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Readiness of US General Surgery Residents for Independent Practice
Brian George¹, Jordan Bohnen², Reed Williams³, Shari Meyerson⁴, Mary Schuller⁴, Andreas Meier*⁵, Laura Torbeck³, Samuel Mandell⁶, John Mullen*², Douglas Smink*⁷, Jeffrey Chipman*⁸, Edward Auyan⁹, Kyla Terhune*¹⁰, Paul Wise*¹¹, Jennifer Choi*³, Eugene Foley¹², Justin Dimick¹, Michael Choti¹³, Nathanial Soper⁴, Keith Lillemoe², Joseph Zwischenberger¹⁴, Gary Dunnington³, Debra DaRosa⁴, Jonathan Fryer^4
1University of Michigan, Ann Arbor, MI; ²Massachusetts General Hospital, Boston, MA;³Indiana University, Indianapolis, IN;⁴Northwestern University, Chicago, IL;⁵SUNY Upstate, Syracuse, NY;⁶University of Washington, Seattle, WA;⁷Brigham and Women's Hospital, Boston, MA;⁸University of Minnesota, Minneapolis, MN;⁹University of New Mexico, Albuquerque, NM;¹⁰Vanderbilt University, Nashville, TN;¹¹Washington University, Saint Louis, MO;¹²University of Washington, Madison, WI;¹³University of Texas Southwestern, Dallas, TX;¹⁴University of Kentucky, Lexington, KY

Objective
The American Board of Surgery has designated 133 procedures as being “Core” to the practice of General Surgery (GS). GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard.

Methods
Attendings in 14 General Surgery programs were trained to use a) the 5-level SIMPL Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (i.e. autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics.

Results
368 attending surgeons rated 393 categorical residents after 5861 procedures. The five most frequently rated Core procedures were laparoscopic cholecystectomy, laparoscopic appendectomy, open inguinal hernia repair, open ventral hernia repair, and exploratory laparotomy. From the first to the last year of training, the proportion of Performance ratings at “Practice Ready” or above for the top five Core procedures (n=1541) increased from 11.8% to 90.0% (p<0.001, 95% CI 7.4-18.1% and 86.2-92.9%, respectively) (Figure 1). For the most frequently rated procedure for residents in their final six months of training (laparoscopic cholecystectomy), the proportion of Performance ratings (n=161) at “Practice Ready” or above was 87.0% (95% CI 80.5-91.1%). For all procedures (n=5861), the proportion of Zwisch ratings indicating meaningful autonomy (“Passive Help” or “Supervision Only”) increased from 16.9% to 67.0% (p<0.001, 95% CI 14.4-19.7% and 64.4-69.5%, respectively) from the first to the last year of training. For the five most frequently rated Core procedures performed by residents in their final 6 months of training (n=342), the proportion of Zwisch ratings indicating near-independence (“Supervision Only”) was 49.1% (n=342, 95% CI 43.7-54.5%) (Figure 2).

Conclusions
US General Surgery residents are generally but not universally ready to independently perform the most common Core procedures by the time they complete residency training. Resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for independent practice.

Figure 1: The relationship between resident post-graduate year (PGY) and the distribution of operative Performance ratings. Ratings indicating readiness for independent practice (Pratice-Ready and Exceptional Performance) are plotted above the line in the top panel, with the percentage of ratings in those two top categories above each bar. The total number of ratings for each PGY is shown in the histogram below each distribution.

Figure 2: The distribution of faculty guidance (Zwisch) ratings for trainees in the last 6 months of their residency training while performing one of the five most frequently rated American Board of Surgery-defined “Core” procedures. Ratings indicating meaningful autonomy (Passive Help and Supervision Only) are plotted in the left panel. The total number of ratings for each procedure is shown in the histogram in the right panel.

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