American Surgical Association

Presidential Forum

A Lifetime of Surgical Education: Can we do better?

Keith D. Lillemoe, MD 1

Mary E. Klingensmith, MD 2

Ara Darzi, MD 3

Spence M. Taylor, MD 4

1. Massachusetts General Hospital

Harvard Medical School

2. Washington University School of Medicine

St. Louis, Missouri

3. Institute of Global Health Innovation at the Imperial College

London, UK

4. University of South Carolina School of Medicine

Greenville, South Carolina

Correspondence:

Keith D. Lillemoe, MD

Massachusetts General Hospital

White 506

55 Fruit Street

Boston, Massachusetts 02114

klillemoe@mgh.harvard.edu

(P) 617-643-1010

(F) 617-726-7593

Surgical education , has traditionally focused on the surgical clerkship during medical school and general surgery residency. Over the last 20 years however, there has been a tremendous evolution in this very important mission of academic surgery. The most dramatic of these changes affecting resident training began with the implementation of residency work hour restrictions in 2003. Changes in assessment of competency of the surgical trainee, challenges in providing resident autonomy in the era of reporting surgical outcomes and rvu-based compensation, and the increased emphasis on fellowship training, including integrated training programs or early specialization, have dramatically affected the training of surgical residents.

Undergraduate medical education in surgery has been affected as medical schools have shortened the time spent on surgical rotations, while students are being asked to make decisions regarding choice of specialty earlier to consider new integrated specialty tracks. On a positive note, after selection of surgical specialty, many schools have an increased emphasis on preparation for residency training with “surgical boot camps”.

Maintenance of certification of trained specialists has added to the administrative burden of surgeons already at risk for burnout. Finally, questions as to how to introduce new technology, or to retrain or retool practicing surgeons, have yet to be answered. Thus, one can safely conclude that the changes in surgical education are now extending throughout the lifetime of a surgeon.

Despite these extensive changes and challenges existing at all levels, surgical education has only been the focus of the American Surgical Association (ASA) Presidential Forum twice over the last 20 years. In 20041 with a report with preceded the presentation of the ASA “Blue Ribbon” panel2 and in 2012 with a review of the issues in general surgery resident training in 2012 3.

It is the purpose of this panel to provide an overview of surgical education from medical school until the late stages of a surgeon’s practice. To lead the discussions, we have called on leading experts and innovators in surgical education from both the United States and the United Kingdom, as well as members of the leadership of the American Board of Surgery.

TRAINING IN SURGERY: IDENTIFYING, PREPARING, AND PROVIDING THE OPTIMAL EXPERIENCE FOR OUR RESIDENTS.

Mary E. Klingensmith, MD

When Medical Students Decide on Careers in Surgery

Several groups have studied how and when medical students decide on careers in surgery. In review of several recent studies it is clear that some factors are modifiable such that we can continue to attract the best and brightest to our specialty. In a longitudinal study of medical students seeking to determine both the factors associated with choosing a surgical career, as well as how those preferences might change over time, it was shown that having a research experience with a surgeon early in medical school as well as presence of an identifiable surgical mentor highly correlated with selection of surgery as career path.4 Further, a recent systematic review of studies addressing key factors influencing the decision to pursue surgical training found those of greatest importance were: mentorship, a positive experience on the surgery clerkship, the timing of exposure to surgery (wherein earlier than third year clerkship was important), stereotypes brought to the decision including preconceived negative connotations of surgeon personalities, and concerns about surgeon lifestyle.5 Beyond surgery, two recent studies are of note, as they can further inform us as to ways we can affect students and their career decisions. A recent systematic review of the world literature noted that personal factors (including personality, lifestyle desires, practice geography expectations, and income and work life expectations), and medical school characteristics (including nature of the curriculum and timing and substance of clinical exposure) were highly influential in determining students’ subsequent career path selection.6 Interestingly, a Problem Based Learning (PBL) curriculum, commonly implemented in medical schools that have undergone recent curriculum renewal, may anecdotally bias students away from surgical careers and toward primary care. In a recent review, three of eleven studies showed increase in primary care specialization in schools with PBL curricula.7

These studies all have implications for surgeons to exert influence on the career decisions of students. Where possible, surgeons should be part of the discussions involving the curriculum design of the medical school, and the length of clerkships for students (which has been declining over the past two decades). If such influence seems beyond the reach of a given surgeon, one can impact the quality of the surgical experience for students on clerkships by providing attentive teaching and mentorship; additionally, allowing for exposure of students to surgeons in the preclinical years, through proctoring and instructing in anatomy and other preclinical courses, being active in interest groups for students considering surgical careers, and sponsoring research activities for junior students can all have a positive impact on students’ interest in pursing surgical careers.

