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Become a member and receive career-enhancing benefits

Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

Membership Benefits

2021 ACS Governors Survey

Surgical Training Paradigms: From Medical School into Practice

Danielle A. Katz, MD, FACS, Peter A. Andreone, MD, FACS, David W. Butsch, MD, FACS, Christopher DuCoin, MD, MPH, FACS, Emily Kalata, Shilpa Shree Murthy, MD, MPH, David J. Welsh, MD, FACS, and John P. Kirby, MD, MS, FACS

May 1, 2022

Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) conducts an annual survey of its domestic and international members. The survey is intended to provide a means of communicating the concerns of the Governors to the College leadership. The 2021 ACS Governors Survey, conducted in July and August 2021 by the B/G Survey Workgroup, had a 95% (277/292) response rate. For the second time, the leadership of the ACS Young Fellows Association (YFA) (Fellows age 45 and under), completed the survey. Several results from the YFA survey have been included in this article for purposes of comparison.

One of the 2021 survey topics was the surgical training paradigm. This article outlines the Governors’ and YFA’s leadership’s feedback on related issues.


The importance of medical education is embedded in the practice of medicine. The singular significance of medical education is the first concept introduced in the Hippocratic Oath. Since then, a variety of frameworks have been introduced to guide surgical education and training. Until the 20th century, US medical schools were lightly regulated, if at all, and surgical training was “an apprenticeship at best.”1

Over time, both medical schools and postgraduate surgical training evolved. A pioneer in the field was William S. Halsted, MD, FACS. The program he developed at The Johns Hopkins School of Medicine, Baltimore, MD, near the end of the 19th century was patterned after a system prevalent in Germany at the time. One of the hallmarks was that during the final phase of training the resident had the privilege of providing almost completely autonomous patient care.1-3

Halsted also introduced the pyramid system to surgical training, with no predetermined duration of training. In the 1930s, Duke University School of Medicine, Durham, NC, also had a pyramid system for progressive autonomy but was limited to 6 years of training.2

For the past several decades, most surgical training programs have resembled the structure implemented by Edward D. Churchill, MD, FACS, at Massachusetts General Hospital, Boston, in the 1940s—a rectangular model in which those who enter the program and maintain satisfactory performance are expected to complete it.2,3 

Recently there has been a resurgence of discussion about our surgical training paradigms in response to increased treatment options and technology and changing societal expectations. Surgical educators today are particularly concerned about:4-8

  • Experiences in medical school (especially in the fourth year)
  • The impact of duty-hour restrictions on surgical residents
  • The decrease in resident autonomy while in training
  • The best way to incorporate new techniques and technologies into practice once surgeons have completed formal training

This reevaluation of the status quo is in keeping with surgery’s commitment to continuous improvement and lifelong learning. 

While surgical training has been through a process of continual, gradual evolution, more recently surgeon educators have suggested a more fundamental restructuring of the US surgical education and training system.4 Because of the many stakeholders involved and the complexity of interrelated issues, the B/G Survey Workgroup sought to understand the Governors’ and YFA leadership’s perspectives on some of these topics.

Table 1. What Should a Surgical Readiness Rotation Include?

Starting IVs


Placing NG tubes


Placing Foley catheters


Identification and initial treatment of shock


Identification and initial treatment of pulmonary embolus


Identification and initial treatment of sepsis


Identification and initial treatment of ACS/MI


Knot tying




Sterile technique


Other (please specify)


Medical School Preparation for Surgical Residencies

The curricula in medical schools have undergone significant changes. One transformation that has been discussed recently is the structure and content of the fourth year. A number of medical educators have indicated that the educational value of the fourth year of medical school has declined. Some residency program directors also have said that incoming residents are not optimally prepared to function at the postgraduate level.9,10

With these perspectives in mind, some institutions offer a training experience designed specifically to ensure that their graduates are ready to assume the responsibilities required at the start of residency training.11-13 The ACS also has invested in this area of educational development through the Fundamentals of Surgery curriculum released in 2009, and the ACS/Association of Program Directors in Surgery/Association of Surgical Educators (ACS/APDS/ASE)Resident Prep Curriculum introduced in 2014. 

