NEW YORK (Reuters Health) – U.S. general surgery residents are not universally ready for independent practice, according to ratings from their attending surgeons.
Several reports in recent years have questioned whether all general surgery residents are competent to enter independent practice by the time they complete residency training.
Dr. Brian C. George from University of Michigan, Ann Arbor, and colleagues in the Procedural Learning and Safety Collaborative evaluated the current state of training in general surgery by assessing how much autonomy general surgery residents have and whether general surgery residency programs graduate surgeons who are ready for independent practice.
A total of 444 attendings rated 536 general surgery residents after 10,130 procedures using three scales: the 4-tier Zwisch scale, which assesses how much guidance faculty give to residents (i.e., how “meaningfully autonomous” a resident is); a performance scale, with 5 levels ranging from unprepared/critical deficiency to exceptional performance; and a three-tier complexity scale.
Performance ratings increased from year-to-year (except from year 2 to year 3). By year 5, trainees were rated as competent (practice-ready or above) for 77.1% of “Core” procedures, and for 80% of Core procedures during the last 6 months of training, according to the July 24 Annals of Surgery online report.
During their final 6 months of training, residents received “competent” ratings for 84.3% of the 5 most frequently rated Core procedures but for only 74.5% of the less frequently rated Core procedures. Results were similar for autonomy: residents were rated as being meaningfully autonomous for 84% of frequently rated Core procedures and for 69.1% of less frequently rated Core procedures.
According to models that accounted for various covariates, the predicted probability that a trainee would be rated as competent after performing a Core procedure was 90.5%, with an 86.1% probability after performing a non-Core procedure.
The probability that a trainee would achieve meaningful autonomy was 91.4% for an average-difficulty Core procedure on an average-complexity patient, 79.5% for a similar procedure on more-complex patients, and 94.9% for a similar procedure on the easiest one-third of patients.
“U.S. general surgery residents are not universally ready to independently perform the most common Core procedures by the time they complete residency training,” the researchers conclude. “Significant gaps remain for less common Core and non-Core procedures.”
“Resident autonomy is also limited and may make it more difficult to ensure resident readiness for independent practice,” they note.
“New standards are needed because we can no longer presume that all surgical residents are competent by the end of training,” the researchers add.
Cheryl I. Anderson, director of Quality Improvement and Surgical Education at Michigan State University, Lansing, Reuters Health by email, “Many educators are diligently working to make improvements that may help address these issues, including initiatives such as endorsement of the SCORE curriculum, enhanced simulation requirements, early efforts to identify and assess Entrustable Professional Activities, and our own MSU GOAL (Guided Operative Assessment and Learning) initiative that uses a web-based platform to assess not only operative performance and autonomy, but resident-patient visit encounters and academic performances.”
“Perhaps, additional analysis of information within this large database may provide some clarity regarding where to begin efforts to improve these findings,” she said. “For example, it may prove beneficial to look at each postgraduate year (PGY) level separately, reanalyzing data by individual resident ratings and determining mean or median scores for each group. Further, if we could determine what percent of residents are practice ready at graduation, we might identify factors that may predict practice readiness and, conversely, those factors that do not.”
“The authors have suggested three possible implications related to their findings: modify our current training format, adjust our standards of competence, or change our general surgery expectations. Since this is the first large study of its kind,” Anderson said, “we might simply use these results to initiate future discussions.”
“Regardless of one’s views on the topic, moving too quickly may lead us in the wrong direction, and moving too slowly may prolong the problem,” she concluded. “We need collective input, thoughtful conversation, and continued investigative efforts to understand the products we are producing. It may be imperative to the future of surgical training.”
Dr. George did not respond to a request for comment.
SOURCE: http://bit.ly/2h8DmYf
Ann Surg 2017.
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