Surgical fellowship match results for 2017

Two weeks ago, I reviewed the preliminary results of the 2017 main NRMP match. Data for the specialty match, also known as the fellowship match, recently became available. Here are the outcomes for the subspecialties of general surgery.

For abdominal transplant surgery, 36 of 58 programs filled, comprising 51 of 74 positions. There were 75 applicants with 24 going unmatched. The number of transplant programs has dropped from 69 in 2013 with a concomitant decrease in the number of available positions from 84 to 74. Applicants numbered 116 in 2013, and except for a slight upturn in 2016, interest has steadily declined. Consistent with the previous four years, US grads filled 31% of the positions in 2017.

Colon and rectal surgery filled all 56 programs and all 95 positions; 35 of the 130 applicants failed to match. Colorectal has filled 100% of positions available in three of the last five years. US grads filled 75% of the slots which is fairly consistent with previous years.

Pediatric surgery’s 44 programs filled all but one of the 45 available positions. This is the first time in the last five years that pediatric surgery did not fill 100% of its slots through the match. There were 96 applicants this year, and 52 of them did not secure a position. US grads filled 80% of the slots which is a slightly lower percentage than previous years.

How can we instill more confidence in our graduating chief residents?

For over six years, I have been writing about problems in surgical education. My seventh blog post ever was about the negative impact of changes in surgical residency training.

In that post, I cited a residency program director who felt that rules imposed by the Accreditation Council for Graduate Medical Education (ACGME) resulted in excessive supervision of residents who never had a chance to operate independently. Many feel that this is a major factor resulting in 80% of graduating chiefs opting to do one or more years of post residency fellowship.

Excessive supervision continues in 2016. In his presidential address to the Southwestern Surgical Congress, John R. Potts, III, M.D., a former surgical program director and now Senior Vice President of Surgical Accreditation for the ACGME, had a similar observation. He said, “I have personally encountered individuals finishing general surgery residency programs who have never completed any operation—regardless how simple and basic—without an attending surgeon being with them throughout that operation.” [Emphasis by Dr. Potts]

Expanding surgical residency training programs—good idea?

One of my Physician's Weekly posts last month was on the subject of surgeons possibly losing proficiency for doing open cases because of the ever-increasing popularity of laparoscopic and other minimally invasive techniques resulting in declining numbers of open operations for residents during their training.

Although some suggested that knowing how to do open cases would be unnecessary in the future, to me that is wishful thinking.

Another commenter said, "We are seeing the result of this in one of our hospitals with a new surgeon. He frequently aborts cases when he cannot complete them laparoscopically because he does not know how to do the open procedure. Worse, instead of seeking the help of someone who does, he transfers the patient to a medical center."

A resident said, "Observing the big name academic center that I train at, it seems that the massive cadre of fellows has led to an extremely low and less interesting case load for the rest of the general surgery trainees. Overload of floor management onto the trainees seems to exacerbate the problem. Why not substitute some of the current residency training with more focused experience with mentors—maybe even community mentors outside of academic centers—who perform the cases they’re lacking?"

The presence of fellows is a huge problem that academic centers and both the Residency Review Committee and the American Board of Surgery have glossed over for years. Fellows are usually not present in large numbers at community hospital programs; therefore, the residents get to do more surgery. Last year, I wrote about the fact that community hospital residents are more satisfied and do more cases.

The suggestion about mentors from outside of academic centers seems logical. However, it assumes that there are large numbers of community hospital surgeons who are dying to have residents around. In my opinion, that simply is not so. This is also a concern regarding the new surgical residency programs that are being established. I think some of them have been the result of initiatives by hospital administrators (residency programs still bring in government cash) and not the surgeons themselves.

I find it hard to believe that a hospital that has previously not had a residency program and has private practice surgeons who do nothing but operate can turn itself into a setting where surgical education is important.

Who is going to let the residents operate? Who will give didactic lectures? Who will write the research papers that are required by the RRC to prove that the faculty engages in scholarly activity? And so on.

I don't think it will work very well. What's your opinion?

Three more papers document the decline of resident education

A study of traditional every fourth night call compared to staggered shifts of every fifth night call or "night float" appeared in JAMA Internal Medicine.

Although interns working on the "night float" and every fifth night shifts got significantly more sleep than the control group of interns working longer shifts every fourth night, "both the every fifth night and night float  models increased hand-offs, decreased availability for teaching conferences, and reduced intern presence during daytime work hours. Residents and nurses in both experimental models perceived reduced quality of care, so much so with night float that it was terminated early."