The 2021 B/G annual survey included questions about surgical training in medical schools, residency, and practice. In total, 277 members of the B/G and 33 members of the YFA leadership completed the survey. Approximately 55% of the Governors who responded indicated that medical schools should require a surgical readiness rotation before advancement to a surgical residency. Approximately 18% of the Governor respondents disagreed, and approximately 27% were unsure.

Respondents younger than 51 years old were more likely to support such a requirement than Governors ages 51 and older. Of the 54 respondents younger than 51 years old, 36 (67%) favored such a requirement, 7 (13%) opposed it, and 11 (20%) were unsure. Among the 223 respondents ages 51 and older, 116 (52%) favored such a requirement, 42 (19%) opposed, and 65 (29%) were unsure. The responses from YFA leaders were similar, with 55% in favor, 20% opposed, and 25% unsure. 

The survey asked which areas should be covered in a surgical readiness rotation (see Table 1) and made an open-ended inquiry as to what other topics should be included. The skills that most Governors thought should be part of this type of educational experience included sterile technique (94%), suturing (90%), knot tying (89%), and identification and initial treatment of shock (89%).

These skills were followed by identification and initial treatment of sepsis (83%), placing nasogastric (NG) tubes (83%), and placing Foley catheters (81%). Starting IVs (76%), identification and initial treatment of pulmonary embolus (PE) (69%), and identification and initial treatment of acute coronary syndrome or myocardial infarction (ACS/MI) (65%) were less consistently considered necessary.

YFA results mirrored those of the Governors, with knot tying and suturing viewed as the most important skills needed, and the least important being initial treatment of PE and initial treatment of ACS/MI. 

Additional suggestions were made in the free text responses. Multiple Governors identified the following skills as essential: Advanced Trauma Life Support®, note and order writing, line placement (especially arterial lines and central venous catheters), chest tube placement, and communication/presentation skills. The YFA free text responses also highlighted instrument identification. 

Forty-nine Governors responded to the question regarding why a surgical readiness rotation is necessary. Several of the Governors’ comments centered on three themes:

  • It is the residency program’s responsibility—not the medical school’s—to teach these skills (echoed in the responses from the YFA leadership)
  • A requirement is unnecessary
  • Experience would vary too greatly across different institutions
  • Furthermore, multiple respondents said that such a requirement could create a barrier to attracting students into surgical fields. Finally, some respondents raised concerns about the College attempting to impose requirements on medical schools. 
  • When asked about the ACS/APDS/ASE Resident Prep curriculum:
  • 29% of the respondents were unaware of this resource
  • 38% were unaware but were interested in learning more
  • 17% were aware of the program and had used it
  • 13% were aware of the program and indicated that they might use it in the future
  • 4% were aware of the program but had no plans to use it

The YFA responses were nearly identical: 28%, 37%, 18%, 15%, and 3%, respectively.

Residency Programs

Just as concerns have been voiced about medical student readiness to start surgical residencies, questions have been raised about whether graduating surgical residents are prepared to enter practice or fellowship training.5-8 These concerns seem to be attributed primarily to two changes in residency training over the past quarter century: the reduced number of hours that residents spend in the hospital and the decrease in resident autonomy.5-8,14,15 Discussions about the need to reevaluate our systems have been ongoing over the same period,4,15 and interest in exploring alternative models seems to have increased in recent years.1-3, 15-20 Most recently, the ACS released a new manual, Optimal Resources for Surgical Education and Training, “The Gold Book,” which provides additional guidance and resources in this area.21

Competency-Based Education and Promotion

Over the past several years, a shift from time-based to competency-based graduate medical education, particularly in surgical fields, has received considerable attention. This concept was piloted with the residency program in orthopaedic surgery at the University of Toronto, ON, and then fully adopted after initial success.16,20 A broad discussion of the potential benefits and costs of such an approach was presented at Clinical Congress 2021 during the Resident and Associate Society (RAS) Symposium (see the August 2021 and March 2022 issues of the Bulletin).*† 

