Don't be afraid of change: a commentary on surgical training and the American Board of Surgery.

In January of 2003 at their retreat in Florida, the American Board of Surgery approved a controversial pilot program entitled early specialization program (ESP). The purpose was to allow program directors in vascular surgery, pediatric surgery, and general surgery to pursue combined training programs to lead to dual certification in 6 years instead of 7 years for general and subspecialty training. For example, a resident in general surgery could train in a specific curriculum that would allow the postgraduate year (PGY) 4 to serve as the traditional chief resident year while the PGY 5 would serve as the final year of general surgery residency and the first year of vascular surgery training. The final, or PGY 6, would serve as the second year of the vascular surgery residency. In this way, a resident would be board eligible in general surgery and vascular surgery in 6 years but would get a concentrated experience of 24 months of vascular surgery at the end of his/her training. This curriculum would concentrate nearly all of the vascular experience into the final 24 months and reserve the initial 48 months of training almost exclusively for the other components of general surgery. The presumptions inherent in the planning of ESP included: (1) that this is a pilot program to be tested, and metrics would be created to measure success or failure, (2) the creation of a specific curriculum would be required to assure that all aspects of current training would be included in the ESP program, (3) not all training programs would qualify for ESP because both general and specialty training must be done in the same institution, and the training program would have to be large enough to support ESP and still fill the needs of all the conventional trainees. On the surface ESP seems harmless, but it has far reaching implications that have created anxiety and anger in various centers of academic and private surgery. The concerns can be summarized as follows: (1) trainees of the ESP program will be inadequately trained; (2) The 80-hour work week is so restrictive that the additional change of ESP will make excellent training impossible; (3) ESP will cheapen the general surgery certificate; (4) creating a special curriculum for these trainees will make the program director's job impossible; (5) the changes likely to follow ESP, such as combined training in cardiac surgery and general surgery, will adversely impact general surgery training. Sensible responses to these concerns over ESP are necessary if the pilot is to be judged by its measured results rather than by presumed results. Below are the authors’ responses to the concerns noted above. Some of these responses are the same as those already generated by the American Board of Surgery and others are merely opinions of the authors. The training paradigm that is being constructed for ESP does not reduce the general surgery training for candidates. Currently the American Board of Surgery (ABS) specifications for months of training allow an element of tracking for surgical residents and the ESP pilot changes those specifications by only 2 months (2 of 60 months differ from the existing rules in ABS specifications). Although the vascular rotations are all shifted to the PGY 5 in the ESP construct, the total months of vascular training are unchanged. It is unlikely that ESP will lead to anything but superior surgical training. The concern over the 80-hour work week and its impact on surgical training is not founded on fact. The experiment of the 80-hour work week in the state of New York has been ongoing for over 10 years. It is clear from this experience that solid training in general surgery can be accomplished in the setting of hours limitations. It is also clear that changing from a 100-hour work week to an 80-hour work week is difficult, and simultaneous change to the ESP pilot will make that task even more difficult for a program director. This does not imply that an 80-hour work week is incompatible with ESP. ESP will not cheapen the general surgery certificate. Surgeons that train in the ESP pilot will have the same experience as 5-year general surgery residents. They will have the same requirements for operative cases and an almost identical monthly requirement. Concern for program directors and their ability to simultaneously function in an 80-hour format and the ESP program is a valid concern. However, ESP is optional and will only be attempted by program directors prepared for the challenge. A pilot program for combined cardiac surgery and general surgery training is currently being discussed by The American Board of Thoracic Surgery and the American Board of Surgery. This pilot program has not yet been designed; therefore, it is not possible to determine its impact. ESP is clearly a challenge for all, but it is widely anticipated by many trainees. As a former program director, I understand the complexity of the task and the potential pitfalls along the way. Still, it is unimaginable to me that the greatest surgical training system in the world cannot evolve into somewhat briefer training and still maintain its excellence. To make this change will require a complete overhaul of the current system. Service issues must be replaced by educational issues even if sacred cows are killed. Competencies must be judged by achievement rather than just by time served. Many programs will not be able to accomplish these goals or have no desire to do so, and will continue to train general surgery residents in 5 clinical years. As there is still a need for the broadly trained general surgeon who has the ability to care for a wide range of surgical problems, such programs will continue to flourish. Surgeons in moderately sized and small communities often serve as not only general surgeons, but as gastroenterologists, gynecologists, urologists, orthopedists, otolaryngologists, and vascular and chest surgeons as well. But a few innovative programs will change. They will evolve and adopt educational principles that foster efficient training, and they will craft curricula that will look considerably different from what we have today. ESP is an opportunity to change for the better for selected programs. We should embrace this pilot and support educational change with the expectation that the result will be residents trained as well, or possibly even better, than they are trained today.