Are Graduating Surgical Residents Ready for Practice?

In our data-driven world, surgeon educators have searched for that elusive outcomes measure that demonstrates the success of our training programs.

The Accreditation Council for Graduate Medical Education (ACGME) relies heavily on first-time board pass rates as the primary outcome measure for evaluating the preparedness of graduating residents for independent practice, but surgeon educators are acutely aware that passing the boards alone does not make one “practice ready.”

Many of our colleagues have raised concerns over whether our national training efforts are producing confident, capable, and practice-ready surgeons.

Mattar and colleagues articulated these concerns in 2013,¹ after a survey of fellowship program directors (PDs) in minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties demonstrated that nearly 40% of first-year fellows in these specialties lacked clinical preparedness and a sense of ownership for their patients. Further, 43% of fellowship PDs suggested that incoming fellows could not independently or safely complete 30 minutes of a basic operation such as a laparoscopic cholecystectomy.

While these findings were not necessarily the first to raise the alarm regarding this issue, the report did receive significant attention and initiated a lot of activity with the goal of understanding the contributing factors leading to this lack of practice-ready surgeons.

The ACS surveyed members of the Board of Governors (representing more seasoned surgeons) and the Young Fellows Association (reflecting more recent surgical attendings) regarding their impressions of graduating residents’ readiness for practice.²

The majority (90%) of younger surgeons suggested that they were prepared for attending practice. However, nearly 60% had completed fellowships after residency, and 20% of those indicated that not feeling prepared to practice was part of the reason for doing a fellowship.

The more senior surgeons, 70% of whom had recently hired a new surgeon, responded that more than 50% of their younger colleagues were not prepared for their attending role. Nearly 80% of senior surgeons supported the concept of a transition-to-practice opportunity for recent graduates.

This report and others raised concerns about the reasons why residents choose fellowship and brought the question of confidence into the foreground. Confidence is not easy to measure, and there are conflicting definitions in the literature. The author concluded that graduating general surgery residents had low confidence in their abilities, though the relationship between confidence, competence, and autonomy is complicated and poorly studied.³

The American Board of Surgery (ABS) examined the readiness of general surgery residents in a large prospective study of the defined core procedures.⁴ It concluded in 2017 that general surgery residents are not universally ready to independently perform core procedures at the end of training and that opportunities for autonomy during training were limited. The study’s authors speculated that the lack of autonomy may be the precipitating factor in being underprepared for independent practice.

We wanted to understand the context for these concerns regarding resident readiness and explore the role of advocacy in creating an environment where some of these factors can be alleviated or modified.

Trainees, Faculty Voice Concerns Regarding Readiness

Both surgical residents and teaching faculty have expressed concerns regarding the preparation of graduating surgical residents for independent practice.

Concerns Raised by Residents

A common sentiment shared by many graduating residents is the perception that appropriate autonomy has not been granted by teaching faculty, whether in the OR or clinical setting.

A recent publication noted significant variability in senior resident and fellow level of supervision during surgical oncology cases. In breast and soft tissue, thyroid, and/or hepatobiliary cases, less than 50% of trainees achieved a practice-ready or better performance as rated by their faculty. More importantly, the study also showed that those trainees who performed at a practice-ready or exceptional level received the lowest level of supervision in less than 25% of cases.⁵

Nonclinical but essential tasks that constitute part of the clinical care of patients, otherwise known as “scut” work, also may affect the clinical and operative opportunities for surgical residents. These include, but are not limited to, acquiring outside medical records, verifying prescriptions through different pharmacies, filling out large volumes of electronic documentation, scheduling outpatient follow-up appointments, and coordinating complex hospital discharges. These tasks are neither part of the general surgery curriculum defined by the ABS nor are they indicative of the essential skills taught in medical school.

This burden of patient care often falls directly upon the residents to complete, particularly in their early years. Unfortunately, these tasks typically occur in direct conflict with clinical and operative opportunities, and, as result, younger residents may be forced to forego opportunities in straightforward cases or to double scrub with their more senior peers. This reality may limit time and familiarity with attendings, resulting in decreased autonomy during surgical cases or in future years on the same surgical service.

