Unsupported Browser
The American College of Surgeons website is not compatible with Internet Explorer 11, IE 11. For the best experience please update your browser.
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.

Become a Member
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

Blue Ribbon Committee II Advises Sweeping Changes in Surgical Education

M. Sophia Newman, MPH

May 8, 2024


Members of the BRC II Steering Committee and Subcommittee Chairs met at ACS Headquarters in November 2023.

The second Blue Ribbon Committee on Surgical Education (BRC II) announced its recommendations for optimizing the future of surgical education at the recent American Surgical Association (ASA) Annual Meeting in Washington, DC.

The inaugural Blue Ribbon Committee on Surgical Education (BRC I) published a groundbreaking report on surgical education1 in the Annals of Surgery in early 2005. That committee, led by the ASA in partnership with the ACS, American Board of Surgery (ABS), and Resident Review Committee-Surgery (RRC-S), assembled in response to projected shortages in surgeons. It held discussions from June 2002 to mid-2004. The group ultimately made 40 recommendations for changes at every level of surgical education.

Twenty years on, much has changed, from national demographics to the rise of artificial intelligence. Facing a new era, the BRC II—after again assembling surgeons from across the field of surgery as well as the ASA, ACS, ABS, RRC-S, and other organizations—is taking the opportunity to ask: How can surgery as a profession best educate the next generation of surgeons?

Why Now?

Steven C. Stain, MD, FACS, who is now the immediate past president of the ASA and a member of the ACS Board of Regents, said the impetus for the BRC II arose at a lecture by Richard K. Reznick, MD, FRCSC, FACS, a colorectal surgeon and past president of the Royal College of Physicians and Surgeons of Canada (RCPSC) at an ABS-sponsored summit on competency-based education. Dr. Stain spoke in rebuttal to a public presentation by Dr. Reznick on entrustable professional activities (EPAs) and competency-based education, which the RCPSC has championed in Canadian surgical training. Dr. Stain advised caution in implementing these new approaches in the US.

In response, John D. Mellinger, MD, FACS, vice president of the ABS, requested that Dr. Stain initiate a second BRC to examine advancements in surgical education more closely. Dr. Stain agreed—on the condition that E. Christopher Ellison, MD, FACS, who was then ACS President, become involved: “He will be the one who will make sure we get it done.”

Dr. Ellison embraced the idea, feeling motivated to address growing work demands, new technology, concerns about insufficient operative readiness in new practicing surgeons, and myriad other issues. “There have been dramatic changes in how we take care of patients. It’s become more and more complex to be a surgeon,” he said.

A Careful Process

The BRC II used a careful process to generate its new set of recommendations. After gathering 67 surgeon members representing general surgery and its related specialties, the group created nine subcommittees. One included all members of the BRC I (which included neither Dr. Stain nor Dr. Ellison). The other eight subcommittees were tasked with discussing one aspect of surgical education as originally outlined by the BRC I and generating current recommendations for its optimization. The proposals of the entire group were then compiled and sorted, and the list was subjected to a Delphi analysis.

The Delphi method, first developed in the 1950s,2 is based on a series of rounds in which a panel of experts shares perspectives on a topic, receives an aggregated summary of the full group’s views after each round, and is given the chance to revise answers in light of these insights. After a few rounds, views often converge; when a predesignated stopping point is reached, the group finalizes a decision.

In the case of the BRC II, three rounds of discussion were held, and each ended with a vote. Only the recommendations with more than 80% approval (in other words, a “yes” from at least 54 members) were considered acceptable to include in the final report. In the first round, which generated 23 recommendations, members also voted on the impact and feasibility of all items on a 5-point Likert scale. Unapproved items were submitted to two more rounds of discussion and voting. Each resulted in four more recommendations.

Given the broad scope of surgical training and logistical considerations, the BRC II found it infeasible to include all surgical disciplines as part of this project. Recognizing that the committee was focused on general surgical specialties and contained few surgical residents, the BRC II also sought to share the report with surgeons in all disciplines. Dr. Ellison explained, “We had a separate meeting with representatives of all the surgical specialties for a 2-hour review of the recommendations. The purpose of this was to share our findings, as many of the recommendations may be applicable to their training programs, and get their feedback.”

Ellison says they gleaned meaningful insights from the session, including that a high level of interest from the surgical specialties and a need for further engagement exist.

In addition, he noted, “We had a focus group with 16 residents as a separate meeting and provided them with the recommendations, and they actually did the Delphi assessment at a separate time from the panel,” generating recommendations that differed slightly from the main BRC II and that, per Dr. Ellison, will be the topic of a manuscript submitted for publication.

What Does the New Report State?

Through these processes, the committee reduced an initial 50 recommendations to 31. They are far-reaching by design, ranging from diversity to finance.

