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Pushing the Edges of the Box: Creating Focused Training within a General Surgery Residency

Kyla Terhune, MD, MBA, FACS, and John Mellinger, MD, FACS

November 1, 2017

Imagine a residency where a trainee who anticipates practicing general surgery immediately after residency has their final four months dedicated to the acute care general surgery service. In so doing, they increase their autonomy, exposure, and repetition to standard general surgery cases, thus participating in a “transition to practice” model within their own residency. Imagine a resident entering a surgical oncology fellowship who spends their final six months of residency devoted to rotations that specifically prepare them for that fellowship. Imagine lengthening rotations to increase repetition and attending-resident comfort, and allowing some chief residents to participate in some rotations selectively (for example, requiring vascular surgery in the chief year for those entering plastics and transplantation, given microvascular work and anastomoses, but not requiring it for the resident entering a breast fellowship if all case numbers have been met). Imagine a situation where all of your chief residents have already matched into their specialty in the PGY-4 match and now have a chief year tailored to optimally prepare them for this specialty.

This is the reality—surgical residency can be a fluid entity, allowing for focus within broad-based training. In recent years, regulating bodies—the American Board of Surgery (ABS) for individual residents and the Accreditation Council for Graduate Medical Education (ACMGE) for surgical residencies—have recognized and embraced the idea that residency progression can be tailored to meet educational needs (and the needs of their future patients). In 2016, 76 percent of graduates from domestic medical school had an average of $189,165 of educational debt,1 there is a distinct individual motive to get to practice sooner and more efficiently. Also, with 74 percent of recently surveyed graduates pursuing subspecialty surgical practice after general surgery training,2 there may be an advantage from an educational and patient standpoint to tailor the residency towards the eventual practice of the individual, whether this is a specialty surgical field or general surgery. This forward thinking also positions our professional training paradigm for competency based training.

Here, we briefly review flexibility options already allowed and sanctioned by both the ABS and the ACGME, which allow the program director to focus the terminal training of residents so that they are best prepared for their eventual specialty; practice-ready at the end of residency, if needed; and with retained interest throughout the final chief year of residency due to the direct relevance of every rotation. The authors believe there are advantages to the individual, clinical faculty, the program, the resident’s own future patients, and society in terms of workforce in such intentionally and individually focused surgical training.

Potential Advantages to Employing Flexibility




Society (Patients)

  • Rotations are seen as directly applicable to practice
  • Better prepares the individual educationally
  • Increased repetition, increased exposure to faculty in planned field leading potentially to greater autonomy
  • Increased investment in individuals who have chosen their specialty
  • Increased exposure to some residents, allowing for focused instruction, increased comfort, and potentially increased autonomy
  • Individualized rotations and schedules appealing to applicants
  • Trainees may be better prepared for fellowships or ready for independent practice, potentially increasing program reputation
  • Increased focus, repetition, autonomy may lead to more practice-ready trainees
  • If combined with competency-based training, could shorten training times and alleviate the bottleneck of training, helping with workforce shortage

There are some common misconceptions that the only way to focus training is through a formal Early Specialization Program (ESP), or being involved in a specific cohort employing Flexibility in Surgical Training (FIST). These programs have been innovative and impactful, with studies demonstrating that trainees participating in such programs—even when training is shortened—still pass the surgery qualifying exam (QE) and certifying exam (CE) at similar rates to those in traditional training models.3 How can one apply the lessons learned from these training scenarios even without making special allowances or using such structures?

We would argue that even without lengthening training, a program director can employ allowances already in existence by the ACGME and ABS to create educationally stronger training within their own program to allow trainees to be better trained for their chosen specialties. We will refer to this as “focused training” in the remainder of the manuscript.