From those who express an interest in surgical careers, identifying the best and brightest who are likely to succeed in training and beyond is the next important question.

Several groups have studied the process of identifying outstanding medical student candidates for surgical careers. Applicant factors including USMLE scores, medical school grades, letters of recommendation, AOA status and a variety of other personal factors have been examined by a number of investigators.8-11Some recent studies have attempted to point out the flaws with the current, commonly used methods to select trainees. An ability to measure a candidate’s work ethic and passion for surgery was deemed critical in a Delphi consensus study of Canadian Program directors seeking to identify candidates who will develop into competent surgeons, yet a process for this is currently poorly understood.12 That same study noted that an ability, at the time of interview, to assess for technical abilities would be highly desirable to help determine those who might be best suited for surgical training. Including these elements would represent a change from current practice in most programs.

Gardner, et al, recently described a novel approach involving the use of simulation in the residency selection process.9 In this feasibility study, tasks were chosen and situations developed in which candidates would demonstrate their ability to learn a new task, problem solve, and work together as a team; basic technical skill stations (suturing, knot tying) were also incorporated. This framework was chosen as surgical educators frequently note that many of the qualities that they find most desirable in potential candidates, such as communication, teamwork, and professionalism are nontechnical competencies which are difficult to formally assess in the current selection process. Further, struggling trainees within programs often exhibit difficulties with nontechnical skills and professionalism, making them excellent targets for assessment prior to residency selection.13 Gardner and colleagues demonstrate feasibility in the use of simulation, especially in the arena of nontechnical skills assessment, and encourage further efforts in this area. 9

In a study presented at the American Surgical Association in 2010, Kelz et al described a novel selection process, which resulted in decreased attrition from a single institution over the study period.8 The selection process key factors included a standardized format for review of applications, a required applicant structured essay which described stress management and organizational skills, and use of a personalized and structured interview script. To date, this novel approach has not been widely adopted or replicated. However, the concept of a structured interview was studied recently by Kim, et al.10 The authors note that from business and industry, blinded interviews and standardized questions represent a “best practice” and improve interview utility and accuracy. However, the authors found that only 20% of programs use blinded interviews, and only 5% use standardized questions suggesting significant room for improvement in this regard.

Boot Camps in Surgery: Current Status

Once candidates identify themselves as interested in surgery and have successfully matched in a surgical program, it is important to ensure that they are optimally prepared for postgraduate training in surgery. The concept of senior medical student preparation courses (aka “Boot camps”) has gained traction in recent years, propelled in part by a study by Antonoff, et al in 2012 which showed that trainees from a single institution who experienced a competency based four-week preparatory course during the final months of medical school experienced objective gains in task-specific confidence and test performance at course conclusion, translating into improved performance and better patient care upon residency matriculation.14 In 2015, Minter, et al published results of a multi-institutional study of the impact of these prep courses and found that interns who participated in them had higher self-assessed ratings of surgical technical skills, professionalism, interpersonal communication skills, and overall preparation.15

In response to the growing recognition of the value of these courses, a consensus statement was published in November 2014 based on consensus of the American Board of Surgery (ABS), American College of Surgeons (ACS), Association of Program Directors in Surgery (APDS) and the Association for Surgical Education (ASE) to encourage and formally endorse Prep Courses.16 The primary tenets of the consensus statement are summarized in Table 1.

While several “home grown” versions of prep courses exist, the need for a shared, high quality resource became evident. As a result, the American College of Surgeons (ACS), in collaboration with the APDS and ASE has developed a robust modular preparatory curriculum intended to ensure that graduating students have the skills necessary to begin their roles as surgery residents. Administered by the ACS Division of Education, the goals of the prep course are summarized in Table 2.17

According to the ACS website, where the content is housed, “faculty can tailor the experience based on the unique needs of students and resources available at each school. The flexible, modular structure allows faculty to organize activities as a four-week experience, or in other ways that will suit the school’s schedule.” The ACS houses a “Prep Curriculum Builder Site”, intended to allow customization and delivery of the content to faculty and students. As of Spring 2017, 67 total medical schools have been part of a pilot program to utilize the Prep Curriculum over the pilot period of 2013-2017 (personal communication with Keith Delman, MD, April 4, 2017). Further study of the utility of these courses is warranted.