The proponents of shifting residency training to a competency-based approach without predetermined timelines suggest that this strategy allows trainees to develop the competence in each area at their own speed and recognizes that the time needed to do so may vary. Thus, the trainee who needs more time to achieve competence in a particular skill can do so more easily, and the trainee who achieves competence more quickly can move on to the next step and thereby reduce some of the inefficiencies and potential expense the system harbors.17

A number of concerns about a complete shift to a competency-based approach also have been raised. One contention has been that programs already are competency-based. If, at the end of a rotation or the end of the standard time of a training program, a trainee has not demonstrated the level of competence expected, then the trainee will be required to undergo additional education or have the program director attest that he or she has demonstrated enough competence to sit for the board certification examination and to enter independent practice.

Others argue that a competency-based system will encourage trainees to achieve the minimum level of competence needed rather than continued refinement and improvement.17 Finally, concerns have been voiced about the assessment of competence and the potential for implicit or explicit biases to influence these determinations.

Among both supporters and opponents of a fundamental change in our surgical residency training paradigms, some have concerns about operationalizing such a system. Specific concerns include:

  • Patient care needs
  • Educational opportunities “overloaded” with learners or, conversely, an inadequate number of learners
  • Financing graduate medical education under such a system 

Many (166) Governors (60%) supported the concept of competency-based promotion in residency training, but 45 (16%) opposed it, and 66 (24%) were unsure. When these responses were analyzed further based on the Governor’s geographic location (US, Canada, or international), it was noted that 9 of the 11 Canadian respondents (82%) supported the concept, whereas 29 of 47 (62%) international respondents supported it, and 128 of 219 (58%) US respondents supported the concept. The YFA leaders responded similarly, with 64% in support, 12% in disagreement, and 24% unsure. 

More variability was apparent in the responses regarding the logistical and financial feasibility of implementing a competency-based promotion system. When asked whether they believed that competency-based promotion was logistically feasible, 38% (105) of the Governors responded yes, 29% (80) said no, and 33% (92) were unsure. Nearly 27% (74) said they believe that competency-based promotion is financially feasible, 29% (80) reported it was not, and 44% (123) were unsure. Among YFA respondents, 33% said it was possible, 27% did not, and 40% were unsure. 

Flexibility in Surgical Training

The American Board of Surgery (ABS), in 2011, approved the option for flexibility in surgical training (FIST). This new structure allows, with advanced approval from the ABS and the Review Committee-Surgery of the Accreditation Council for Graduate Medical Education (ACGME), for 12 of the last 36 months of time-based training to be customized to meet a resident’s interests or needs. Several residency programs in surgery offer this option, and though some challenges need to be addressed, overall satisfaction is high.22 An interim analysis did not detect significant differences in ABS In-Training Examination scores or in ACGME milestone requirements for the residents who participated in FIST compared with residents who did not.23 

Respondents indicated strong support for flexibility in surgical training programs to better meet their residents’ needs. Among the Governors, 79% indicated that they believed programs should be able to vary experiences to better meet the needs of trainees’ anticipated practice models; 8% disagreed, and 14% were unsure. Seventy percent said they supported a 2-to-3-year core surgical curriculum followed by flexibility in the last 12−36 months to concentrate on an area of interest; 12% did not support this concept, and 18% were unsure.

The YFA had similar responses, with a resounding 76% in support of FIST and only 6% opposed. 

When asked about potential benefits or concerns with FIST as an open-ended question, the responses fell into the following general categories, and the same themes were repeated frequently among respondents. Potential benefits included:

  • Better preparation for specialty practice
  • Improved ability to assign rarer cases to residents who will care for such patients in the future (more efficient use of resources)
  • Greater resident engagement
  • Potential concerns included:
  • Loss of a standardized general surgery skill set and the inability to predict practice needs in the future (including taking call)
  • Logistics of varied resident schedules
  • Clinical/educational supply meeting resident demand if a high percentage of residents want to pursue the same opportunities
  • Fairness and possible bias/disparities
  • Residents with interests that change over time 
Figure 1. What Does Your Hospital Require?
Figure 1. What Does Your Hospital Require?

