Surgical Performance: A Pathway to Excellence
In 2012, Lewis and Klingensmith2 considered ongoing concerns in general surgery residency training. Technological advances such as laparoscopic and intraluminal approaches, the impact of cross-sectional imaging on management of trauma patients, outpatient surgery for breast, gallbladder and hernia procedures, continued postresidency training in fellowships, increasing American Board of Surgery examination failure rates, and challenges for autonomy during residency were declared as negative impacts on resident training. Curriculum updates, online learning and self-assessment modules, decreased service responsibilities, pre-residency boot-camps, simulation-based training, earlier specialization tracks, and extended residency training length were considered plausible solutions to the issues at hand.
At a broader level, there is a national agenda to implement competency-based medical education, underpinned by competencies, milestones, and entrustable professional activities (EPAs).3 It is the aspiration that this educational structure will ensure trainees are placed under regular scrutiny with regard to their performance, and more importantly, to hold residency programs accountable for outcomes of their graduates. A laudable goal, as indeed there is a defined relationship between where one undertakes residency, and clinical outcomes in independent practice.4
The challenge is how to translate and coalesce all aspects of medical school, residency, and fellowship education into delivery of high-quality surgical care. Ultimately, the intention is to produce physicians who have acquired and can demonstrate their clinical knowledge, the skills to question, examine, investigate, diagnose, and manage patients, and behaviors or attitudes to engage colleagues, nursing and ancillary staff, patients, and their families. In addition, there is a desire to produce surgeons who also excel as educators, scholars, health advocates, and consummate professionals.
The current alphabet soup of SCORE, EPAs, FES, OPRS, ATLS, mini-CEX, and so on, perhaps unintentionally, serves to fragment surgical education processes and outcomes, into piecemeal training models. The polar end is continuity of care, being the hallmark of high quality clinical practice, from symptoms, to diagnosis, treatment, and follow-up care. Care should be team based, patient-centered, and enable patient-physician relationships to develop, which are beneficial to both parties. Daly et al5 studied continuity of care for 228 patients undergoing operative procedures involving general surgery residents, and reported frequency of operative resident involvement in the preoperative consultation (9.2%), postoperative clinic visit (9.0%), and the entire course of care (0%). Although this may be ascribed to challenges with regard to rotation length, residents were on service for greater than 40 days, with average total duration of care per patient of 26 days. Indeed, Lewis and Klingensmith2 agreed that ‘…longitudinal experience with patients… have been markedly reduced’ and that ‘…residents have minimal opportunity to evaluate these patients before surgery or to follow them up afterward.’ Again, duty-hour restrictions and increasing outpatient surgical procedures were mentioned as challenges, associated with reduced opportunities for mentoring and apprenticeships.
The Halsted-based apprenticeship model comprised long and arduous hours of training, steep hierarchies, subjective feedback of performance, and ambiguous definitions of competence.