Current training pathways in surgery in the USA

The training of surgical residents in the United States is evolving, as more and more trainees are electing to pursue fellowship training with a de facto increase in the length of training. This shift has occurred concurrent to other forces impacting the training environment.3,18

The standard pathway to training is completion of a five-year “categorical” residency program, which leads to board eligibility in Surgery; currently, more than 80% of trainees move on from categorical training to fellowship training, of one to three years’ duration. However, since 2004, a number of additional options have become available: the Early Specialization Program (ESP) in vascular and cardiothoracic surgery which has been summarized elsewhere 19,20, the Flexible Training Pathway of the American Board of Surgery which began in 201121,22 (currently impacting 233 individuals over 29 programs) and integrated training programs in Plastic Surgery, Cardiac Surgery and Vascular Surgery.23-25 Based on the successes of the Flexible Training option, as well as equivalent to superior outcomes from the ESP programs, a recent pilot has been developed for an ESP-like option in Transplantation Surgery which is being undertaken at Washington University in Saint Louis in collaboration with the American Society of Transplant Surgeons (ASTS) (personal communication with William Chapman, MD, June 26, 2016). In addition, the American Board of Colorectal Surgery has been in discussions with the American Board of Surgery to implement an ESP-like program in Colorectal Surgery, with the possible added flexibility of trainees performing their fellowship-level experience at a residency separate from that where the General Surgery training took place (personal communication with Jo Buyske, MD Associate Executive Director of ABS, February 15, 2017). While these training options remain in pilot phase, if results similar to other options are realized, trainees will complete these training paradigms with equivalent board passage rates, improved mentorship and autonomy, high levels of satisfaction, and possibly in fewer years than traditional training requires. Further study of these expanded options is anticipated.

Competency Based Residency Redesign Efforts

In 2004, the American Surgical Association (ASA) convened a “Blue Ribbon Panel” to outline a rationale and structure for residency training reform.2 Central tenets to that proposal included a call for a unified curriculum, training to meet societal needs (workforce distribution to rural and urban environments), and flexibility in training (with an ability to differentiate earlier). This ASA-led call aided in the eventual formation of the Surgical Council for Resident Education (SCORE), which has resulted in a unified curriculum for training in surgery, now disseminated via a web-portal and in use in over 96% of residency programs in the United States.26

After the 2004 ASA Blue Ribbon panel, progress in residency reform had been relatively slow, but continued drivers for reform have persisted, including: recognition of an “uneven” product of training programs with too many trainees graduating with deficiencies27-29; recognition of gaps in training30; and, a general desire to improve educational and clinical outcomes. All of these have coalesced against a backdrop of the continued changes in resident duty hours in 2003 and 2011. Further, it was recognized that while trainees were generally experiencing more operative cases during residency, there was reduced breadth of exposure31. Residents continued to experience progressive responsibility during training, but with reduced autonomy, in part due to changes in public expectations and social values. Finally, several recent studies have indicated a lack of confidence among graduates and their mentors, in both procedural and leadership and practice competency,27,29,32 although this is not a universally held view.33,34

As a result, in January 2015, the American Board of Surgery made a unified commitment to move to Competency Based Education for restructuring residency training.35 In making this commitment, the ABS proposed working with all stakeholder groups, including the ACGME, RRC, ACS and APDS around several redesign elements which are summarized in Table 3.

As of January 2017, these stakeholder groups are working together in developing 5 EPAs for pilot in late 2017. Further, the ABS and RRC have implemented new case minimums for both junior and senior residents, including defined numbers intended to increase both overall experience and autonomy. Additionally, the ABS was one of several groups that funded the FIRST duty hour trial which resulted in recent modifications to the ACGME duty hours; these changes greater focus on a learner dependent rather than educator dependent environment.37,38 Finally, the ABS has helped to fund a study on the use of hand-held devices for assessment of operative skills and readiness for independent practice39, improving both faculty engagement and establishing feasibility of such a process. While there is consensus that redesign and reform residency training is needed, it will take continued collaborative efforts from all stakeholder groups to bring these changes to fruition.

ARE GRADUATING RESIDENTS PRACTICE-READY? CURRENT STATE OF THE ART OF ASSESSMENT AND FUTURE INNOVATIONS

Ara Darzi, MD

Learner assessment, to enable progression and ensure competency, is one of the major guiding principles of educational theory, and one that is central to modern surgical training. Ensuring graduates’ fitness to practice is an essential part of patient safety and care quality, but is important also to maintain accountability as well as public trust. The current system rests upon the presumption that having successfully completed prescribed exams and assessments, trainees have become competent surgeons and safe independent practitioners.