To enhance medical student education in surgery, the BRC II recommended providing better support programmatically and financially, to the faculty and residents engaged in teaching medical students. The group also suggested convening multiple organizations to optimize the residency selection process, so that it evaluates leadership, decision-making, ethical, and technical skills via standardized assessments.

To enhance work-life integration and wellness, the BRC II suggested a mixed qualitative and quantitative approach: on the one hand, advising the creation of best practice recommendations for a surgical “culture of belonging,” and on the other, suggesting a multidisciplinary group of national organizations be convened to assess how to equitably and sustainably improve resident wages, particularly by considering the return on investment for surgical training.

Other subcommittees also focused on finance. The faculty development portion of the recommendations noted a need to examine the economic value of surgical trainees to negotiate hospital payment for their work, as well as ways to pay surgeons for their efforts educating medical students and surgical trainees. The financing section proposed efforts to address caps on surgical residencies and determine how to best pay for resident education.

Elsewhere, resident education recommendations include expanding mentorship during residents’ transition from training into independent practice, while further faculty development suggestions describe a need for a national curriculum for faculty training and an assessment tool for faculty teaching performance.

The recommendations also address the original impetus behind the BRC II: EPAs and competency-based education. The BRC II proposes both, including EPAs to be included in the proposed national faculty training curriculum and promulgating national guidelines for comprehensive, competency-based reforms, as well as a national research consortium that will critically review the effectiveness of such reforms.

Finally, the BRC II report contains meaningful suggestions for “people who really want to become surgeon-scientists,” Dr. Stain noted.

“Typically, you do 2 years of research in the middle of your residency, then do your fellowship—and by that time, it’s 5 years later and your research is probably not up to date enough to get you funded,” he explained. “We’re suggesting a paradigm where people can do a continuum of their research and fellowship in the same span.”

Although this raises questions on resources and funding, he acknowledged, “It’s the way it’s been more successful in getting a funded research scientist, so there are some tracks that we recommended for that.”

24maybullblueribbonsidebarweb4-29.jpg (2)

Recommendations of the BRC I

In total, the BRC II represents a step forward from the BRC I. The BRC I report1 addressed issues ranging from medical student education in surgery to continuous professional development. Its 40 recommendations were sweeping—“no less than a new surgical education system,” the article stated, continuing, “This will require major redesign of surgery residency training and allocation of sufficient resources to achieve the desired outcomes.”

In specific, the BRC I proposed expanding the workforce and recruiting more surgeons to address a then-pending surgical workforce shortage. Read more on workforce shortage in the April issue of the ACS Bulletin. In part, to create a workforce pipeline, the group recommended increased focus on educating medical students, including “surgical education centers”1 which emphasize teaching expertise and education science.

In addition, the BRC I suggested creating and implementing a national curriculum for residents; devising a modular, competency-based course in the fundamentals of surgery; and shifting all noneducational activities to the nonphysician workforce. It also suggested the integration of educational technologies, such as surgical simulation, as soon as resources become available.

The report featured a proposal for a structure of surgical training that included an optional research period or advanced degree in the middle of residency, reflexive training in basic research methodologies for all residents, and the creation of a surgeon-scientist training pathway—a recommendation the BRC II has now significantly updated.

Finally, the report included recommendations to change the structure and functions of academic surgical departments to improve teaching—even though to do so, the report acknowledged, would require the same problem the BRC II aims to confront: that surgical departments “develop a mechanism to enable faculty to devote more time in the nonrevenue-generating educational activities.”1

These suggestions included several other items familiar from the BRC II, such as asking all surgical chairs and division chiefs to demonstrate fundamental knowledge of education, providing the training necessary for existing surgeons to develop skills in teaching, evaluation, and education research, and standardizing methods of evaluation for residents.

Impact of the BRC I

In the 19 years since the BRC I report was published, many of those efforts have taken place. Some are reflected in ACS offerings, including courses such as Surgeons as Educators and Successfully Navigating the First Year of Surgical Residency, which is aimed at medical students and PGY-1 residents. The College also has a program, Clinical Scholars in Residence, that grants surgical trainees in mid-residency 2 years of research experience, matching the BRC I’s outline of surgeon-scientist development.

“Simulation centers came out of the first BRC,” Dr. Stain added, which aligned with a comment from Dr. Ellison that the ACS has helped surgeons embrace surgical simulation techniques via its annual Surgical Simulation Summit and other resources.

Success of the BRC I report went well beyond the College. While both Drs. Ellison and Stain readily admit that not all the recommendations have come to fruition, they describe the outcome similarly. “The things that were under control of surgeons,” Dr. Ellison said, as opposed to items requiring federal regulation or C-suite participation, “actually got done.”

