Introduction

Undoubtedly, the residency program is the greatest progress in medical education throughout the history of medicine and is even more relevant in case of those specialties requiring manual skills, as general surgery. During the opening of the Congreso Argentino de Cirugía in 1960, Professor Dr. Mario M. J. Brea offered a vision for the future. In his speech, Dr. Brea presented a review of the literature and his own experience with the creation of the first residency program in surgery in Argentina at the Hospital Durand, which was later transferred to the Hospital de Clínicas. The first residents were Oscar Rocatagliata, Florentino Sanguinetti, Mario Capurro and Jorge Albertal¹. He also stated that the residency system was necessary in the absence of an organized system for training surgeons not depending on the good will of the masters. Looking at reality 60 years later, one can appreciate that Dr. Brea’s wishes were fulfilled. In the speech, he defined the residency system as “a system of progressive training with a pre-established program, promotions, and the allocation of more responsibilities, until reaching those corresponding to certified surgeons...requiring close direction, guidance, and supervision...”². This definition is still valid. The aim of this review is to try to outline the situation of the medical residency system in 2020, with special focus on the training of surgeons in the United States.

Brief history

The residency programs emerged as the natural evolution of the apprenticeship method. This old training system was used for almost 1000 years, lasted 5 to 7 years and could start around the age of 12 or 13 (considering life expectancy in those years)³. Historically, apprenticeship depended upon the good will of the master and the motivation of the disciple; only in the sixteenth century, in Edinburgh, the master was obliged to instruct and had the obligation not to transfer his prentice to another master. This system lacked a specific training program and was based on the master’s experiences.

By the end of the 19th century and the beginning of the 20th century, a new model of learning emerged that would transform Medical Education: the residency system. The system was proposed by Dr. William Osler in 1890 at the Johns Hopkins Hospital in Baltimore. His intention was that the students would have contact with the patients and participate in the rounds along with the Master Surgeons. At the same time, Dr. William Halsted⁴ was appointed Chief of Surgery at the Johns Hopkins Hospital and, after visiting Europe, he soon became involved with the system that was emerging. In this way, he integrated the training system of German surgeons with incorporation of basic sciences into the training curriculum of Osler’s system and developed his own principles for training surgeons:

▪▪Repetitive tasks

▪▪Direct supervision

▪▪Full knowledge of clinical surgery

▪▪Increasing complexity until achieving independence⁵.

It has been 120 years since Osler and Halsted made their statements; however, they are still valid and are still practiced, although, as one might expect, the context is constantly changing the implementation.

Selection process

In the United States, residents are selected once a year through a system coordinated by the Association of American Medical Colleges (AAMC) through a platform called ERAS® (Electronic Residency Application Service). Every year, third- and fourth-year medical school students begin searching for potential positions to which they want to apply. Once the information is submitted to the ERAS application, the candidates must upload their curriculum vitae, letters of recommendation, personal statement, medical student performance evaluation, and select the preferred institutions to apply for residency. Then, the matching process between the applicants and the institutions begins. The interview provides both actors in the process with an approach to each other’s needs, i.e. whether the institution meets the expectations and the training project of the future resident, and whether the candidate meets the profile of the resident needed by the institution. Once these steps have been completed, the final results are published and the positions are allocated. In 2019, 2563 applicants submitted program choices for 1432 categorical positions with five years of training in 304 programs; that is, availability of positions for 55.9% of the candidates⁶.

Residency functioning

The Accreditation Council for Graduate Medical Education (ACGME) is the body responsible for accrediting all graduate medical training programs including the residency program in general surgery. The educational program in surgery must be five years in length: the first year of the program is the internship and all PGY-5 residents are chief residents. Once the training program has been completed, the specialty is certified by the American Board of Surgery (ABS).

Since 2003, a regulation by the ACGME determined that work hours must be limited to no more than 80 hours per week. In 2011, this limitation became stricter by establishing time off between shifts, maximum shift lengths and the maximum number of shifts per week⁷. These requirements raised a number of concerns, mainly that residents’ education would suffer; yet, this was not demonstrated by most studies.

Nowadays, the 80-hour workweek should not be further discussed, but the restrictions added later are still a matter of debate. In 2016, The New England Journal of Medicine published the first prospective randomized trial comparing the restrictions implemented in 2011 with a cohort assigned to more flexible policies on time off between shifts (but respecting the requirements of limiting work to 80 hours per week). The study demonstrated that flexible, less-restrictive duty-hour policies for surgical residents were associated with similar patient outcomes and no significant difference in residents’ satisfaction with overall well-being and education quality⁸.

Another tool that was implemented to comply with the 80 hours was the night float that replaces the residents who perform day shifts so that they can go to rest. This rotation eliminates the 24-hour shifts in many cases, especially during the first years when work demands even more time⁷. This modality requires careful planning so as not to interfere with residents’ training. Night float rotations must not exceed two months in duration, four months of night float per PGY level, 15 months for the entire program and one day-off-in-seven requirements.

The ACGME defines the minimum numbers of procedures to certify the specialty (Table 1). In this sense, residents are committed to keep a detailed record of the procedures they perform every day through an online platform using a personal password. This record is supervised by the Residency Program Director. This is an important step because it shows the real number of procedures in which residents participated.