On the basis of this, clinical peers, policy-makers, and patients, are assured, residents graduate fully ready for safe and independent practice. And yet, despite the rigorous quality assurance systems in place for healthcare, medical error remains a too-common cause of mortality, with cited figures which place it behind only heart disease and cancer as the third most common cause of death in the United States.40

Health systems and trainees today face challenges as never before. Demographics and the changing burden and nature of disease have increased patient volumes while patient empowerment has acted to increased expectations. Surgical residents must train to use increasingly complex technologies and do so within reduced training hours, rendering many traditional apprenticeship-based assessment techniques invalid and making occupational burnout an increasing problem.

In order to meet these challenges, it may be necessary to adjust the bar for surgical performance. To be able to do so, we must first explore the means to appropriately measure it.

Current assessment methods

“Traditional” assessment tools such as multiple choice exams and standardized patient assessments, although reliable and well established, are heavily knowledge based. Within surgery, many assessments, focus too much on operative competency. They underemphasize many other domains important to professional competence, such as integration of knowledge and skills, context of care, information management, teamwork and leadership, and the patient-physician relationship. To ignore these other domains risks overemphasizing what is easy to measure, rather than important to measure, and fails to consider the holistic view of the clinician.

Acknowledging this, the development of the Six Core Competencies41 of 1) patient care, 2) medical knowledge, 3) practice-based learning and improvement, 4) interpersonal and communication skills, 5) professionalism, and 6) systems-based practice have marked a paradigm shift towards a more holistic definition of the desired qualities of a resident. However, defining the means by which to measure performance in these domains has proved more difficult. The ACGME Milestones program begins to redress this, with domain-specific rating scale assessments (i.e. interpersonal skills, practice-based learning, professionalism) linked to expected behaviors for each assessment level. Early data has shown great buy-in (with almost 100% data reporting) and apparent good correlation between skills assessments and trainee progression.42 However, more granular assessment of trainee skills remains the Holy Grail.

The adoption of the ACGME Milestones and other similar assessments recognizes the fact that clinician skill is dependent on more than just knowledge or technical ability, it is now universally accepted that decision-making, communication, and leadership play at least equally important roles in determining patient outcome.

Beyond the knife: Non-technical and team skills

The systems view of surgical performance holds that the factors that determine processes of patient care and, in turn, patient outcomes, are multifaceted (figure 1). Individual technical and non-technical skills must be considered in parallel with the teamwork and communication necessary to make multi-disciplinary care teams cohere, as well as the environmental context in which they function.

The evaluation of technical skills has over the past two decades matured into a well-established field with numerous well-evidenced specialty, procedure, and skill-specific assessment methods available.43-46 Gradually, the evidence base for non-technical skills has been increasing too.

Increasing team complexity, shift work, and reducing duty hours mean that stable and cohesive teams are becoming increasingly a thing of the past. The importance of non-technical performance has become increasingly clear, with non-technical errors lying at the root of the vast majority of medical errors, and identified as the leading sources of failure by Joint Commission sentinel event root cause analysis.47

Tools with high levels of validity evidence for non-technical skills assessment have been well described in peer-reviewed literature. The Observational Teamwork Assessment for Surgery (OTAS) was developed at Imperial College and first described by Undre et al in 2006.48 Content and construct validity evidence for OTAS have been described in multiple studies and across several specialties including urology, vascular, and general surgery. With the development of a train-the-trainers intervention for OTAS, a comprehensive framework for use of OTAS has been described.49 Other frameworks such as the Non-Technical Skills Score (NOTECHS)50 and Non-Technical Skills assessment in Surgery (NOTSS) have also been described.51 Common to all of these scales is the assessment of skills domains (i.e. communication, team working) matched to example behaviors graded on a scale of 1-5, producing a quantifiable marker of non-technical performance.

