The second Blue Ribbon Committee on Surgical Education (BRC II) announced its recommendations for optimizing the future of surgical education at the recent American Surgical Association (ASA) Annual Meeting in Washington, DC.
The inaugural Blue Ribbon Committee on Surgical Education (BRC I) published a groundbreaking report on surgical education1 in the Annals of Surgery in early 2005. That committee, led by the ASA in partnership with the ACS, American Board of Surgery (ABS), and Resident Review Committee-Surgery (RRC-S), assembled in response to projected shortages in surgeons. It held discussions from June 2002 to mid-2004. The group ultimately made 40 recommendations for changes at every level of surgical education.
Twenty years on, much has changed, from national demographics to the rise of artificial intelligence. Facing a new era, the BRC II—after again assembling surgeons from across the field of surgery as well as the ASA, ACS, ABS, RRC-S, and other organizations—is taking the opportunity to ask: How can surgery as a profession best educate the next generation of surgeons?
Why Now?
Steven C. Stain, MD, FACS, who is now the immediate past president of the ASA and a member of the ACS Board of Regents, said the impetus for the BRC II arose at a lecture by Richard K. Reznick, MD, FRCSC, FACS, a colorectal surgeon and past president of the Royal College of Physicians and Surgeons of Canada (RCPSC) at an ABS-sponsored summit on competency-based education. Dr. Stain spoke in rebuttal to a public presentation by Dr. Reznick on entrustable professional activities (EPAs) and competency-based education, which the RCPSC has championed in Canadian surgical training. Dr. Stain advised caution in implementing these new approaches in the US.
In response, John D. Mellinger, MD, FACS, vice president of the ABS, requested that Dr. Stain initiate a second BRC to examine advancements in surgical education more closely. Dr. Stain agreed—on the condition that E. Christopher Ellison, MD, FACS, who was then ACS President, become involved: “He will be the one who will make sure we get it done.”
Dr. Ellison embraced the idea, feeling motivated to address growing work demands, new technology, concerns about insufficient operative readiness in new practicing surgeons, and myriad other issues. “There have been dramatic changes in how we take care of patients. It’s become more and more complex to be a surgeon,” he said.
A Careful Process
The BRC II used a careful process to generate its new set of recommendations. After gathering 67 surgeon members representing general surgery and its related specialties, the group created nine subcommittees. One included all members of the BRC I (which included neither Dr. Stain nor Dr. Ellison). The other eight subcommittees were tasked with discussing one aspect of surgical education as originally outlined by the BRC I and generating current recommendations for its optimization. The proposals of the entire group were then compiled and sorted, and the list was subjected to a Delphi analysis.
The Delphi method, first developed in the 1950s,2 is based on a series of rounds in which a panel of experts shares perspectives on a topic, receives an aggregated summary of the full group’s views after each round, and is given the chance to revise answers in light of these insights. After a few rounds, views often converge; when a predesignated stopping point is reached, the group finalizes a decision.
In the case of the BRC II, three rounds of discussion were held, and each ended with a vote. Only the recommendations with more than 80% approval (in other words, a “yes” from at least 54 members) were considered acceptable to include in the final report. In the first round, which generated 23 recommendations, members also voted on the impact and feasibility of all items on a 5-point Likert scale. Unapproved items were submitted to two more rounds of discussion and voting. Each resulted in four more recommendations.
Given the broad scope of surgical training and logistical considerations, the BRC II found it infeasible to include all surgical disciplines as part of this project. Recognizing that the committee was focused on general surgical specialties and contained few surgical residents, the BRC II also sought to share the report with surgeons in all disciplines. Dr. Ellison explained, “We had a separate meeting with representatives of all the surgical specialties for a 2-hour review of the recommendations. The purpose of this was to share our findings, as many of the recommendations may be applicable to their training programs, and get their feedback.”
Ellison says they gleaned meaningful insights from the session, including that a high level of interest from the surgical specialties and a need for further engagement exist.
In addition, he noted, “We had a focus group with 16 residents as a separate meeting and provided them with the recommendations, and they actually did the Delphi assessment at a separate time from the panel,” generating recommendations that differed slightly from the main BRC II and that, per Dr. Ellison, will be the topic of a manuscript submitted for publication.
What Does the New Report State?
Through these processes, the committee reduced an initial 50 recommendations to 31. They are far-reaching by design, ranging from diversity to finance.
To enhance medical student education in surgery, the BRC II recommended providing better support programmatically and financially, to the faculty and residents engaged in teaching medical students. The group also suggested convening multiple organizations to optimize the residency selection process, so that it evaluates leadership, decision-making, ethical, and technical skills via standardized assessments.
To enhance work-life integration and wellness, the BRC II suggested a mixed qualitative and quantitative approach: on the one hand, advising the creation of best practice recommendations for a surgical “culture of belonging,” and on the other, suggesting a multidisciplinary group of national organizations be convened to assess how to equitably and sustainably improve resident wages, particularly by considering the return on investment for surgical training.
Other subcommittees also focused on finance. The faculty development portion of the recommendations noted a need to examine the economic value of surgical trainees to negotiate hospital payment for their work, as well as ways to pay surgeons for their efforts educating medical students and surgical trainees. The financing section proposed efforts to address caps on surgical residencies and determine how to best pay for resident education.
Elsewhere, resident education recommendations include expanding mentorship during residents’ transition from training into independent practice, while further faculty development suggestions describe a need for a national curriculum for faculty training and an assessment tool for faculty teaching performance.
The recommendations also address the original impetus behind the BRC II: EPAs and competency-based education. The BRC II proposes both, including EPAs to be included in the proposed national faculty training curriculum and promulgating national guidelines for comprehensive, competency-based reforms, as well as a national research consortium that will critically review the effectiveness of such reforms.
Finally, the BRC II report contains meaningful suggestions for “people who really want to become surgeon-scientists,” Dr. Stain noted.
“Typically, you do 2 years of research in the middle of your residency, then do your fellowship—and by that time, it’s 5 years later and your research is probably not up to date enough to get you funded,” he explained. “We’re suggesting a paradigm where people can do a continuum of their research and fellowship in the same span.”
Although this raises questions on resources and funding, he acknowledged, “It’s the way it’s been more successful in getting a funded research scientist, so there are some tracks that we recommended for that.”