A JAMA Surgery paper surveyed 213 surgical interns from 11 university hospitals in July of 2011 and May of 2012. This was the first academic year that the new 16-hour limit was in force.

Although 82% of the interns reported a neutral or good quality of life, more than a quarter of them had symptoms of emotional exhaustion and depersonalization and 32% said their work-life balance was poor. Two-thirds said they thought about their satisfaction with being a surgeon daily or weekly and 14% said they considered dropping out of surgery training at least weekly.

Over half of the residents said that the work hours changes had decreased their time spent in the operating room, and at the end of their intern year, 44% said they did not believe that the work hours limits led to reduced fatigue.

So in both medicine and surgery, the 16-hour work restriction has resulted in unintended consequences.

As if that is not bad enough, check out this blockbuster. The title of a paper in Annals of Surgery this month is "General Surgery Residency Inadequately Prepares Trainees for Fellowship: Results of a North American Survey of Program Directors."

General surgery subspecialty fellowship directors were surveyed and 91 (63%) responded.

From the abstract: "21% [of fellowship program directors] felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications." [Emphasis added]
 
Note that the residents in the Annals paper had not yet been subjected to the 16-hour work limits as that rule was not in effect when they were first-year trainees.

The good news is that by the end of their fellowship training, 82% could perform advanced cases independently. There was no word on the fate of the 18% who could not perform advanced cases independently.

Now that's reassuring, isn't it?

What? American College of Surgeons establishes "Transition to Practice" fellowships

The finding that more than 25% of general surgery residents are not confident that they can practice independently after finishing their residency training has prompted the American College of Surgeons (ACS) to create "Transition to Practice" fellowships.A pilot program at five medical schools and one rural community teaching hospital will place newly graduated residents with community hospital surgeons who will serve as mentors.

The program was introduced in an article in the February 2013 issue of the ACS Bulletin. It says, "current fifth-year residents often lack confidence in their capabilities and may be ill-prepared to enter practice due to a lack of general surgery mentorship and limited exposure to open surgical procedures."

The article goes on to say that the deterioration in training is due to "a number of factors, including reduced work hours, fewer hands-on experiences, and reduced volume of cases, especially emergency cases. Of particular concern is the lack of continuity of care and supervision."

But one of the members of the committee that planned the program said, "The transition from being a chief resident on June 30 to a surgeon in independent practice on July 1 is a daunting step. They haven’t done an operation without an attending across the table."

So which is it—not enough supervision or too much?

It seems to me the ACS feels that general surgery residency training is inadequate.

This confirms what I have said in previous blogs. Last July, I suggested that open surgery fellowships might be necessary to train residents who lacked sufficient exposure to open cases during their residencies. In January of 2012, I pointed out that residents who have never operated alone (the situation in most training programs—confirmed by the ACS) are analogous to pilots who have never soloed before. Would you want to fly with such a pilot? Back in November of 2011, I reviewed the paper that reported the lack of confidence expressed by 27% of residents who were surveyed. I have heard that in a paper about to appear in a major surgery journal, that number is approaching 40%.

If we can't produce confident graduates, why not simply change the way we train them instead of adding another year to the already long process (4 years of college, 4 years of med school, 5 years of surgery residency)?

I have discussed several areas of the curriculum that could be reduced or eliminated, such as insisting that all residents do research whether they want to or not, the heavy emphasis on basic science and the needless transplant rotation.

With a little thought, I am sure more changes could be made so that graduating residents will not feel the need to "transition to practice."

What do you think about "Transition to Practice" fellowships?

This post originally ran on General Surgery News in early March.

Things that puzzle me about surgical education

When I was a surgical residency program director, I often wondered what the establishment, you know those guys who ran surgical education, were thinking. Some may remember the rule that a resident had to see at least 50% of the patients he operated on in the clinic or the private surgeon’s office in order to claim credit for having done the case.

There was the emphasis that still exists today on making sure every resident did research. At last, some are questioning the value of this for the average clinical surgeon. Contrary to the prevailing wisdom, there is no evidence that a resident who is dragged kicking and screaming through a clinical research project or who spent a year in someone’s lab really learns anything about research or how to read and understand a research paper.

Then there is the obsession with a transplant rotation, recently noted in a published paper to be a waste of time in the opinion of surgical residency program directors.