A study published in the Journal of Surgical Education may support this assertion. The authors demonstrated that a substantial time of a resident’s workweek involved electronic health record (EHR) usage and documentation. In this study, second-year residents had the highest median usage per week (28.9 hours) and had a significant negative correlation with operative case logs (r = -0.2, p = 0.038). Throughout all 5 clinical years, 30% of the 80-hour workweek was focused on documentation and EHR work.⁶

Concerns Raised by Faculty

Surgical faculty may have a different perspective regarding the readiness of the new generation of graduating surgical residents.

Legal Challenges

The first barrier to appropriate autonomy may be in the legal landscape surrounding an attending’s own ability to grant such autonomy. As highlighted in a 2018 ACS Bulletin article, the legal statutes surrounding the role of the resident are well defined by the US Centers for Medicare & Medicaid Services (CMS), Bell Commission of 1989, and the Omnibus Budget Reconciliation Act of 1989.7 (see Figure, above).

80-Hour Workweek

Although implemented 20 years ago, the impact of the 80-hour resident workweek policy may still have some effect on faculty perceptions regarding the preparedness of the graduating resident. First introduced in 2003, the effects of the change in duty hours on various aspects of patient care and surgical training have been studied extensively.

A meta-analysis published in the Annals of Surgery found no definitive improved patient safety after the implementation of duty-hour restrictions nor increased resident satisfaction.⁸ And while faculty members might assume that the change to the 80-hour workweek had a negative impact on the number of resident or chief operative cases, this assumption is not entirely accurate.

A meta-analysis by Ashraf and colleagues found no substantial correlation between the institution of duty-hour restrictions and operative case volume. Of the 26 studies included, 11 studies (61%) demonstrated a neutral or positive effect, while seven studies (39%) demonstrated a negative effect on total operative numbers.⁹

Lifestyle and Generational Aspirations for Work-Life Balance

Seasoned attending surgeons may hold the perception that residents and graduating chiefs “didn’t experience the same residency training they did.” Other perceptions from this group might find this generation “softer” or “not as dedicated to the profession.”

Recently, an article in The Wall Street Journal, “Young Doctors Want Work-Life Balance. Older Doctors Say That’s Not the Job,” highlighted personal anecdotes throughout the US regarding the differences in mindset between senior and junior medical faculty in a variety of specialties.

This article included top-ranked institutions such as Johns Hopkins, where younger medical staff advocated for more sick leave and freedom to take days off, which resulted in a doubling of the number of on-call physicians to achieve adequate coverage.¹⁰

Studies regarding the attitudes of the Millennial and Gen-Z workforces in the business and technology sectors reveal similar views. According to one such study by Sanchez-Hernandez and colleagues, Millennial and Generation Z workers understand the need for work-life balance and give it greater importance than previous generations.

Millennials prioritize factors related to promoting a suitable work-life balance, specifically vacation and free time, and work flexibility. This is counter to the views of older Baby Boomers, who mainly sought stability and security in their work, and Generation X, who assigned more importance to work relations over other variables.¹¹ Although a work-life balance approach may prevent burnout for young physicians, this mindset may may lead to fewer hospital hours, resulting in decreased residency clinical experiences for new attendings.

Empowering New Surgeons Through Targeted Programs

What solutions can The House of Surgery^® offer to aid in the preparation of new attendings? We highlight a few advocacy strategies and programs to help address the issues described in this article.

Entrustable Professional Activities

The Entrustable Professional Activities (EPAs) represent a significant shift in the assessment of surgical trainees introduced by the ABS in July 2023.¹² The EPA framework was incorporated into general surgery residency programs by the ABS in collaboration with other surgical bodies, including the ACS, Association of Program Directors in Surgery, and the ACGME Surgery Review Committee.¹³

These EPAs aim to transition the assessment model from time-based training to a competency-based approach, prioritizing the achievement of specific competencies necessary for providing effective patient care.¹³ By assessing competency rather than adhering to a predetermined time for training, graduating residents will have achieved specific mandatory competencies to successfully and effectively care for patients. Evaluation of the efficacy and resultant competency-based resident assessment of these EPAs is a key consideration in the perceived readiness of graduating residents to enter surgical practice. Support from other professional societies, such as the ACS, and evaluation of quality outcomes are essential for full incorporation.

Debt Relief

Many residents enter surgical training carrying a significant burden of debt incurred during their undergraduate and medical education. This debt, which is more than $230,000 on average, excluding premedical undergraduate and other educational expenses, affects approximately 73% of medical school graduates.¹⁴

The weight of this debt can exert undue pressure on residents to prioritize the shortest possible path to becoming an attending physician in order to repay their loans. This pressure may discourage them from pursuing additional training or opportunities, such as fellowships and transition-to-practice programs, which could enhance their skills and career prospects.

