The transition from undergraduate to graduate surgical education creates challenges for learners and educators. High among these challenges is ensuring entering surgical residents have the necessary skills and knowledge to effectively function in their new roles. Standardizing this transition may also aid with ensuring that the level of supervision provided to trainees is appropriate. Beginning in 2009, to address this opportunity, the American College of Surgeons (ACS), Association of Program Directors in Surgery (APDS), and Association for Surgical Education (ASE) collaborated to create a pilot curriculum for a residency preparatory course—the ACS/APDS/ASE Resident Prep Curriculum. These types of courses have been shown to improve the confidence, knowledge, and skills of entering residents.1–10 In 2014, the American Board of Surgery (ABS), ACS, ASE, and APDS issued a joint white paper stating that “requiring all matriculants of surgery residencies to successfully complete a multidimensional preparatory course before residency should accelerate the speed at which trainees acquire basic clinical and technical skills and reduce variability in these skill sets among entering residents.”11 Although recommended by the ABS, ACS, ASE, and APDS, there is currently no mandate for students to complete such a course.
As with many innovations, necessity bred creativity. Even prior to the establishment of the joint effort, many institutions had developed innovative content to meet the needs of their graduating students. Unfortunately, none of these efforts were standardized, quality was not ensured, and transferable assessments were generally unavailable. Recognizing the opportunity to coordinate and standardize content, the newly formed committee, led by Dr. Rebecca Minter, solicited content experts from all three organizations to pursue the initial task of establishing a comprehensive curriculum with complete goals and objectives. Seventy-four institutions have utilized the program (see Appendix A below). Further efforts focused on identifying and cataloging the broad subject matter that a graduating fourth-year medical student entering a surgical residency should know to optimize their transition to residency.8 One of the primary intentions of this group was to provide a standardized format and digital curriculum-building tool, which course directors could select from based on the goals of their specific program. Importantly, the curriculum was designed to be:
- Modular—different institutions could utilize only those modules that they wanted to deliver
- Standardized—students taking the same modules at different institutions would achieve the same competencies
- Evaluable—assessments of said competencies, supported by validity evidence, would be utilized
- Certificate-generating—successful completion of a module or subject would be accompanied by documentation that could be transferred with a student and kept in a longitudinal file or portfolio
After establishing the comprehensive set of goals and objectives, the committee set out to collate and review available content. Peer review was performed for every submitted module and assessments were analyzed for validity evidence. In content without appropriate assessments (either absent or not of adequate reliability), assessments were generated by a dedicated and trained team of committee members. This effort is designed to provide residency program directors with robust information about the strengths and areas in need for improvement of their incoming residency classes. Coupled with the ACS Entering Resident Readiness Assessment (ERRA) and other assessments, an increasing array of products provided through the ACS are becoming available to program directors.12 These tools will ultimately provide residency programs the information needed to tailor individual or whole-class educational content to ensure that new trainees have appropriate autonomy and supervision while also rapidly moving up the learning curve. This could also provide opportunities for program directors to capitalize on the strengths of some incoming residents by aligning their early rotation schedules with areas of advanced skill.
With further refinement of the content and assessments within prep course curricula, it would be reasonable for some of the current Accreditation Council for Graduate Medical Education (ACGME) requirements for early residents to be addressed prior to beginning residency. In particular, the ACGME provides recommendations for patient care and procedural skills that interns must be directly supervised until competency has been demonstrated.13 At present, attaining these skills and performing competency assessments occur in the context of many other new responsibilities at the beginning of residency. Applying a mastery learning framework and assessment of competency for these items in residency prep courses would allow trainees to attain these new skills in a lower-stakes and less time-pressured environment. It would also free up the resources allocated to the supervision of new residents for these skills to other patient-focused tasks. Furthermore, as novel educational models are evaluated, such as longitudinal assessments or EPAs, introducing appropriate components in medical school is appealing, especially when transferable assessments are available.
Resident prep courses are often viewed as one of the most enjoyable parts of medical school for those pursuing surgical residencies. In part, this is due to the focus on content of clear relevance to their future training and career. The strength of these programs is also likely because of the courses’ local design and implementation. Each institution understands the specific needs of its students and available resources. Content is designed to optimize their alignment. If broader application of prep courses is to be considered, standardized core content must be identified. Without core content, there is potential for excessive variability in content and assessment in these areas most important to the delivery of safe patient care. As an example, the ACGME recommends direct supervision for the management of hypertension until competency is demonstrated. It seems reasonable that an appropriately structured training and assessment could be created to determine competency in a prep course. However, in order for program directors to feel comfortable accepting this determination from a medical school, they should insist that some minimum standard is met in making this determination. With these considerations in mind, the content of the ACS/APDS/ASE Prep Curriculum is designed as a modular tool. Site directors can choose the modules that they can both administer and afford as well as those that fill gaps or complete their local goals. At present, efforts are under way to identify a core set of modules that program directors would expect from all trainees entering their programs. The core content would not need to detract from the inclusion of other modules based on local interest and resources. It would be expected that the core would be a small kernel of a larger course built from or augmented with modules from the ACS/APDS/ASE Prep Curriculum Builder. This core would need to be of reasonable scope and resource utilization to ensure broad implementation without undue strain.
Despite the benefits, it is appropriate to consider that some medical schools may not have the resources available to support a prep curriculum. This would be problematic if universal participation were required. With the large number of institutions already participating across a wide geographic distribution, however, a system of course regionalization could be envisioned as was described in the ABS, ACS, ASE, and APDS white paper on this topic.11 Regionalization could even take advantage of the well-established ACS network of Accredited Educational Institutes in the future, allowing students to enroll in the core modules at facilities that are established, financially viable, and have some process of quality assurance. This could similarly address the needs of international graduates starting in U.S. surgical residency programs. The cost of these courses varies based on the selected content. Many programs include sessions utilizing cadavers that substantially increases the cost. Others, however, use only available materials and have designed excellent courses at minimal expense. The modular nature of the ACS/APDS/ASE Resident Prep Curriculum builder allows institutions to select the elements they wish to include and that match their available financial and other resources.
It is important to note that the courses described in this article are very different from the programs offered at the beginning of many surgery residencies for new interns. Those courses, often called “intern bootcamps,” are individualized to the residency programs and are frequently focused on knowledge and skills specific to their institution, such as the electronic health record, structure of services, and culture of the program. These two types of training experiences complement each other in that the ACS/APDS/ASE Resident Prep Curriculum, offered to medical students, provides the foundation of cognitive, interpersonal, and technical abilities that can then be further developed through an intern bootcamp offered to new residents.
Residency prep courses have developed nationally into robust programs that meaningfully impact new surgical trainees and their residency programs. The ACS/APDS/ASE Resident Prep Curriculum provides a standardized, modular format that stands to significantly improve the value of these programs nationally. Future work in identifying core content and assessments with strong evidence for validity may mitigate some variability in the knowledge and skills of entering surgical residents. The end result stands to improve the quality of surgical care delivered by the newest doctors in our specialty.
