Journal Review in Surgical Education: Blue Ribbon Committee II

Hello, and welcome to another episode of Behind the Knife in Surgical Education. We are the General Surgery education team from Cleveland Clinic. I'm Puja Varen, a general surgery resident and surgical education research fellow. And I'm Judith French. I'm the PhD Education Scientist for the Department of General Surgery at the Cleveland Clinic. And I'm Jeremy Litman, the DIO and Director of Graduate Medical Education here. On today's episode, we discuss the second blue ribbon committee, the inaugural committee convened in 2002 to identify surgical needs of the modern era and make recommendations for changes needed in surgical education. Their first set of recommendations published in 2005, focused on the structure of general surgery, residencies and specialization through fellowships work-life balance, simulation-based training and dedicated research time. As the medical landscape has transformed substantially over the last 20 years, a second Blue Ribbon Committee convened in 2023 to

update these recommendations. We're joined today by the co-chair of this committee, Dr. Steven Stan. Attended uc, Irvine for medical school and completed general surgery residency in visceral and transplantation surgery fellowship at LA County USC Medical Center. He's a hepatobilliary surgeon and chair of surgery at Lahey Hospital and Medical Center in Burlington, Massachusetts. He has quite the national presence. Having served as chair of the Board of Governors of a CS, chair of the American Board of Surgery and President of the American Surgical Association and the Society of Black Academic Surgeons, we're very excited and honored to welcome this leader in surgical education to the show. Welcome Dr. Sta. Thank you, Dr. Barman, for having me. So let's go ahead and start with some background for our listeners who aren't familiar with the Blue Ribbon Committee. Can you tell us about some of the key issues that motivated the creation of the BRC back in 2002?

When Heidi Debas was president of the American Surgical Association, he assembled a committee of leading educators to evaluate state of surgical education and came up with some recommendations that were published, as you said, in adults surgery in 2005. I think there was a belief that we could do better. Training surgery residents and subsequently people went into fellowship as well. So I think some seminal recommendations came out of that, and in retrospect had a tremendous impact upon surgical education over the last 20 years. If you were to highlight the impact that the first set of recommendations from the BRC has had, what would you share with our audience? Tim Flynn, who was a member of the BRC one committee, was a vascular surgeon at University Florida. He was also chair of the American Board of Surgery. He was also chair

of the A CGB. He wrote up the reflections of the BRC one committee on what happened that was published in Annals this month. And in that he outlined what. The group of BRC one members thought were the most significant things and I think it's sometimes we forget what came out of that group. So, just a few things that I've would like to point out. Score educational curriculum that was started by Dick Bell and Frank Lewis has become the sort of the basic curriculum for surgical residency training. Also simulation labs. Which were recommended, that program are now universal and all of surgical training programs and our A-C-G-M-E requirement, the American College of Surgeons, accredit Educational Institutes, came out of those recommendations and probably I think the three most important things were a combination of the American

Board of Surgery and the residency review Committee for surgery allowed. More flexibility in training is available now. You can do chief resident rotations in your fourth year and vice versa. Still required 12 months. Of chief experience in those last 24 months. There always specialization programs which were instituted in cardiac and thoracic surgery have been quite successful in the few programs that have done that, but they have not been widely adopted. Lastly, the integrated vascular. Training programs were and thoracic programs where they're matched right outta medical school, I think is a great innovation and may have some potential for how other specialties may decide to be trained. That being said, I think there still is a tremendous need to train general surgeons. You know, most of our listeners trainees. And even, you know, younger faculty that are listening, couldn't imagine surgical training

without those things you're describing and maybe don't realize that it went back to the first iteration of this committee, you know, incredibly impactful. So how did you come to recognize that it was time to come back around again and regroup and come up with some new plans? So, as you said, I was a former chair of the American Board of Surgery and the American Board of Surgery has every fall, the A BS Summit. And two years ago I was invited to come back to the summit. I hadn't been in a number of years. I. And at that summit it was partially to discuss competency-based medical education and the American Board of Surgery had just instituted the EPAs and trustable professional activities as a requirement for board certification. And I was asked to respond to a talk given by Richard Resnick, who is sort of the father of, of surgical competency based education out of Canada, where he instituted that. Throughout all of surgical

