Statement on Surgical Residencies and the Educational Environment

Residency programs in surgical specialties have always been challenging—both physically and intellectually. Hard work, long hours, high levels of stress, and a strong emphasis on personal responsibility and accountability have long characterized the training of a surgeon. Even so, most surgeons remember their residencies with great fondness, believing these years to be among the most rewarding of their professional careers.

However, the working conditions for surgical residents have been changing. The information explosion in medicine, the increase in bureaucracy that characterizes medical practice today, and the trend toward ambulatory care and a much abbreviated hospital stay for most patients, accompanied by an emphasis on inpatient care only for critically ill patients, have substantially increased both the work load and the stress of being a surgical resident. Some medical specialties have chosen to focus on reducing the hours worked by residents as a solution to these pressures. With their long tradition of providing continuity of care for their patients, however, surgeons have come to a different conclusion. We have chosen to focus on the quality of the educational program and the work required, and we have come to support changes in the working environment as important factors in making the surgical residency a better environment for learning and for providing patient care.

The following statement, SURGICAL RESIDENCIES AND THE EDUCATIONAL ENVIRONMENT, is a product of many months of deliberations by members of the College's Graduate Medical Education Committee. It expands upon the content of the College's Statement on Fundamental Characteristics of Surgical Residency Programs, which was published in August 1988 and which described continuity of care as a fundamental characteristic of surgical residency programs. We encourage the reading and use of the recommendations put forward in this document by all program directors, faculty members, and leaders of teaching hospital administrations. Our surgical residents are the future of our profession, and it is our obligation to ensure that our system of surgical education continues to produce the best surgeons in the world.

The American College of Surgeons has long been concerned with the education of surgeons of the future—our surgical residents. Following the establishment in 1937 of minimum standards for surgical residencies and field surveys of programs, the first of the Residency Review Committees, the RRC for Surgery, was established in 1950 as a tripartite collaboration of the College, the American Medical Association, and the American Board of Surgery. Similar tripartite RRCs were subsequently established for colon and rectal surgery, neurological surgery, otolaryngology, plastic surgery, thoracic surgery, and urology. These committees have set high standards of quality for graduate surgical education that are used in evaluation and accreditation of surgical residency programs in the United States. As a consequence, continuous improvement in the educational process in surgical residencies has been achieved.

A major focus in the educational programs is, of course, the curriculum. Driven in part by requirements of the certifying boards, the didactic and practical curricula for surgical programs have undergone constant evolution as the practice of surgery has advanced. The environment in which this intense curriculum is carried out must facilitate learning so that the educational experience will be maximized. Many observers, largely outside of the surgical discipline, have been highly critical of one characteristic feature of the environment in surgical residencies—namely, the duty hours. In 1989, an initiative was undertaken in the Accreditation Council for Graduate Medical Education, the umbrella organization for all RRCs in medicine, to place strict limits on the hours per week that residents would be permitted to work. Many nonsurgical residencies developed systems, such as night float rotations, so that shifts of residents could be developed to reduce the hours worked. During the long and vigorous debate that followed, surgeons have become aware that the emphasis on hours worked diverted attention from more pressing problems in residency education, namely the conditions under which residents are asked to work—that is, the working environment and the nature of the educational program.

Little attention has been given to the working environment despite an uneasy truce that was achieved in 1992, which resulted in the addition of broad language relative to duty hours and call schedules in the Essentials of Accredited Residencies¹ General Requirements and the additions of specific language on hours worked in the Special Requirements for each specialty. The position of many surgical educators is that resident fatigue related to excessive work load is accentuated by burgeoning paperwork, pressures to reduce length of hospital stay, the need to cope with the increasing complexity of care, and required involvement in patient care activities that should be the responsibility of support staff. Addressing these issues would go far in achieving the goal of assuring each patient that the resident assigned will be a "healthy, alert, responsible, and responsive physician."

