The Accreditation Council for Graduate Medical Education (ACGME) unveiled a new model to measure resident performance in 1999 that endorsed six general competencies. These include patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and system-based practice. The purpose behind the ACGME’s shift in measuring resident performance was to create an effective way to educate and evaluate physicians, explains Christian de Virgilio, MD. “The ultimate goal was to breed physicians who are well trained, educated, ethical, and compassionate.”
Few studies have examined how successful surgical residency programs have been at achieving the ACGME-endorsed competencies. “The advent of the 80-hour workweek restriction and a 16-hour shift limit for interns has affected educational quality,” says Dr. de Virgilio. “Residents are now forced to compress required tasks into a shorter timeframe with reduced work hours. In turn, this can increase the likelihood that future surgical residents will be inadequately trained.”
Examining Remediation Among Surgery Residents
There are several measures of the adequacy of education for surgery residents. One of these measures is whether or not residents require any form of remediation during their residency. In the September 2012 Archives of Surgery, Dr. de Virgilio and colleagues had a study published that aimed to determine the frequency of resident remediation with regard to the six ACGME competencies. The study team also sought to identify factors predictive of the need for remediation and the rate of attrition by surgical residents. Dr. de Virgilio says “this information may provide insights into ways that we can more effectively modify the surgical curriculum in this new era of limited hours.”
After conducting an 11-year retrospective analysis of 348 categorical general surgery residents at six California surgical residency programs, Dr. de Virgilio and colleagues found that about one-third of residents (31%) required remediation at some time during their training, and 8% of those students required remediation more than once. Remediation was initiated to repair deficiencies in one of the six ACGME competencies in 74% of residents. The remediation process consisted mostly of monthly meetings with faculty and specific reading assignments, but sometimes involved mandatory attendance at review courses or conferences and other interventions.
In a multivariate analysis, the study revealed that remediation was linked to United States Medical Licensing Examination step 1 scores, but median scores were generally high among both remediated and non-remediated residents and were higher than the national average (Table 1). In addition, residents requiring remediation were high achievers and were more likely to have received honors in their third-year surgery clerkship. “It’s important to note that most remediated residents successfully completed their residency program and went on to pass their surgery boards at the same high rate as those who did not need remediation,” adds Dr. de Virgilio.
Looking at Attrition Among Surgery Residents
Although most residents required remediation to fill gaps in medical knowledge, they were not prompted by poor performance to leave the field of surgery. Remediation did not appear to be a predictor of attrition. “Attrition rates did not differ significantly between remediated and non-remediated residents,” Dr. de Virgilio says. About 20% of remediated residents quit their program, compared with a 15% rate for those not requiring remediation. The vast majority of residents—more than 96%— who left did so voluntarily, usually for personal reasons. The only predictor of attrition was the American Board of Surgery In-Training Examination score at the postgraduate year 3 level (Table 2).
“Some residents may be successful and high functioning but decide that their personal sacrifice is too great, and they subsequently choose to find an alternative career path that may be less stressful to complete,” says Dr. de Virgilio. “In some cases, residents strive for excellence but have difficulty keeping up with the fast pace and high workload demands. Others fall behind and need extra help to meet faculty expectations, but are sufficiently committed to surgery so that they persevere.”
Assessing the Implications for Medical Institutions
Considering the high demands and stress that are inherent in today’s medical institutions, Dr. de Virgilio says it is important for medical schools to place greater emphasis on adequately preparing students for the rigors of surgical residency and to improve education during the residency period. “Efforts are needed to eliminate non-essential tasks and to give residents time to learn what they need in order to become competent surgeons. When these efforts come to fruition, we’ll have a better chance of training and retaining the best and the brightest surgeons in the future.”
Readings & Resources (click to view)
Yaghoubian A, Galante J, Kaji A, et al. General surgery resident remediation and attrition: a multi-institutional study. Arch Surg. 2012;147:829-833. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=1358529.
Williams RG, Roberts NK, Schwind CJ, Dunnington GL. The nature of general surgery resident performance problems. Surgery. 2009;145:651-658.
Naylor RA, Hollett LA, Castellvi A, et al. Preparing medical students to enter surgery residencies. Am J Surg. 2010;199:105-109.
Esterl RM Jr, Henzi DL, Cohn SM. Senior medical student “boot camp”: can result in increased self-confidence before starting surgery internships. Curr Surg. 2006;63:264-268.
Sachdeva AK, Bell RH Jr, Britt LD, et al. National efforts to reform residency education in surgery. Acad Med. 2007;82:1200-1210.
Longo WE, Seashore J, Duffy A, Udelsman R. Attrition of categoric general surgery residents: results of a 20-year audit. Am J Surg. 2009;197:774-778, discussion 779-780.
Yeo H, Bucholz E, Ann Sosa J, et al. A national study of attrition in general surgery training: which residents leave and where do they go? Ann Surg. 2010;252:529-534, discussion 534-536.
Torbeck L, Canal DF. Remediation practices for surgery residents. Am J Surg. 2009;197:397-402.