Beyond the OR: Peri-operative skills assessment

Surgical assessment has traditionally focused heavily on the OR environment, for obvious reasons. Increasingly, other environments are being pulled into the spotlight. Numerous studies have now described the concept of failure to rescue, wherein variation in risk-adjusted mortality rates may be attributed to the management of postoperative complications, rather than operative outcomes.52,53

The bedside visit, or ward round, has been central to patient care since the invention of medicine., despite this it remains one of the few processes of patient care not separately considered as a “skill” to be taught or assessed. The combination of talents required for an effective round – clinical knowledge, critical evaluation, decision-making, leadership, communication – are no less than those required for a successful operation. Recent work at Imperial has described not only variability which exists between rounds, but also the significant association between thorough or higher-quality rounds and the reduction of postoperative morbidity.54 The Surgical Ward Care Assessment Tool (SWAT) and Ward Non-Technical Skills (W-NOTECHS) assessment have been shown in both clinical and simulated environments to be valid frameworks for the quantification of ward round practice.55

No longer “soft skills”: Quantifying empathy and communication

Tools such as OTAS, SWAT, and W-NOTECHS have added to a growing armamentarium for trainers and trainees to draw upon in improving practice. It has also highlighted the fact that many of the Core Competencies, perhaps once dismissed as “soft skills” not conducive to quantifiable assessment, may indeed be measured. The American Psychology Association, in defining the framework for validity evidence of assessment tools, has stressed the importance of context.56 The more specific a rating tool is to a given process or skill, the more effective and relevant it can be. The Patient Physician Interaction Scale, for example, brings quantifiable metrics to what has historically been measured only by patients’ word of mouth.57 Here, bedside manner is summarized by a Likert scale anchored to exemplar domains, across the four domains of empathy, organization, verbal and non-verbal expression.

In contrast to the routine bedside manner lies the clinician’s reaction to crisis scenarios and the need to escalate care for unwell patients. The increasing complexity of hospital care has resulted in ever increasing opportunities for communication error and breakdowns in information transfer. Again, the development of tools to address this provides not only a further metric to quantify clinician performance, but also valuable granular analysis of a hitherto overlooked skill and a breakdown into its component parts. The Quality of Information Transfer (QUIT) tool considers the process of verbal sign-outs or handovers, and establishes different domains of performance with the aim of ensuring that each event results in a complete information transfer with required patient identifiers, problems, and treatment plan.58

From trainee to trainer: Complex decision-making and debriefing

With competency at an individual skill level established, more complex decision-making and diagnostic tools can be considered. Case vignettes have long been the staple of diagnostic knowledge testing and with the development of computerized case simulations, added layers of complexity can be introduced, assessing the subject’s decision making ability and accuracy on multiple levels.

Further still, the complex decision-making often required in cancer care has led to the establishment of multidisciplinary teams (MDTs) or tumor boards, where diagnostic and treatment decisions are made by multiple clinicians in consensus to optimize care. In practice, however, variability in patient presentation, and dominance or absence at MDTs by particular specialties or individuals, means that the decision-making of MDTs may be impaired or biased. Tools such as MDT-Metric for the Observation of Decision-making (MDT-MODe) allow not only for trainee evaluation when learning to work within MDTs, but also the assessment of working MDTs to improve patient care.59

Finally, the aim of all training is for trainees to acquire the skills necessary to ultimately become trainers in their own right. As with the above skills, the ability to teach and provide feedback forms is one of the ACGME training targets. One way in which this can be measured is through the Objective Structured Assessment of Debriefing (OSAD), developed by an international collaboration of UK, US, and Australian experts, which captures key elements of effective debriefing.60

Graduated responsibility and benchmarked assessment: the UK model

Entrustable Professional Activities have been used in the UK for over a decade now, with electronic assessments gathered in the form of Work-Based Assessments (WBAs). Using WBAs, the longer UK residency period of up to 10 years of postgraduate training is managed with graduated responsibility determined through pre-defined assessment metrics. The Intercollegiate Surgical Curriculum Programme sets out expected levels of trainee performance which range from Level 1 (able to assist a procedure) to Level 4 (able to perform procedure fluently without guidance or intervention), commensurate with the level of training, for over 65 named elective and emergency general surgical operations, and over 140 different pathologies. Each trainee is required to return a minimum of 80 annual assessments with the aim of ultimately demonstrating “level 4” performance (defined as ready for independent practice) across all domains by completion of training. Throughout residency, competency-based progression allows trainees who demonstrate level 4 competency signed off by multiple trainers, for a given procedure, to operate independently for anything from an elective hernia to an emergency laparotomy subject to the trainer’s judgment.

Additionally, regional programs s uch as the London Deanery Skills Program provide a structured training program for London-area trainees with monthly technical and non-technical training sessions based in simulated settings with assessments made using validated tools such as OSATS and fed back to institutional trainers. Excellent buy-in from both trainees and trainers has resulted in the London model being adopted in other regions across England.61

The future of training and assessment

With evolving demographics, technologies, and patient needs, the future of surgical training must also evolve to a system of proven assessment and credentialing to ensure that the next generation of surgeons are adapted to meet these needs.

