American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Surgical education: The good, the bad and the ugly

OCTOBER 23, 2017
Clinical Congress Daily Highlights, Monday Second Edition

Surgical education in the United States has a long pedigree of colorful personalities, struggles for dominance — and an impressive evolution in standards, technology, and quality, said John R. Potts, MD, FACS, senior vice president of accreditation, Accreditation Council for Graduate Medical Education, in Monday’s Charles G. Drake History of Surgery Lecture.

The future of surgical education, in Potts’ view, will be a mixture of “the good, the bad and the ugly,” each of which he summarized in an hour-long address that covered demographic and educational trends in surgical training for seven specialties: neurosurgery, obstetrics-gynecology, orthopedics, ophthalmology, general surgery, urology, and otolaryngology.

Potts’ vision of the future also included a fourth element that he hailed as “the really good.”

“The really good thing is that surgeons love surgery. We’ve always loved it, we always will love surgery,” he said. “We love the privilege to do things no one else can do … legally,” he said, drawing laughter. “We love the challenge of doing it, the responsibility that goes with being a surgeon, but most of all we love the patients in whose care we get to participate.”

On top of all that, surgical educators “get to see the ‘Aha!’ moment in the eyes of the residents,” along with “just a little bit of eternity, inasmuch as we get to practice through our trainees and then through theirs.”

Among the high points of Dr. Potts’ three-part crystal ball (in reverse order):

Ugly: Corporatization of teaching institutions. “Too often institutions actually established for the purpose of education and research have become clinical mills for the generation of dollars. Too often that educational mission which was once the bright North Star for an institution has become a footnote for a glossy advertisement or television ad. Too often educational decisions are made based on the financial well-being of the institution, rather than the well-being of the learners or the patient.”

Another “ugly” trend to watch, Potts’ said, is the long-term impact of health system consolidation into a handful of “truly mega” systems, each with its own medical school and residency program, whose graduate surgeons it hires. He asked whether external accreditation would even be of financial value to closed-loop systems that train residents in what they believe is needed for their system.

“If they can track every data element on every surgeon, every day, and determine who they think are their good surgeons and who are not their good surgeons, would they challenge the external board certification? Or would these be unnecessary accoutrements?” Such systems could work for patients within the system, he acknowledged, but if they fell out, they might be relegated to doctors who attended unaccredited medical schools or cared for by surgeons who are not board-certified.

Bad: “We normally think of bigger being better, but I am here listing larger (residency programs) being a bad thing,” he said, stressing that he was speaking for himself.  More residents, more faculty, more clinical sites make effective resident feedback and evaluation more difficult. Less time together impairs supervision of the residents, which erodes the cornerstone of the American system – progressive responsibility, he said.

Other “bad” trends he cited – from the perspective of residents’ education – include increasing turnover in residency program directors, more focus on subspecialty training of fellows at the expense of residents and the rise of competing certification boards and accrediting agencies.

Good: High-quality simulation training will become integral to residency programs, making curricula much more robust. Programs within and across institutions will do more sharing of equipment. Although telehealth operations are years off, remote consultations in surgery are here today, to the extent that training to do them should become part of residency training, Potts said.

With respect to training in patient safety, quality improvement, team-based care, and communication skills, “I think we’re moving the needle in the right direction,” he said.

Additional Information:
The Named Lecture, Charles G. Drake History of Surgery Lecture, was held October 23 at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at

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