Practicing Surgeons

Surgical practice requires lifelong learning, and surgical fields continue to evolve. Better understanding of diseases as well as the development of new or improved techniques and technologies foster the continued growth and refinement of all surgical disciplines. What at times has been unclear is how surgeons who have completed their formal training should decide when to adopt new ideas or treatments and how to do so safely and responsibly.

The topic of credentialing surgeons, especially in the adoption of new procedures, has been discussed in the ACS Communities. Some guidance was provided in the 2017 ACS manual Optimal Resources for Surgical Quality and Safety (“The Red Book”).24 Subsequently, in October 2018, the College put forth a Statement on Credentialing and Privileging and Volume Performance Issues,25 which defined principles for learning and incorporating new surgical procedures and technologies into practice. These principles include “mastering didactic content, technical training in an inanimate model, precepted incorporation of the new technique or technology into practice, and demonstration of satisfactory patient outcomes.” The College also is working on an accreditation program for rural surgery that provides guidance on this issue.

The 2021 B/G annual survey sought to explore training for attending surgeons in addition to residents and medical students. Among the Governors, 77% indicated that university programs should offer education regarding new procedures and technologies to private practice groups in their specialty; 4% thought they shouldn’t, and 19% were unsure. Interestingly, the responses to this question were similar regardless of practice type and were similar to the YFA leadership responses of 66% in favor, 6% opposed, and 27% unsure (numbers rounded). 

Asked whether hospitals had a standard process for granting privileges to attendings for using new procedures, techniques, and technologies, 67% of the respondents said yes, 19% said no, and 14% were unsure. These responses differed greatly from the YFA responses, which were more evenly split: 40% said yes, 30% said no, and 30% were unsure. Of the Governors who affirmed that a standardized approach existed in their institutions, 186 answered more specific questions about the process. Ninety-two percent indicated a requirement for documentation of training in the requested new privilege; 5% indicated that their institution did not have such a requirement, and 3% were unsure. Furthermore, 84% indicated that their institutions had proctoring of performance of a new privilege, 9% indicated they did not have proctoring, and 7% were unsure (see Figure 1). 

Fewer hospitals require reapplication for privileges/credentialing if a specified amount of time has passed since a surgeon has performed a procedure; 58% responded that their hospital does, 30% that their hospital does not, and 12% were unsure. However, 69% indicated that their hospital requires other safety/quality assurance measures (such as documentation of outcomes) with new privileges, procedures, or technology; 21% indicated their hospital does not, and 10% were unsure. 


Surgical training is a process of lifelong learning that starts in medical school and continues throughout one’s practice. The surgical training paradigms have changed and evolved over time and are at a critical point of evaluation. The responses to this survey seem to be consistent with much of the literature. Governors and YFA leaders have some concerns about the existing models of surgical education in both medical school and residency, but it is difficult to find consensus around which aspects of our surgical training paradigms should change or how best to do so. 

Respondents expressed a range of opinions around the idea of a surgical readiness rotation in medical school. Approximately half the respondents said that such an experience should be required, whereas the rest felt that it should not be a requirement or were unsure. If such an experience exists, there was greater consensus around the educational content that should be included, but respondents indicated that the ACS should not attempt to create additional mandates for medical schools.

Two-thirds of the respondents were unaware of the ACS/APDS/ASE Resident Prep Curriculum. More than half of those who were unaware of the program expressed an interest in learning more about it. This finding would suggest that perhaps clerkship directors of medical school surgical rotations would benefit from more regular dissemination of information about this and other pertinent resources available to them. 