A prime example lies in the establishment of a national curriculum for training in general surgery and related surgical specialties. After the BRC I published its report, a second group, the Surgical Council on Resident Education (SCORE), convened in 2006.3 Many of the organizations represented in the BRC I were part of this new nonprofit consortium. Together, they devised a curriculum meant for general surgeons and those in related specialties, that focused on patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning, and systems-based practice.4

SCORE has since been adopted nationally, and its offerings have extended to curricula for vascular surgery, pediatric surgery, surgical critical care, and surgical oncology. It also has been aligned with board certification examinations, such as the ABS In-Training Examination and the General Surgery Qualifying Exam. In 2019, SCORE merged with the ABS, the key administrator of board certification in surgery.7 In its new recommendations, the BRC II advised the ongoing review and update of SCORE to ensure its lasting relevance.

“The College is the largest surgical organization in the world, and it has the reach and scope to bring these groups together.”

Dr. Chris Ellison

What Comes Next

While the current process in many ways is an extension of the BRC I, it is in some ways more robust. The BRC I was completed in mid-2004; its report was published in the Annals of Surgery in early 2005.1 The BRC II also aims for publication of its recommendations in the Annals of Surgery, having already submitted a draft. Unlike the BRC I, however, each subcommittee in BRC II and its surgical resident and fellow focus group have written their own papers. As with the full report, these are intended for publication in the near future.

In addition, the BRC II, its surgeon members, and the organizations they represent will undoubtedly pursue many of the aims that have been laid out. One of the key recommendations was for the establishment of a multidisciplinary surgical education committee to facilitate and monitor implementation of the recommendations. Unlike the BRC I, the new recommendations list organizations that could join multiorganizational task forces on specific issues. Others omit organizational names but call for new processes, systems, and best practice recommendations, implying a need for collaboration across groups. In time, Dr. Ellison said, those will surely come.

The ACS will no doubt be important to this process, Dr. Ellison added: “The College is the largest surgical organization in the world, and it has the reach and scope to bring these groups together. The ACS is the House of Surgery, and surgical education and training are vitally important to the continued success of our profession in providing the healthcare needs of our country and beyond. The ACS has been at the table and very involved. I think they will play an important role in convening the groups to move this effort forward.”

Adding to a Rich History

Of course, the history of concerns about surgical education and training go much farther back than the BRC I. Indeed, the question of how surgeons should be educated and trained has been central to the ACS since before its founding. In 1913, Franklin H. Martin, MD, FACS, a surgeon-gynecologist, and others founded the ACS in part in response to a lack of postgraduate surgical education, building on surgeons’ strong collective drive to improve their training and outcomes.

The ACS entered a world in which the surgical residency was nascent. The legendary surgeon William S. Halsted, MD, FACS(Hon), was the first to establish a surgical residency5­—one with surprisingly durable central concepts. In a speech at Yale University in 1904, Dr. Halsted said, “We need a system, and we shall surely have it, which will produce not only surgeons but surgeons of the highest type,” an outcome possible only through reforms “providing the requisite opportunities for the prolonged and thorough training of those preparing for the higher careers in medicine and surgery.”6

It was in, in essence, what both BRCs have attempted to continue more than a century later with the 2,848 graduate surgical education programs now in existence,7 from the overall vision to the assurance that, in large part, “we shall surely have” the proposed changes made real in many respects.

In the same speech, Dr. Halsted articulated the qualities a surgeon should attain through education and training: “to be an impressive teacher of surgery, to attract important cases in large numbers, to exert an influence far and wide as a surgeon, to know his subject thoroughly.”6

Through the residency system that Dr. Halsted himself devised, many surgeons have attained exactly those attributes—and with the BRC II now advancing the same core ideas in our own time, many more will, too.

M. Sophia Newman is the Medical Writer and Speechwriter in the ACS Division of Integrated Communications in Chicago, IL.

  1. Debas HT, Bass BL, Brennan MF, et al. American Surgical Association Blue Ribbon Committee Report on Surgical Education: 2004. Ann Surg. 2005;241(1):1-8.
  2. Barrett D, Heale R. What are Delphi studies? Evid Based Nurs. 2020;23(3):68-69.
  3. Sachdeva AK, Bell RH, Britt LD, et al. National efforts to reform residency education in surgery. Acad Med. 2007;82(12):1200-1210.
  4. American Board of Surgery. About Us: The Surgical Council on Resident Education. No date. Accessed February 4, 2024. https://www.absurgery.org/about-abs/score/.
  5. Cameron JL. William Stewart Halsted: Our surgical heritage. Ann Surg. 1997;225(5):445-458.
  6. Halsted WS. The training of the surgeon: The annual address in medicine delivered at Yale University, June 27, 1904 / by William Stewart Halsted. Wellcome Collection. No date. Accessed February 4, 2024. https://wellcomecollection.org/works/sap5h2ex.
  7. Brotherton SE, Etzel SI. Graduate Medical Education, 2022-2023. JAMA. 2023;330(10):988-1011.