The financial burden of education-related debt not only affects the well-being of residents but also has potential implications for patient care. Limiting the number of physicians pursuing advanced or additional training may contribute to a shortage of specialists in certain fields and reduce the quality and availability of healthcare services.

Addressing the issue of education-related debt can contribute to a more diverse and inclusive healthcare workforce. Individuals from socioeconomically disadvantaged backgrounds may be disproportionately affected by educational debt, limiting their ability to pursue medical careers. By reducing the financial burden on residents, we can encourage learners to pursue their training goals without compromising their well-being or the quality of patient care.

Advocating for policies to reduce educational debt is crucial to address this issue. This may include measures such as increasing the availability of need-based financial aid, expanding loan forgiveness programs, and providing more affordable options for medical education.

The ACS has endorsed two pieces of legislation aimed at addressing the financial burden of medical education. The Resident Education Deferred Interest (REDI) Act (S 942/HR 2028), introduced by Senators Jacky Rosen (D-NV) and John Boozman, OD (R-AR), and Representatives Brian Babin, DDS (R-TX), and Chrissy Houlahan (D-PA), would allow borrowers in medical or dental internships or residency programs to defer student loan payments without interest until the completion of their programs.

The Specialty Physicians Advancing Rural Care Act (S 705/HR 2761), introduced by Senators Rosen and Roger Wicker (R-MS) and Representatives Joyce and Deborah Ross (D-NC), would establish a new loan repayment program allowing specialty physicians who agree to practice in a rural area for 6 years to have up to $250,000 of their student loans forgiven. The ACS Division of Advocacy and Health Policy is working with lawmakers to advance both bills.

Video-Based Assessment and Certification

Video-based assessment and certification opportunities are increasingly more common with the advancement of technology. These pathways allow residents to receive mentorship and evaluation from experts on surgical skills, ensuring competency and providing valuable feedback.^15,16 Residents can benefit from ongoing feedback during their training, allowing for the assessment of their competency and readiness for graduation. Additionally, post-training video assessments can evaluate residents’ long-term skill retention. Advocating for a Health Insurance Portability and Accountability Act-compliant and a bias-free platform and framework are essential for the use of this technology in this context.

Impact of Surgeon Shortages

The US is facing a severe shortage of surgeons in general surgery and several surgical specialties, particularly in rural communities, and the number of surgeons is expected to continue to decline in the future.¹⁷ The surgeon shortage has several potential consequences, including longer wait times for surgery, which can lead to delays in diagnosis and treatment and result in serious health consequences. Additionally, long travel distances to receive surgical care can be a burden for patients in rural or medically underserved areas, who may have limited access to transportation or other means of access to care.

Ensuring graduating residents are prepared to enter the workforce is essential as they may require broad expertise to practice in rural or underserved communities. Previous studies have demonstrated that 75% to 80% of general surgery graduates pursued fellowship training due in part to concerns about attaining an adequate breadth of expertise needed for community practice.¹⁷ A competency-based assessment of surgical skills rather than a time-based assessment may allow more residents to enter practice and meet these gaps.

With looming surgeon shortages and increasing numbers of surgical specialists, concerns arise about the readiness of general surgery residents to enter practice. The question remains whether our residency training programs, as currently outlined, can prepare trainees for practice in a rapidly evolving surgical landscape.

Disclaimer

The thoughts and opinions expressed in this article are solely those of the authors and do not necessarily reflect those of the ACS.

Dr. Eric Lazar is chair of surgical services at Valley Medical Group in Paramus, NJ, and director of the General Surgery Residency Program in partnership with the Icahn School of Medicine at Mount Sinai in New York, NY.

References

1. Mattar SG, Alseidi AA, Jones DB, Jeyarajah DR, et al. General surgery residency inadequately prepares trainees for fellowship: Results of a survey of fellowship program directors. Ann Surg. 2013;258(3):440-449.
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10. Chen TP. Young doctors want work-life balance, older doctors say that’s not the job. Wall Street Journal. November 3, 2024. Available at: https://www.wsj.com/lifestyle/careers/young-doctors-want-work-life-balance-older-doctors-say-thats-not-the-job-6cb37d48. Accessed November 14, 2025.
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