Table 1 Minimum number of surgeries according to the ACGME in 2018¹⁵ 

Research is an activity that is frequently encouraged, especially in institutions with a strong academic background. The publication of articles in indexed journals not only improves the curriculum, but also opens possibilities to apply for fellowships and better paid positions in more prestigious institutions. According to the ACGME requirements, no more than six months total may be allocated to research during the residency program according to the ACGME requirements.

The evaluation of residents’ performance is an important aspect of the program. In 1999, the ACGME and the ABS defined the 6 core competencies of resident education:

▪▪Medical knowledge

▪▪Patient care

▪▪Interpersonal and communication skills

Table 2 General description of the milestones levels¹⁶  

The American Board of Surgeons evaluates residents once a year with an examination called ABSITE (American Board of Surgeons In-Training Examination). The ABSITE is taken by all the residents of the country and the results are shown using the normal distribution of the examinees.

Since the evaluation system is integrated throughout the country, the need for creating an organization to implement a standardized, national curriculum was suggested in 2002. This recommendation resulted in the development of the Surgical Council on Resident Education (SCORE), an organization made up of the ABS, the American College of Surgeons, the American Surgical Association, the Association of Program Directors in Surgery, the Association for Surgical Education, the Residence Review Committee for Surgery of the ACGME and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). SCORE provides residents with all the necessary information (books, videos, classes and presentations) for their permanent training and updating⁹.

After completing the Milestones, the ABSITE and the ABS examinations, a surgeon is qualified to practice surgery in the United States.

Fellowships

Fellowship is advanced graduate medical education beyond a core residency program for physicians who desire to enter more specialized practice. Fellowships can last between 1 and 3 years and may include research. Completing this subspecialty prolongs the duration of training and also poses a challenge in many cases in terms of competition with residents when tasks overlap (Table 3).

Table 3 Supply and demand of fellowships in 2019 in the United States¹⁷ 

Quality

All the progress made in surgeon’s training over the last century is mainly aimed at improving surgical education and generating a final product that is better qualified to perform procedures that are increasingly complex and more dependent on technology. The Instituto de Medicina (now called Academia Nacional de Medicina) defined the six elements that constitute quality in medicine:

▪▪Safety

▪▪Efficacy

▪▪Efficiency

▪▪Opportunity

▪▪Equitable

▪▪Patient-centered¹⁰.

These six elements are intended to increase the quality of care, focusing on the reduction of medical error (through simulation and teamwork), increasing efficacy (using the methods that have proved to achieve the best results) and increasing efficiency (obtaining the best results with the least resources). Care should be timely delivered, patient-centered and accessible to all. This is not always achieved, but there are teams working on optimizing every aspect¹¹.

TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) is a teamwork system developed by the Government of the United States and subsequently transferred to the Agency for Healthcare Research and Quality. This nationwide course is intended to establish communication strategies to reduce medical error, which is mainly caused by poor or lack of communication. The target audience includes all actors in the health system, from medical and health sciences students to doctors, paramedics and administrative staff. The course provides tools for effective communication (many of which are used in aeronautic environments) with the use of simulation¹².

Simulation

Simulation has been used for several years under different names (experimental surgery, hands-on courses, etc.). However, there has been an exponential increase in the development of simulation courses, always focusing on the six elements of quality of care defined in the previous section. Simulation provides the opportunity to learn surgical, clinical and communication skills (also known as non-technical skills [NTS])¹³.

Simulation allows residents for repeated practice on models with the highest level of fidelity and realism in a protected environment, under direct supervision and with feedback at the end of the activity. The models currently available cover basic manual skills exercises such as the FLS® (Fundamentals of Laparoscopic Surgery), low and high fidelity mannequins (Figure 1), and the use of animals and cadavers. Other tools include digital simulation developed through simulation modules or integrated into a system such as the da Vinci® system. These tools can provide medical students and residents with the opportunity to acquire skills and become familiar with the procedures and instruments in an environment outside the operating room where teaching was associated with risk for the patient¹⁴. Simulation should be emphasized for basic procedures such as knot tying and suturing, fundamentals of laparoscopic surgery, hand-eye coordination, prevalent surgeries (hernia repair, cholecystectomies, and tracheotomies, among others), and less prevalent procedures which every surgeon should learn (cricothyroidotomy).

Figure 1 Laparotomy model of the Advanced Modular Manikin™ project for training in trauma surgery is a Department of Defense funded pro ject, driven by the University of Washington Medicine Center for Re search in Education and Simulation Technologies (CREST). 

Adequate simulation methods should be used under appropriate supervision. An optimal simulator should be:

▪▪accesible

▪▪affordable

▪▪realistic

▪▪reusable

With these requirements, simulators could be available in all the residency programs and the competencies acquired would be transmitted to the patient in the operating room (or in the doctor’s office in the case of NTS), minimizing the risk for the patient. Probably, the final simulation model will be virtual reality, a field that is currently under development and that will greatly benefit surgery. With simulation, the “see one, do one, teach one” concept is rethought and contrasted with the “see one, simulate one (or many), do one, teach one” concept.

Training of surgical residents is a dynamic phenomenon that is constantly being reinvented and evolving. All actors are responsible for ensuring the continuity of this system, always looking for constant improvement in quality to ensure the greatest safety in patient care.