As pointed out by Spencer in his response to the hours debate, "The primary purpose of a residency program is education of the resident, not service to the hospital."² Spencer has also stated the obvious: "Preserving the crucially important ability of the physician to provide continuity of care to his or her patient—without producing severe physical exhaustion in the physician—is clearly one of our most important objectives."³

The American Board of Surgery (ABS) addressed the resident working environment in a position paper that was developed in 1992.

"The ABS acknowledges that presently the Resident Working Environment is not optimal in some general surgery residencies. Adverse factors impacting on the working environment include: (1) Undue amount of time spent on tasks that could be better accomplished by other members of the health care team; (2) Excessive, inappropriate, and uncoordinated use of the paging system; (3) Inattention to personal physical needs, such as nutrition, adequate sleeping quarters, safety, and so on; and (4) Insufficient attention to psychological and emotional stresses, such as lack of time for family, indebtedness, recreation, and lack of adequate support systems and groups. The residents' problems have been exacerbated by sicker inpatients, a markedly expanded base of knowledge, and multiple sites of care delivery."

The ABS recommended that the RRC for Surgery make the status of the working environment an important consideration in accreditation of programs, and the RRC has subsequently taken steps to implement this recommendation.

The Graduate Medical Education Committee has also considered the resident work environment, and it has developed the following recommendations and proposals.

