     

Path to bariatric nurse certification: the practice analysis

BackgroundIn 2005, the American Society for Metabolic and Bariatric Surgery (ASMBS) nursing membership embarked on a journey to develop a specialty certification program for nurses caring for morbidly obese and bariatric surgical patients. In keeping with the certification industry best practices, a practice analysis study was conducted to create an empirically sound foundation for the new nursing specialty certification examination.MethodsTask force meetings, subject-matter expert interviews, and an external review process were implemented to create a definition of the specialty in terms of 4 domains of practice, 45 nursing tasks, and 54 knowledge areas. The definition encompassed the work of bariatric nurse coordinators, bariatric program directors, and floor nurses caring for morbidly obese and bariatric surgical patients. A survey was administered to 1084 nurses practicing in the specialty to validate the domains, tasks, and knowledge.ResultsSome differences in the time spent in each of the domains and tasks were noted for the survey respondents in the different job roles. Nevertheless, the respondents for all job roles rated the domains and tasks moderately or highly important in optimizing the outcomes for morbidly obese and bariatric surgery patients. In addition, most respondents agreed that the 54 knowledge areas were acquired during the first 2 years of practice in the specialty.ConclusionThe survey results validated a specialized body of nursing knowledge rooted in the tasks that define professional practice. The results are being used to guide the development of a certification program for nurses practicing in the specialty and to provide guidance for education and training initiatives.     

Fundamentals of laparoscopic surgery: a surgical skills assessment tool in gynecology

Objective:

To describe our experience with the Fundamentals of Laparoscopic Surgery (FLS) program as a teaching and assessment tool for basic laparoscopic competency among gynecology residents.

Methods:

A prospective observational study was conducted at a single academic institution. Before the FLS program was introduced, baseline FLS testing was offered to residents and gynecology division directors. Test scores were analyzed by training level and self-reported surgical experience. After implementing a minimally invasive gynecologic surgical curriculum, third-year residents were retested.

Results:

The pass rates for baseline FLS skills testing were 0% for first-year residents, 50% for second-year residents, and 75% for third- and fourth-year residents. The pass rates for baseline cognitive testing were 60% for first- and second-year residents, 67% for third-year residents, and 40% for fourth-year residents. When comparing junior and senior residents, there was a significant difference in pass rates for the skills test (P=.007) but not the cognitive test (P=.068). Self-reported surgical experience strongly correlated with skills scores (r-value=0.97, P=.0048), but not cognitive scores (r-value=0.20, P=.6265). After implementing a curriculum, 100% of the third-year residents passed the skills test, and 92% passed the cognitive examination.

Conclusions:

The FLS skills test may be a valuable assessment tool for gynecology residents. The cognitive test may need further adaptation for applicability to gynecologists.     

General surgery and fellowship training: opinions of surgical intern applicants and fellowship directors

BACKGROUND: Given the pressures that exist today to modify surgical training programs, this study was undertaken to ascertain the opinions of surgical intern applicants and fellowship program directors with regard to the length of surgical training. METHODS: Surveys were sent to fourth-year medical students who were applying for categorical surgical training during a 2-year period at a single university medical center and to fellowship program directors in 6 surgical subspecialties. RESULTS: Ninety-three percent of the applicants planned to pursue fellowship training. Sixty-eight percent of the applicants did not feel that 5 years of general surgery are necessary before beginning a fellowship. Seventy-one percent of the applicants indicated that they would be willing to "short track" into a subspecialty to reduce training time. Virtually all fellowship directors in pediatric surgery (94%), transplantation surgery (94%), and oncologic surgery (100%) felt that 5 years of general surgery training are necessary before entering a fellowship. Significantly fewer fellowship directors in vascular surgery (53%), cardiothoracic surgery (30%), and plastic surgery (17%) felt that 5 years of general surgery are essential before beginning a fellowship (P < or = .001). CONCLUSIONS: For some general surgery subspecialties, a shortened, integrated training program may be desirable from the point of view of both trainees and fellowship directors. Vascular, cardiothoracic, and plastic surgery appear to be those subspecialties that are most amenable to such programs.     

The relationship between surgical and its subspecialty boards in Japan

This article deals with a 7-year endeavor to reform the board certification system of the surgical specialty and its subspecialties. The most important lesson learned is that the societies running the board must work not for the societies but for trainees and patients. The new postgraduate surgical training program is an overlapping system composed of a general surgery program of 5 years and optional subspecialty program of 7 years. There are four types of subspecialty program: cardiovascular; respiratory; gastroenterological; and pediatric surgery. The written examination for general surgery is taken 4 years after the start of training. Those who pass it and experience 350 general surgery cases within 5 years are eligible for oral examination by the surgery board. Those who pass the written examination for general surgery and experience a certain number of subspecialty surgeries within 7 years after the start of training are eligible for the oral and/or written examinations for the subspecialty board. The surgical societies are responsible for constantly improving the quality of the surgical training programs and qualification systems so that board-certified surgeons are accepted and treated as true surgical specialists in this country.