The anticipated product of a general surgery residency program has evolved as the complexity within the American healthcare system increases and demands on the academic surgeon have expanded. The public expects graduating surgical residents to be competent clinicians, able to navigate ailments necessitating operative (or non-operative) intervention from presentation to long-term follow up. The benchmarks for graduating surgical residents from the Accreditation Council for Graduate Medical Education (ACGME) and the Surgery Residency Review Committee have evolved alongside resident education. The ACGME began in 1999 by defining six initial core competencies, which in 2013 became general surgery resident milestones to address the nebulous nature of the initial core competencies.1 Now, attempting to address meaningful and measurable clinical activities, the American Board of Surgery is defining specific entrustable professional activities (EPAs) which assess graded proficiency of ability. EPAs are a more tangible method of evaluating competence in the clinical setting, by distilling elements of core competencies to reproducible, observable tasks. For example, an EPA linked to the core competency of interpersonal skills and communication could be a demonstration of signing out a patient.2,3 A qualified observer (for example, senior resident or attending) can have a junior resident demonstrate this activity in multiple observed instances, while evaluating the level of supervision necessary for the trainee and providing constructive feedback so that the trainee continues to improve with this EPA. The EPA could be defined as, “Provide appropriate handoff of patient care to other healthcare providers.” These EPAs together help form an improved holistic view of trainee competence and can more consistently track progress of trainees as they become more independent in their training.
While EPAs will more completely identify tasks necessary for the clinical evaluation of residents, surgeons continue to take on increasing responsibility outside of the clinic, and many of these burdens can become a significant challenge in the early years of attending practice. This is particularly notable in academic surgery, where the demands on a physician’s time often go beyond the operating room. Residency programs must produce surgeons who can safely, effectively, and equitably care for patients. However academic surgeons are also expected to be competent beyond clinical work, through scholarly pursuits and increasing administrative responsibility. The role of a residency program in developing and nurturing these scholarship skills is nebulous and inconsistent, despite the immense importance that the ACGME has focused on defining clinical competency in recent years. The onus of learning these extra-clinical skills often falls on the individual trainee or early-career attending surgeon and will likely differ for surgeons who pursue work in a community or hybrid academic setting. This article aims to discuss these gaps and assist with future residency training tracks in these areas as well as creating categories for these academic surgical EPAs. We attempted to use the previously validated and utilized frameworks for resident assessment, including ACGME milestones and core competencies, to ground our proposed EPAs in salient evaluation frameworks. We created these EPAs under the premise that expertise in the practice of medicine goes beyond the clinic and the operating room and includes the wellness of one’s own professional community as well as the advancement of medical knowledge and practice.
Scholarship and Productivity
What is the responsibility of the residency program in fostering scholarly activity in the era of EPAs? Graduates pursuing a career in academic surgery are expected to collect and interpret information which leads to improvement of the healthcare system. They also must write thoughtfully and precisely, communicating significant findings in a complete manner. Most residency programs do not formally teach the pursuit of novel and innovative knowledge despite its significant role in academic surgery. Residents may acquire these skills in various phases of training but importantly are expected to be thoughtful and productive while driving research projects that advance their fields of interest or expertise as attending surgeons.
Programs may incorporate varying degrees of scholarship in residency, from a few weeks to multiple years of dedicated research time. Implementing this opportunity as a strongly encouraged component of residency training may prove useful in satisfying this skill requirement for graduating residents. Use of this time is varied, but can include research into the basic sciences, education, health services, and clinical translational work or the pursuit of additional degrees. This time has been shown to increase scholarship and publication over the course of a surgeon’s career.4 However, effective mentorship continues to be the key to consistently produce effective academic surgeons. Residency programs should be encouraged to develop effective programs, such as matching residents with research mentors in their fields of interests while teaching study design, scientific writing, and multi-disciplinary collaboration throughout training. This culture of lifelong learning for improvement should be nurtured by residency programs through promotion of academic opportunities, collaborative culture, and appropriate levels of intellectual autonomy. EPAs assessing scholarship and academic productivity, although not necessary for every graduate of a surgery residency, would be important to incorporate as a method to better prepare trainees for success in academic surgery. The current ACGME “Core Competencies” could guide the proposed scholarship and productivity EPAs as illustrated in Table 1. As an example, the proposed EPA “Prepare a Manuscript for Publication” in Table 1 requires an understanding of academic literature and current systems’ based practice in the creation of a compelling body of work that improves or informs current clinical or educational practice. We feel that grouping these proposed EPAs under ACGME core competencies helps to bridge the transition to EPA-based assessment and evaluation from current practice.
Administrative
Residency graduates are assigned a significant deal of administrative responsibility as they advance through their careers. Administrative tasks include maintaining certifications/licensure, responding to emails in a timely manner, hospital or departmental leadership, balancing costs versus revenue, and accurate clinical documentation. Surgeons must also advocate, serve, and represent surgical interests on hospital committees. Expertise in these areas can be acquired in degrees outside of residency training, such as pursuit of a master’s in business administration (MBA), or a master’s in public health (MPH), among others. However, it is unrealistic to expect most residency programs to pay for advanced degrees as these skills could be developed by the programs themselves. One example of formal training in administrative responsibility is the role of the administrative chief resident. In this role, surgical trainees learn to manage scheduling rosters, perform conflict resolution, and implement changes in program policy. Often this process is challenging and unstructured5, perhaps analogous to the administrative challenges experienced by new attending surgeons. Additionally, not all trainees get the opportunity to be administrative chief residents. Abbreviated courses in cost-effective practice, leadership, accounting, and finance could support resident interests and prepare them for these demands. Whether as part of one’s role as a chief resident or in another setting, structured administrative training would facilitate academic surgeons’ preparation for a successful career. In the era of EPA-based assessment, administrative EPAs could become useful for residency programs to incorporate in their assessment of graduates as proposed in Table 1.