Emerging technologies will allow the simplification and integration of assessment technologies into the modern training space. Already, clinical information is being transmitted via encrypted smart phone apps to improve communication amongst clinical teams.62 Institutions such as Imperial College have established partnerships with major data analytics companies including DeepMind to develop clinical apps which not only simplify task management, communication, and delegation for clinical teams, but can use data to feedback on workflow and efficiency.63 Distributed resources such as online virtual worlds can be used to simulate major incidents and train institutions’ disaster response teams for scenarios otherwise impractical or unfeasible to carry out in situ.64 Throughout all of these advances, the underlying technology also computes communication and performance scores and feeds this back to trainees during debriefing – such advances will continue to drive advances in training going forward.

Conclusion

The aim of surgical training is to create a modern, thinking surgeon, able to demonstrate their ability to transition to practice in the challenging climate of today’s healthcare systems. It is uncertain, even unlikely, that current training benchmarks are sufficient to meet the needs of the modern independent surgeon. Innovations in assessment must be embraced, and advances in technology adopted, to ensure that the future continues to see graduating residents able to provide the highest standards of care, and achieve the best outcomes, for their patients.

MAINTENANCE OF CERTIFICATION: THE REALITY OF SUSTAINING COMPETENCY (THE FOUNDATION, THE FUSS, AND FIX)

Spence M. Taylor, MD

This is a question of much recent debate. Contemplate the following: in 1950 it took 50 years to double medical knowledge; in 1980, it took 7 years; in 2010, it took 3.5 years and 2020 the projection is that it will take 73 days. Approximately 7,300 new clinical articles with pertinent information are published monthly requiring an estimated 627.5 hours/month (of the total 730.5 hours in a month) to keep current.65,66 While the general public may not be aware of the extraordinary rate in which medical knowledge turns over, they are aware that we live in an age of information where new ideas and thoughts flow constantly. Is it then reasonable to assume that the general public will accept the premise that a doctor can be certified as competent at the completion of training and then need not demonstrate maintenance of competency until retirement?

I think not.

Indeed, Gallup data from 2003 showed that 98% of those polled believed that their doctor should be board certified and 79% believed their doctor should undergo periodic re-certification.67 That same audience might be troubled to learn that physicians are frequently reticent to adapt to new treatments, their funds of knowledge often lagging up to 17 years behind evidence based therapies.68,69 From these data, it is difficult to deny a role for processes which encourage or require lifelong learning and adaptation of current best practices for health professionals. After all, if plumbers are required to document continuing education to maintain licensure,—and they are— why shouldn’t doctors? As such, the question regarding verification of competence is less one of “if”, and more one of “how” and “what”.

The Foundation

So, how have physicians traditionally assessed their competence? There are three mechanisms: state licensure, staff credentialing and specialty board certification. Within this construct, assurance at the basic level of professionalism and medical competence rests with state licensure and local credentialing. Credentialing, the oldest form of competency assessment, dates back to the Middle Ages and licensure in America to post-Civil War nineteenth century. While these important institutions continue today, it was in 1933 and the development of the Advisory Board for Medical Specialties—the precursor to the American Board of Medical Specialties (ABMS)—that specialty physician competency was assessed. Initially meant to be considered a step above basic licensure and credentialing, board certification was a voluntary system; an indicator of excellence and exceptional professional achievement until the 1980’s-1990’s when consumer activists and managed care insurance panels began to recognize board certification as a desirable and differentiating distinction for providers. As a consequence, the financial implications of not being board certified created enormous pressure on physicians to become certified. In 1972, the American Board of Family Medicine, followed by the American Board of Surgery (ABS) in 1976, began limiting the duration of certification—requiring a written exam every 7-10 years in order to maintain certification. As such, the early vestiges of Maintenance of Certification (MOC) were beginning to materialize.70 Other specialties followed suit and by 2005, the ABMS formally introduced its requirements of MOC for all specialty boards: Part I) Professionalism & Professional Standing, Part II) Lifelong Learning and Self-Assessment, Part III) Assessment of Knowledge, Judgment & Skills and Part IV) Improvement in Medical Practice. Over the next decade the ABMS component boards, including the ABS were allowed to independently develop standards, acceptable practices and implementation timelines for each element—with oversite by the ABMS. Unlike other specialties, the ABS, on its own volition, developed and implemented many of the requirements long before the 2005 ABMS directive (Part I in 1937, Part II in 2000, Part III in 1976 and Part IV in 2005). The ABS officially began enrolling diplomates into the three-year MOC administrative cycle in 2005.71

