Russell G' Postier, MD, FACS

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Russell G. Postier, MD, FACS

• This presenter will not discuss any commercial
  product or service. Nor will the presentation
  include discussion of any off-label and/or
  investigational use of any products or services.
  This presenter will not use any trade names in
  his presentation. The presenter does not have
  any relationship with the commercial supporters
  of this program.
• The sponsoring unit will not include discussion
  of any commercial product or service, nor will
  they discuss any off-label and/or investigational
  use of any product or service. Trade names will
  not be used.

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A New Paradigm for Surgical TrainingRole of
Rural Surgery

• Outline
• Regulatory agencies for American Surgery
• Current training paradigm
• Possible new paradigms
• Role of rural surgery

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Regulatory Agencies

• ABMS and its member boards
• ACGME and its member committees

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ABMS and the Boards

• Determine and publish requirements for
  individuals
• Develop and administer examinations
• Monitor for lapses in meeting requirements

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ABMS and the Boards

• Developed requirements for recertification
• Developed requirements for MOC

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ACGME and its Committees

• Determine and publish program requirements
• Monitor programs for compliance

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ACGME and its Committees

• Developed 80 hour work week requirement
• Developed minimum case numbers for programs
• Required endoscopy for surgeons

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Current Training Paradigm

• General Surgery
• Five years of clinical training
• Final two years in the same program
• Operative experience submitted to the ABS but no
  specific requirements
• Pass QE and CE examinations

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Current Training Paradigm

• Vascular Surgery
• Thoracic and Cardiovascular Surgery
• Plastic Surgery
• Pediatric Surgery
• Surgical Critical Care

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General Surgery Training

• 70 of trainees do additional training
• ACGME approved
• ACGME unapproved
• Why?
• They feel inadequately trained?
• They need an additional piece of paper for
  marketing?
• They desire to limit their practice?

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General Surgery Training

• Too many of the surgeons finishing the training
  programs today do not have the skills expected by
  the ABS and senior leadership in surgery
• Timothy Flynn, M.D. Chairman, ABS

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New Paradigms

• Major in general surgery with a minor
• 3-4 years in core general surgery
• 1-2 years in area of interest
• Define and standardize training
• What is general surgery?
• What needs to be taught and when?
• Competency based not time based

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Major in General Surgery with a Minor

• Advantages
• Continues to provide broadly trained surgeons
• Mitigates need for additional specialty training
• Saves complex procedures for those who will do
  them
• Would allow for a rural track

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Major in General Surgery with a Minor

• Problems
• Continuity of training?
• Further fragmentation of surgery?
• Who would pay for additional training?
• How many years of core training?

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Standardized Training Curriculum

• SCORE Project
• Surgical Council on Resident Education
• Voluntary consortium of six organizations
• ABS
• ACS
• ASA
• ASE
• ASPD
• RRC
• SCORE is an advisory group that provides a forum
  for the major stakeholders in resident education

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There is a Problem With Surgical Education

• Variable surgical experience in core procedures
• Inadequate knowledge in basic anatomy,
  physiology, pathology, and therapy
• Poor exposure to the breadth of diseases general
  surgeons should know about
• Lack of confidence in their own skills

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Why is There a Problem?

• 80 hour work week?
• Reduced time for patient contact
• Reduced time for peer-peer interaction
• Inefficient use of off hours
• Competency requirements?
• Perceived as needing time away from patients
• Poorly understood by programs and inefficient
• Difficult to evaluate
• Socioeconomic pressure on faculty

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The Solution

• Define expectations
• Identify the conditions we should be able to
  treat
• Identify the operations we should be able to do
• Create the didactic component of the process
• Dont recreate textbooks
• Assemble a web-based link to source material
• Make certain operative procedures mandatory
• Those they need to be able to do
• Those that help develop transferable, universal
  skills
• Document and evaluate progress

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The Role for Rural Surgery

• Are rural surgeons different?
• Should their training be different?
• Is it possible under a new paradigm?

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Are Rural Surgeons Different?

• 2005 Data Recertification Exam Operative
  Experience Report
• OPERATIVE EXPERIENCE (MEANS) of Rural Urban
  (MSA) GRE GROUPS 2005
• Statistically significant differences in the
  following operations
• Procedure s P value
• Fewer breast 63 v 47 .03
• Fewer small intestine 12 v 10
  .05
• More anorectal 17 v 12 .002
• More biliary 61 v 52 .04
• Fewer pancreas 0.5
  v 2.3 .01
• More GU 3 v 1 .001
• More gyn 6 v 2
  gt.001
• More endoscopy 228
  v 46 gt.001

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Are Rural Surgeons Different?

• With the exception of endoscopy, there are minor
  differences in the reported operative experience
  of rural and urban surgeons
• This data does not examine other differences in
  rural v urban practices that could require
  differences in training

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The Role for Rural Surgery

• Define what rural surgeons do
• Develop curricula to address that
• Incorporate curricula into general surgery
  training?
• Develop more rural surgery post-graduate training
  opportunities?

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Summary

• Regulatory and certifying agencies affect the
  lives of rural surgeons
• A new paradigm for surgical training is being
  developed
• The role of rural surgeons and their training
  needs can be addressed in this process
• We need to know more about what rural surgery is
  and what rural surgeons do