The idea of focused training is not a new concept—one can follow a logical progression in national addresses and current literature for as long as surgical education has been considered. In 1940, the acclaimed surgeon E.D. Churchill described a “frozen five-year curriculum” as “unthinkable as it allows no latitude.”4 There have been many iterations of this throughout the years by some of the most prominent surgeons of each era. In 2004, the American Surgical Association (ASA) Blue Ribbon Committee published the results of a two-year study on the topic of surgical training in which they suggested that surgical residencies be restructured to ensure a “common grounding” in basic principles, acceptance that most surgeons will confine their scope, and “earlier differentiation into goal-oriented specialty tracks.”5

In studying the effect of specialization on general surgery residents, Stain et al. published a manuscript in 2010 demonstrating that allowing for flexibility in rotation assignments actually helped those planning to specialize in general surgery to have more exposure to general surgery cases, and thus anticipated better preparation for practice.6 Probably the most recent recognition of focused training is the recent approval by the American Board of Medical Specialties (ABMS) of the establishment of a new Focused Practice designation, currently established in one field and being piloted in another, recognizing “areas of specific expertise… continuing certification efforts in the very area on which much of their professional practice is based.”7 We believe that all the tools for focused educational curricula, to both adequately prepare general surgeons and prepare specialty surgeons, are already present.

In order to succinctly summarize the requirements of both the ACGME and ABS, please see the following table compiled from the ACGME Surgery Program Requirements and ABS General Surgery Training Requirements8,9:



Clinical Curriculum

“Sequential, comprehensive, and organized from simple to complex”

“Progressive residency education” at an accredited program

Total Months

60 months

60 months at ≤ 3 programs

Clinical Assignments (months)

54 months

54 months
48 weeks in each year (averaged over years 1–3 and then 4–5)

Emergency Care, Critical Care

“documented experience”

Essential Content Areas

42 months

  • Abdomen and contents
  • Alimentary tract
  • Skin, soft tissue, breast
  • Endocrine
  • Head and neck
  • Pediatric surgery
  • Surgical critical care
  • Surgical oncology
  • Trauma
  • Non-operative trauma (for example, formal burn rotation, but not required)
  • Vascular surgery

42 months

  • Alimentary tract (including bariatrics)
  • Abdomen and contents
  • Breast, skin, soft tissue
  • Endocrine
  • Solid organ transplantation
  • Pediatric surgery
  • Surgical critical care
  • Surgical oncology (including head and neck)
  • Trauma and emergency surgery
  • Vascular surgery

Other Requirements

Formal transplant rotation ≤12 months devoted to surgical discipline other than “principle components”

≤ 12 months devoted to “any one surgical specialty” other than general surgery during junior years (PGY 1–3)

Allowed (but not required)

≤ 6 months of nonsurgical disciplines (anesthesia, medicine, pathology)

  • can have > 6 months of endoscopy (GI)

≤ 6 months of non-surgical disciplines during junior years (PGY 1–3)

Chief Year

  • Must be in fifth year unless specific approval by Review Committee to “take advantage of a unique educational opportunity” in which can be completed in fourth year
  • Clinical assignments MUST be at primary or integrated sites
  • Must be in “essential content areas” (see above)
  • No more than 6 months to one content area
  • May include non-cardiac thoracic and transplant
  • Acting in capacity of chief resident (senior most resident involved) for 12-month period, with majority served in final year
  • Entire chief resident experience in content areas of general surgery (above) or thoracic surgery
  • No more than 4 months devoted to any one area
  • All rotations must involve substantive operative experience

With these regulations in mind, one can see that even without a specific application to the Residency Review Committee (RRC) or to the ABS, a program director can effectively tailor rotations to an individual resident, as long as the distribution of rotations takes into account both ACGME and ABS requirements. If one wants to increase flexibility further (or increase specialized focus to greater than four months in the chief year), one could also petition the RRC for the allowance that PGY-4 rotations be designated chief rotations (if the rotations meet specific requirements), thus allowing additional flexibility or repetition, as well as potential added autonomy in the final year of residency. If further flexibility or concentration within one area is desired, the program director should file a separate request to the RRC and to the ABS.