At face value, the ABMS MOC process seems logical and manageable; addressing the information explosion which challenges its diplomates by motivating practice-based learning and self-assessment of practice habits. It protects the public, whom the diplomates serve, and it empowers self-directed learning by its diplomates. Seemingly, all good—except for two critical miscalculations: the timing of implementation and the executors of the process. Who could have predicted that these miscalculations would drive the ABMS to its brink?

The Fuss

Over the past decade, changes in American healthcare have arguably affected the practicing physician more than any other time in history. Financial pressures, narrow insurance networks, hospital employment, challenging productivity expectations, loss of autonomy, the electronic health record (EHR), burdensome and often inexplicable regulatory requirements, increased patient volumes, complexity of aging baby boomers and physician workforce shortages have all increased the work load beyond what could ever have been anticipated72. In recent years, we have discovered a relatively new hazard in the work place, “occupational burnout syndrome”—a condition first described in the mid 1970’s disproportionately affecting those whose work involves interaction with people (teachers, health workers, soldiers, etc.).73 Burnout is characterized by a symptom complex that includes emotional exhaustion, depersonalization (cynicism) and decreased effectiveness (inefficiency). According to survey data, burnout is widespread and increasing, affecting as many as 54% of practicing physicians in 2015 compared to 45% in 2011.74,75 It involves all specialties, including surgery. In a recent editorial published in the Journal of the American Medical Association, authors described burnout as being a consequence of excessive workload, increased clerical burden, loss of control of work environment, practice inefficiency, problems with work-life balance and a feeling of loss of purpose.72 The true impact of burnout on the overall condition of US healthcare is not completely understood, but experts believe its effect to be both impactful and significant. High rates of burnout can be considered both a marker of dysfunction in the healthcare system as well as a contributing factor to dysfunction—not to mention a driver of provider attrition.76 In other studies, the top three causes for burnout, in order, include the increasingly bureaucratic nature of practice, computerization of practice and excessive work hours (no doubt related to bureaucracy and computers).77

Particularly incriminating is the EHR. Unlike other industries where computerization has significantly improved operational efficiency, the EHR has done just the opposite in healthcare. While magnificent in capturing data and documenting treatment, EHR data input, for some reason, has been relegated to health professionals (labeled as “best practice” by the computer vendors); thus assigning to our most sophisticated, expensive and critically deficient workforce resource (doctors and nurses) to the most menial task of clerical documentation. The consequences of such practices in many cases have created massive access bottlenecks and patient dissatisfaction, not to mention professional burnout. In a recently published time motion study where 57 physicians were observed for over 430 work hours, approximately 50% of the physician time was spent doing non-clinical clerical work (e.g. EHR related tasks) compared to 33% spent doing direct patient care (with 37% of this time associated with a doctor in front of an open computer at the patient’s side). For every hour spent performing clinical work, two hours were spent performing clerical work.78 Some have suggested that the EHR may ultimately prove to be the most significant occupational health hazard (Burnout) in medicine since X-Ray of the early 20th century.

It is within this environment that the ABMS introduced MOC. And like the EHR, it was a new process administratively assigned to the physician, significantly adding to his/her non-clinical burden and no doubt contributing to burnout. And also like the EHR, the effectiveness of MOC has been significantly questioned and difficult to prove. While many physicians, including surgeons, accept the theoretical rationale for MOC and are familiar with data showing the benefits of initial certification, most have concerns about the relevance and value of current MOC programs.79-83 Indeed, MOC has sparked major controversy in the medical community as evidenced by editorials, letters, petitions, opinion polls, and even efforts to create an alternative certification board.81,84-94 In a recent survey of greater than 800 physicians, more than 80% agreed that MOC is a burden; the vast majority considering MOC activities such as self-assessment CME and exam preparation as being of little value for practice improvement or patient care. Dissatisfaction was pervasive across all practice settings and all specialties, including surgery.95