Ongoing discussions regarding surgical residency training, the optimal degree of flexibility, and the idea of competency-based education and promotion undoubtedly will continue. The survey results reflect a broad spectrum of opinions. Hence, the Governors would recommend that the ACS act as a facilitator for these ongoing discussions rather than advocating for one approach or another at this time. 

Finally, innovation and evolution of surgical techniques and technologies will continue. The responses to these survey questions suggest a reasonable level of consistency among hospitals, although this process can be challenging, particularly in rural and community hospitals. The College’s Statement on Credentialing and Privileging and Volume Performance Issues25 and “The Red Book” provide some guidance.24 The ACS should continue to monitor and advocate for best practices in this realm to allow for the development and adoption of novel treatment options while maintaining the safety and trust of our patients.



Donald R. Mackay, MB BCh, FACS, G. Thomas Marshall, MD, FACS, Bryan K. Richmond, MD, MBA, FACS, and Arghavan Salles, MD, PhD, FACS.



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  8. Bell RH Jr, Biester TW, Tabuenca A, et al. Operative experience of residents in US general surgery programs: A gap between expectation and experience. Ann Surg. 2009;249(5):719-724.

  9. Lyss-Lerman P, Teherani A, Aagaard E, et al. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med. 2009;84(7):823-829.

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  12. Brunt LM, Halpin VJ, Klingensmith ME, et al. Accelerated skills preparation and assessment for senior medical students entering surgical internship. J Am Coll Surg. 2008;206(5):897-904.

  13. Boehler ML, Rogers DA, Schwind CJ, et al. A senior elective designed to prepare medical students for surgical residency. Am J Surg. 2004;187(6):695-697.

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  16. Nousiainen MT, Mironova P, Hynes M, et al. Eight-year outcomes of a competency-based residency training program in orthopedic surgery. Med Teach. 2018;40(10):1042-1054.

  17. Frank JR, Snell LS, Ten Cate O, et al. Competency-based medical education: Theory to practice. Med Teach. 2010;32(8):638-645. 

  18. Skjold-Ødegaard B, Søreide K. Competency-based surgical training and entrusted professional activities–Perfect match or a Procrustean bed? Ann Surg. 2021;273(5):e173-e175.

  19. Mickelson JJ, MacNeily AE, Samarasekera D, et al. Competence in pediatric urology upon graduation from residency: Perceptions of residents, program directors and pediatric urologists. CUAJ. 2008;2(3):205-210.

  20. Ferguson PC, Kraemer W, Nousiainen M, et al. Three-year experience with an innovative, modular competency-based curriculum for orthopaedic training. J Bone Joint Surg. 2013;95(21):e166(1-6).

  21. Hoyt D, Sachdeva AK, Flint LM, Richardson JD (eds). Optimal Resources for Surgical Education and Training. Chicago, IL: American College of Surgeons; 2021.

  22. Klingensmith ME, Awad M, Delman KA, et al. Early results from the Flexibility in Surgical Training Research Consortium: Resident and program director attitudes toward flexible rotations in senior residency. J Surg Ed. 2015;72(6):e151-e157. 

  23. Cullinan DR, Wise PE, Delman KA, et al. Interim analysis of a prospective multi-institutional study of surgery resident experience with flexibility in surgical training. J Am Coll Surg. 2018;226(4):425-431.

  24. Hoyt D, Ko C (eds). Optimal Resources for Surgical Quality and Safety. Chicago, IL: American College of Surgeons; 2017.

  25. American College of Surgeons. Statement on Credentialing and Privileging and Volume Performance Issues. 2018. Available at: https://www.facs.org/about-acs/statements/111-credentialing. Accessed March 21, 2022. 


*Ryans R, Heremans K, Vigneshwar N, Koo K, Essig R. RAS-ACS Symposium: Competency-Based Training: A Gateway to Efficiency or a Hurried Sprint to the Finish Line? Bull Am Coll Surg. 2022;106(8):56-61.

†RAS-ACS Symposium: Competency-Based Training: A Gateway to Efficiency or a Hurried Sprint to the Finish Line? Bull Am Coll Surg. 2022;107(3):25-32.