Recommendations

• The relationship of resident and attending staff faculty should be mutually supportive. Education of the resident is the primary goal, with exemplary patient care as its cornerstone. Residents should be treated with respect and dignity, and should, in turn, demonstrate personal attributes of honesty, diligence, and responsibility. The impetus for lifelong self-learning must be strong.
• Residency training is an educational experience in a complex setting. Program directors therefore must provide an environment conducive to education, where teaching is expected and teaching skills are enhanced by instruction, precept, and feedback.
• The balance of time worked and time off must be carefully structured so that residents assume increasing responsibility for patient care during the course of the program. Residents, especially in the chief or senior years, should be personally responsible for their patients, and this responsibility should not be compromised by the time of the day, day of the week, the number of hours already worked, or on-call schedules.
• On the other hand, time for personal activities should be provided. All surgical residents should be encouraged (and permitted) to fulfill their responsibilities toward home and family. Junior residents, to whom fewer responsibilities and more non-educational duties are assigned, should have designated time off.
• Residency programs must provide for appropriate supervision for all residents. The attending physician has both an ethical and legal responsibility for the overall care of the individual patient and for the supervision of the resident involved in the patient's care. Residents are supervised by teaching staff in such a way that the residents assume progressively increasing responsibility for patient care according to their level of training, ability, and experience. The level of responsibility accorded to each resident must be determined by the attending staff, based on direct observation and knowledge of each resident's skills and ability. Supervision does not imply constant observation, but members of the teaching staff must always be immediately available for consultation and support. Constructive criticism and praise for excellence are important elements of supervision and serve to highlight areas believed by the teaching staff to be important. Suboptimal clinical, academic, or personal performance should be met with appropriate counseling, the development of remedial programs, or other measures designed to assist each resident in achieving the goals and objectives of a surgical residency program.
• Supervision of residents should be specified in the bylaws, policies, procedures, rules and/or regulations of the department.
• Support services must be adequate so that residents do not spend an unreasonable amount of time in noneducational activities that could be easily performed by paramedical and clerical personnel. Due both to the growth of medical technology and budget-driven reductions in ancillary personnel by institutions, residents are increasingly being used to perform medical chores that are unrelated to direct patient care. The educational program, especially the curriculum and the educational goals, must have the highest priority. The proportion of education to service must be constantly monitored by the program director and adjusted to maintain the proper environment for learning. The institution sponsoring the residency program must be engaged as a supportive partner in the educational enterprise, and the areas where residents are used for noneducational activities should be addressed by added ancillary personnel, including nurse clinicians, physician's assistants, technicians, and so forth.
• Efforts should be made to eliminate the excessive and uncoordinated use of the paging system by minimizing calls of a nonessential nature. Improved systems of communications between residents and the hospital personnel should be developed so that residents are not constantly interrupted during their work day for inappropriate reasons.
• It should be understood by the institution and by the department sponsoring the residency program, that the personal needs of residents for adequate, private, and convenient sleeping quarters while on-call, food facilities for nutritious meals, study areas and a lounge, and a safe physical environment are essential to the working environment. Provision of these basic facilities is evidence of the institution's commitment to graduate medical education, and deficiencies should be seriously considered by the Residency Review Committee when deciding on accreditation status and constitute grounds for an adverse accreditation action.
• Medical liability insurance should be provided to all residents. Insurance for health care and disability, inclusive of HIV infection, should be available for residents and their families. If possible, the disability insurance policy should be portable when the resident leaves the institution and expandable to meet the needs of a practice income.
• A maternal leave policy should be specified at the time of the resident's employment. The resident should cooperate by informing the program director at an early stage of pregnancy to permit adequate planning and scheduling, and the requirements of the program and of the appropriate specialty board should be explicitly discussed. Parental and other personal leave policies should be specified.
• The institution should be strongly encouraged to provide adequate day-care services for all residents' families.
• Rapid expansion of surgical knowledge and the development of new technology have placed increasing responsibilities on residents, requiring sustained intellectual and physical effort. Therefore, programs should facilitate access to appropriate and confidential counseling and psychological support services. These services include stress management, financial counseling, physician impairment, and substance abuse programs.
• The educational environment should be enhanced with a library of current textbooks and journals that are readily accessible at all hours to residents. In addition, a computer with access to on-line data bases, educational and interactive self-assessment programs, and word-processing capabilities are essential for modern resident education.
• Residents should be fairly compensated for their work, and every resident should be salaried and provided with reasonable annual paid vacations and educational and personal leave. Incentive income rather than salary may be detrimental to ensuring appropriate priorities with regard to learning, family life, and patient care.
• Indebtedness of residents as a result of student loans is a pressing problem. Initiatives to provide relief for student-incurred debt should be explored and developed.
• The curriculum should include formal preparation for the practice of surgery, including education in the ethics of practice and the profession. In addition, residents should be given the opportunity to become educated with regard to the various types of practice arrangements that are available and as to what factors should be considered in selecting a type of practice and site. Programs in actual practice management should be made available to senior residents. Residents should also be involved in learning risk management and cost-effective practice patterns.
• A policy regarding sexual harassment that is consistent with the policies of the institution and the law should be in place in each department and should be strictly enforced. Educational programs for all attending and resident staff relative to sexual harassment and gender bias should take place on a regular basis.

"The surgical profession remains dedicated to the education and training of highly qualified young surgeons. Residency programs must be structured in such a fashion, and with enough flexibility, that the individuals who complete the residency will be the best...that our system can produce."⁴ Those of us who are responsible for overseeing surgical residency programs must strive to meet that goal in order to meet our obligation to our profession, to our patients, and to the public.

References

1. Directory of Graduate Medical Education Programs, 1992-1993. Chicago: American Medical Association, 1992.
2. Improving Efficiency While Maintaining Emphasis on Continuity of Care. Proceedings of a Conference on Surgical Resident Education. Chicago: American College of Surgeons, 1989. Comments of Frank C. Spencer, MD, FACS, p. 9.
3. Position paper on Resident Working Environment. Philadelphia: American Board of Surgery, 1992.
4. Improving Efficiency While Maintaining Emphasis on Continuity of Care. Proceedings of a Conference on Surgical Resident Education. Chicago: American College of Surgeons, 1989. Comments of Paul A. Ebert, MD, FACS, p. 3.

Reprinted from Bulletin of the American College of Surgeons
Vol. 79, No. 1, Pages 89-93, January 1994