That the current MOC controversy could potentially collapse the ABMS is evident by the unresolved conflict between the American Board of Internal Medicine (ABIM) and its diplomates. Widely reported in the lay press, this conflict represents a perfect storm where a specialty of diplomates, already experiencing significant clinical burnout, were informed in January 2014 that their requirements to maintain certification were going to substantially broaden. Though bemoaning the additional administrative burden posed by the new requirements, the diplomates’ objection took a different angle: alleging that the new MOC requirements were financially motivated, with the ABIM reaping millions in new profits on the backs of its diplomates. A sequence of events—a near revolt—followed, including the formation of a competing certifying board not requiring MOC the National Board of Physicians and Surgeons (NBPAS); a number of embarrassing news articles including Newsweek Magazine; a call from the American Medical Association to scrap MOC; a public apology by the ABIM temporarily suspending MOC and legislation in multiple states aimed at eliminating MOC. At the time of this writing, there is legitimate concern over the future of both the MOC and even ABMS itself. In the meantime, the NBPAS continues its fight to gain legitimacy with credentialing bodies and diplomate opposition continues to escalate. At present, the controversy seems far from over.

The Fix

As an ABS Director, I have closely followed the MOC controversy. In order to better understand the opinions of our diplomates, the ABS conducted a targeted cross-sectional survey of 1500 surgery diplomates during the summer of 2016. The top priorities for improving MOC identified by the diplomates included modification of the self-assessment CME requirements, improved practice relevance of the MOC exam and cost reduction of the process. As a consequence, the ABS Directors, after a year-long review, voted in June 2017 to replace MOC with a new life-long learning and continuous certification process—one that eventually makes the ten year recertification exam optional, reduces CME requirements and explores new summative evaluation methods for its diplomates. In fact, the MOC terminology and taxonomy will no longer be used. While the Board concedes these changes are necessary, it also believes, as do I, that life-long continuous learning is an essential and valuable process. And even as some diplomates grumble, most recognize the need to stay current and demonstrate their accountability to the public. The new ABS process ostensibly accomplishes both.

Finally, as the leader of a large health sciences center, I experience the effects of physician burnout daily on patient access, revenue generation, patient satisfaction, teaching and research. I have come to appreciate that any improvements in healthcare that impose more administrative burden on the clinicians will likely be unsuccessful. In fact, I believe there is a “five alarm fire” that needs extinguished; we must immediately deploy administrative support for our providers—“physician support specialists” who are capable of relieving administrative burden. Surely the financial investment for such individuals will off-set their cost. We need to get the doc’s out from behind the EHR and back in front of their patients; we need to re-engineer work flows that place the patient, not the health record, first; we need to make access to care the priority, not mundane documentation; we need to develop inter-professional practice teams where clinicians provide care using their most advanced terminal degree, accepting it does not require an MD, DO or BSN to type information into a computer; and above all we must take every measure to eliminate unnecessary non-clinical burden on our clinicians. And that includes MOC. Only then will continuous certification assume its appropriate role; the administrative duty only doctor can do—embraced as desirable, not rebuked as onerous.

What should the public expect regarding the competency of its surgeons? —The answer, obvious; the solution, ours to figure out.

CONCLUSION

As we conclude this panel, we recognize that we have only “scratched the surface” of issues and challenges facing surgeons throughout their lifetime of surgical education. Fortunately, as we move forward, our profession will benefit from the contributions of a new generation of young surgeons who are focusing their careers on surgical education. We can expect that this group will provide the innovation and leadership necessary to better train the surgeons of the future.

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Figure 1. Factors and skills affecting patient care.

Tables:

Table 1: Primary Tenets of Consensus Statement on Prep Courses

Primary Tenets of Statement on Surgical Pre-Residency Prep Courses

1. Medical students who have successfully completed a pre-residency prep course report increased confidence and an improved sense of preparedness for surgical residency

2. Surgery residency program directors confirm these observations

3. Individuals who arrive at their residency program with fundamental clinical and technical skills are able to perform patient care, including procedures, more effectively and safely

Table 2: Prep Curriculum Goals

ACS/APDS/ASE Resident Prep Curriculum Goals

Strengthen the fourth year of medical student education

Graduate students better prepared for surgical training

Reduce variability in skills of entering residents

Support safer patient care

Table 3: Residency Redesign Elements

Competency Based Education Proposed Redesign Elements

The development of EPA’s, (Entrustable Professional Activities) which will define progression and completion (36).

Competency-based assessment tools

No longer relying solely on number of cases to measure competency

Learner dependent (not educator dependent) education

Enhanced surgical experience with greater early operative exposure both in numbers and complexity 

Faculty development to enhance teaching and assessment of technical skills and competence in and out of the OR

34