There are some common misconceptions that the only way to focus training is through a formal Early Specialization Program (ESP), or being involved in a specific cohort employing Flexibility in Surgical Training (FIST). These programs have been innovative and impactful, with studies demonstrating that trainees participating in such programs—even when training is shortened—still pass the surgery qualifying exam (QE) and certifying exam (CE) at similar rates to those in traditional training models.3 How can one apply the lessons learned from these training scenarios even without making special allowances or using such structures?
We would argue that even without lengthening training, a program director can employ allowances already in existence by the ACGME and ABS to create educationally stronger training within their own program to allow trainees to be better trained for their chosen specialties. We will refer to this as “focused training” in the remainder of the manuscript.
The idea of focused training is not a new concept—one can follow a logical progression in national addresses and current literature for as long as surgical education has been considered. In 1940, the acclaimed surgeon E.D. Churchill described a “frozen five-year curriculum” as “unthinkable as it allows no latitude.”4 There have been many iterations of this throughout the years by some of the most prominent surgeons of each era. In 2004, the American Surgical Association (ASA) Blue Ribbon Committee published the results of a two-year study on the topic of surgical training in which they suggested that surgical residencies be restructured to ensure a “common grounding” in basic principles, acceptance that most surgeons will confine their scope, and “earlier differentiation into goal-oriented specialty tracks.”5
In studying the effect of specialization on general surgery residents, Stain et al. published a manuscript in 2010 demonstrating that allowing for flexibility in rotation assignments actually helped those planning to specialize in general surgery to have more exposure to general surgery cases, and thus anticipated better preparation for practice.6 Probably the most recent recognition of focused training is the recent approval by the American Board of Medical Specialties (ABMS) of the establishment of a new Focused Practice designation, currently established in one field and being piloted in another, recognizing “areas of specific expertise… continuing certification efforts in the very area on which much of their professional practice is based.”7 We believe that all the tools for focused educational curricula, to both adequately prepare general surgeons and prepare specialty surgeons, are already present.
In order to succinctly summarize the requirements of both the ACGME and ABS, please see the following table compiled from the ACGME Surgery Program Requirements and ABS General Surgery Training Requirements8,9:
With these regulations in mind, one can see that even without a specific application to the Residency Review Committee (RRC) or to the ABS, a program director can effectively tailor rotations to an individual resident, as long as the distribution of rotations takes into account both ACGME and ABS requirements. If one wants to increase flexibility further (or increase specialized focus to greater than four months in the chief year), one could also petition the RRC for the allowance that PGY-4 rotations be designated chief rotations (if the rotations meet specific requirements), thus allowing additional flexibility or repetition, as well as potential added autonomy in the final year of residency. If further flexibility or concentration within one area is desired, the program director should file a separate request to the RRC and to the ABS.
The following is an example of two chief residents in one of the authors’ institutions. The first is entering a surgical oncology fellowship. The second is entering a cardiac surgery fellowship. Both must have a general surgery “check off” in their final chief year where they can demonstrate competence. Their rotations in the final year are as follows (of note, both had trauma rotations in the PGY-4 year designated chief rotations, allowing for two months in the final year to be elective):
One can see in this example that the rotations are specifically chosen with the resident’s career and future patients in mind, and that rotations are strategically placed to create continuity and preparation that flows into the fellowship years. One can imagine a “melding” of the final year of residency seamlessly into fellowship, potentially setting the stage for future internally tracked fellowships.
Barriers to tailoring rotations are that the program and faculty must remain flexible themselves—as the complement of senior residents and their interests and fellowship matches change with each resident class. This means that from year to year, the program must reassess faculty complement, strength of rotations, potential experiences, and fellowship matches of the chief residents. The authors recommend yearly updates to the RRC and ABS as well as continual assessment via graduate surveys and outcome data of board pass rate and fellowship status within the program. However, if all of these are carefully considered, tailored rotations can help “fix the five,” addressing many of the issues of concern within residency training today—namely repetition, autonomy, and ensuring that all educational experiences are relevant to one’s future patients, optimally preparing their future surgeons.