The following is an example of two chief residents in one of the authors’ institutions. The first is entering a surgical oncology fellowship. The second is entering a cardiac surgery fellowship. Both must have a general surgery “check off” in their final chief year where they can demonstrate competence. Their rotations in the final year are as follows (of note, both had trauma rotations in the PGY-4 year designated chief rotations, allowing for two months in the final year to be elective):

Chief Matched in Surgical Oncology

(two-month rotation blocks)

Chief Matched in Cardiothoracic Surgery

(two-month rotation blocks)

Vascular Surgery

General Surgery

General Surgery

Surgical Oncology

General Surgery

Advanced Laparoscopic/Foregut (for example, esophageal and paraesophageal)

Colorectal Surgery

Vascular Surgery

Surgical Oncology

Advanced Laparoscopic/Foregut (for example, esophageal and paraesophageal)

Surgical Oncology

Cardiac Surgery Elective

One can see in this example that the rotations are specifically chosen with the resident’s career and future patients in mind, and that rotations are strategically placed to create continuity and preparation that flows into the fellowship years. One can imagine a “melding” of the final year of residency seamlessly into fellowship, potentially setting the stage for future internally tracked fellowships.

Barriers to tailoring rotations are that the program and faculty must remain flexible themselves—as the complement of senior residents and their interests and fellowship matches change with each resident class. This means that from year to year, the program must reassess faculty complement, strength of rotations, potential experiences, and fellowship matches of the chief residents. The authors recommend yearly updates to the RRC and ABS as well as continual assessment via graduate surveys and outcome data of board pass rate and fellowship status within the program. However, if all of these are carefully considered, tailored rotations can help “fix the five,” addressing many of the issues of concern within residency training today—namely repetition, autonomy, and ensuring that all educational experiences are relevant to one’s future patients, optimally preparing their future surgeons.


  1. Medical Student Education: Debt, Costs, and Loan Repayment Fact Card. Association of American Medical Colleges. Published October 2016. https://members.aamc.org/eweb/upload/2016_Debt_Fact_Card.pdf, Accessed May 4, 2017.
  2. Klingensmith ME, Cogbill TH, Luchette F, et al. Factors influencing the decision of surgery residency graduates to pursue general surgery practice versus fellowship. Ann Surg. 2015 Sep; 262(3): 449-55.
  3. Klingensmith ME, Potts JR, Merrill WH, et al. Surgical Training and the Early Specialization Program: Analysis of a National Program. J Am Coll Surg. 2016 Apr; 222(4):410-6.
  4. Churchill ED. Graduate training in surgery at the Massachusetts General Hospital. Harv Med Alum Bull. 1940; 14: 28-36.
  5. Debas HT, Bass BL, Brennan MF, et al. American Surgical Association Blue Ribbon Committee Report on Surgical Education: 2004. Ann Surg. 2005 Jan; 241(1):1-8.
  6. Stain SC, Biester TW, Hanks JB, et al. Early tracking would improve the operative experience of general surgery residents. Ann Surg 2010 Sep; 252(3):455-9.
  7. American Board of Medical Specialties announces new, focused practice designation [news release]. Chicago, IL: American Board of Medical Specialties; March 14, 2017. http://www.abms.org/news-events/american-board-of-medical-specialties-announces-new-focused-practice-designation/#sthash.LLJt2942.dpuf. Accessed November 20, 2017.
  8. ACGME Surgery Program Requirements. Accreditation Council for Graduate Medical Education. http://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/24/Surgery. Accessed May 4, 2017.
  9. Training and Certification General Surgery Training Requirements. American Board of Surgery. http://www.absurgery.org/default.jsp?certgsqe_training. Accessed May 4, 2017.

About the Authors

Kyla Terhune, MD, MBA, FACS, is vice chair for education, section of surgical sciences; associate professor of surgery; and surgery residency program director at Vanderbilt University Medical Center. 

John Mellinger, MD, FACS, is the J. Roland Folse Endowed Chair in Surgery; vice chair, department of surgery; chair of general surgery; and surgery residency program director at Southern Illinois University School of Medicine.