General Surgery Residency Inadequately Prepares Trainees for Fellowship

Results of a Survey of Fellowship Program Directors

Rohan Jeyarajah, MD, FACS; Lee L. Swanstrom, MD, FACS; Ralph W. Aye, MD, FACS; Stephen D. Wexner, MD, FACS, FRCS, FRCS(Edin), PhD (Hon); José M. Martinez, MD, FACS; Sharona B. Ross, MD, FACS; Michael M. Awad, MD, FACS; Morris E. Franklin, MD, FACS; Maurice E. Arregui, MD, FACS; Bruce D. Schirmer, MD, FACS; Rebecca M. Minter, MD, FACS


Annals of Surgery. 2013;258(3):440-449. 

In This Article

Abstract and Introduction


Objective: To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America.

Methods: A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains.

Results: There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.


The practice of general surgery is undergoing significant change. The rapid adoption of new technologies, the integration of advanced minimally invasive techniques, and the exponential expansion of the knowledge and variety of procedures that trainees must learn have coalesced to dramatically and permanently alter the landscape of surgery. In many cases, these rapid changes overwhelm the ability of surgeons to readily adopt and master new techniques. Many surgery training programs also struggle to effectively integrate new procedures and technologies into residency curricula. Yet increasing demand by the public and hospital administrators has pressured surgeons to seek proficiency in all these new procedures.

General surgery residents are particularly subject to these changes in the practice environment. The majority of residents recognize the forces that will influence their future marketability and many feel unprepared to compete. Recent limitations and safeguards imposed by regulatory bodies, which include strict adherence to duty hours and an enhanced level of supervision with markedly diminished degrees of autonomy, have limited residents' exposure and experience compared with prior decades of surgical training.[1] Moreover, an ever-increasing complexity of procedures and the pronounced decrease in transferability of skills among procedures (eg, open, laparoscopic, and endoluminal) require a compensatory increase in exposure and autonomy during training. In some cases, the mentors who train residents may themselves feel they have been inadequately prepared to teach new techniques such as robotic surgery, per-oral endoscopic myotomy, and natural orifice surgery.[2] These factors undoubtedly help explain the unprecedented high demand by residents to invest in additional training and specialization, including specialized fellowships, after general surgery residency. Currently, greater than 80% of chief residents proceed to 1- or 2-year fellowships in various subspecialties.[3] A recent survey of surgical residents has revealed that nearly 40% of residents lack confidence in their skills after 5 years of training, including 23% of graduating chief residents.[4]

In response to this high demand for subspecialty training, many fellowship programs have emerged over the past 2 decades. These have a variety of oversight and affiliation, and include certificate-granting "fellowships," sanctioned by the American College of Graduate Medical Education (ACGME): vascular, cardiothoracic, colorectal, pediatric, and most recently oncologic surgery. In addition, there has been a rise in numerous non–ACGME-supported postgraduate training programs. These include specialty society-governed programs (eg, breast, endocrine, and trauma). Finally, there have been a large number of training programs in advanced gastrointestinal surgery, minimally invasive surgery, bariatric surgery, hepatopancreatobiliary surgery, advanced gastrointestinal surgery, flexible endoscopy, colorectal, and thoracic surgery. These last 2 fellowships provide additional training following completion of an ACGME-accredited colorectal and thoracic training program. Initially, all these fellowship programs were diverse and isolated, typically controlled by individual surgeons or institutions, with little consistency or oversight. The fellowship directors of these programs and the specialty societies supporting them ultimately came to recognize the merits of standardization and oversight, resulting in the creation of the Fellowship Council (FC) (

The FC is an association created in 1997 to coordinate general surgery subspecialty fellowships toward the common objective of delivering standardized, quality training through a strong accreditation process. Program accreditation is a rigorous process that is supervised by members of the Accreditation Committee who perform site visits, review fellow case logs, fellow and faculty evaluations, conduct exit surveys, and ensure that training is being conducted according to standard curricula that have been published by the FC. The FC also manages a universal process for matching prospective candidates to fellowships. These fellowships comprise minimally invasive, bariatric, hepatopancreatobiliary, colorectal, thoracic, and flexible endoscopy specialties. The Board of Directors of the FC is formed of 13 members, and there are 9 committees that are charged with executing various projects that address or advance every realm of fellowship training. The research committee of the FC, which was charged with this study, is composed of 9 members from the component societies. The FC oversees 156 training programs, which encompass 210 fellowship positions. In 2012, 191 open fellowship positions were filled through the FC match for advanced specialty training after general surgery residency.

FC-accredited programs deliver comprehensive training augmented by a large volume of specialty-specific cases, offering trainees ample opportunities to gain proficiency in their skills. These programs emphasize the development of independence and safe, graduated responsibility. Because the duration of most of these fellowships is 1 year, the trainees' learning curve is steep. Of all the factors that influence the slope of this curve, the most important may be the foundational abilities the fellows bring to the fellowship from general surgery training. Several studies have revealed that the more prepared the trainee is, the faster the learning curve is ascended, allowing more time for refining necessary skills that are specific to a given specialty.[5–7] Conversely, new fellows who are not adequately trained during their residency in fundamental skills, for example basic laparoscopic skills, will usually take longer to reach a steady state in their advanced training, and consequently may not be able to advance to the point of performing complex procedures independently by the completion of their fellowship.[8,9]

This study, therefore, seeks to evaluate the level of preparedness of incoming fellows to FC subspecialty surgical fellowships to determine whether there are domains in which gaps in training exist that could be targeted for intervention during general surgery residency. If these gaps can be identified, these data could be utilized to develop a more directed training experience in the final year of general surgery residency, allowing for a greater likelihood of successful, independent transition to practice by the conclusion of a specialty-specific fellowship.