training in Canada. So he gave a talk about the value of competency-based education. And although I had not been a fan of it at that meeting, I told the group that I thought it had value, but it needed to be refined if it was gonna be more effective. And John Mellinger, who was the clinic chair of the American Board of Church at the time, asked me if I would reinstitute another blue ribbon committee. My answer without thinking much was yes, but only if I could get the assistance of Chris Allison, who was also a former chair of the America Board of Surgery, and we'd worked very closely together on the American College of Surgeons response to CO. And I know he was a great strategic thinker and could help bring us together in a way that we could come up with some recommendations. So it came out of the American Board of Surgery Summit and what we decided, Chris and I, was to follow the same areas of focus that the

BRC one had done. And those were surgical and medical workforce, medical student education, residency work hours and lifestyle. The structure of surgical training. Residency education, education support, and faculty development training and surgical research and continued professional development. So we found chairs and co-chairs for each of those committees and asked them to work with us to develop experts in those areas to come up with individual recommendations. So you mentioned the EPAs and competency-based education and surgery. Tell us about your initial impressions about implementing EPAs in surgery. So on a, on a recent call with Joe Beki, who is the executive director and president of the American Board of Surgery, she corrected me that really what we're doing right now is competency-based medical assessment. So before I think we can move towards

competency-based education, we have to learn how to do better assessment, and the EPAs are one vehicle. Which has the potential to allow us to do better assessment. So, most programs use a simple app, which is one method of assessment, but I, I don't think I have been adequately trained in how to do proper assessment. Most of us grew up in a time where. You know, we received direct feedback during the operation or on the floor from our attendings, and I think the EPAs has potential if done correctly, to give the learner accumulated data about how they're progressing. But you said something controversial there a few minutes ago that you were not a believer in competency-based medical education. It seems like that's like saying you don't like apple pie and puppies anymore. Well, I'm a believer in its potential. I do not believe yet. It has been proven to be effective in US-based

education. The conflict between surgeons who are primarily compensated for clinical productivity to take extra time out of their regular day to do good assessment, I think it's possible, but I think it's gonna take an investment in training of the faculty to be able to reach its potential. So when the board instituted EPAs, it's just for assessment. There was really little training that I received on how to give effective feedback to trainees to allow them to assimilate the information given and use it to their value. I'm not saying I'm against it, but I think we have to do it better if it's gonna be effective. Yeah, I think that's a really important point. Like I said, you know, people talk about it as a panacea, but there, there's a whole process to getting there and we're still in the early steps. Early in my career when I was at USC I was a co-faculty member with Gary Dunnington and he and Deb DeRosa came out for some seminars for us to teach us how to

teach better. And I think that one of the things that I think the BRC two is going to try and do is to come some tools that can help educate faculty how to do better assessment. That's one of our focus areas that we're trying to create and implement. Can you say more about that? How you sort of see that progressing? I mean, I think all of us would love to have had Gary Dunnington and Deb DeRosa coming out and teaching us how to do those things. How do you see this working on a large scale? The BRC two committee started with 50 possible recommendations, and we had a Delphi process, which I had never run, but asked all 42 of the chairs and co-chairs of these committees and members to assess which of these 50 recommendations could be done. And we used the process of acquiring more than 80% agreement and three rounds of the recommendations. And we had 10 that came up with more than 80%

concurrence that we should be doing those. And one of those was to develop a curriculum to educate faculty on how to do better teaching and better assessment. So you listed in your list of priorities in BRC two, you know, medical student education, resident work-life balance. I'm curious if there was an avenue for medical student and or resident voices to be incorporated into the process for making the recommendations or commenting on the recommendations from BRC two. Lemme tell you the process first. The process was each of these eight subcommittees had a leader and two co-chairs, and they picked a group of people who had worked on this project. One of them was the residents, and we tasked each subcommittee to write a manuscript on what their subcommittee did, and Keith Limo, the editor of Annals, agreed to publish all of those papers. The

individual subcommittees areas that they thought were most important. And those were published this month in, in Annals surgery. And the one for the resident experience was led by a Vanderbilt resident, now a fellow named Wally Johnson. They surveyed 16 residents and fellows and came up with their recommendations of what they thought were most important. So that's how we got resident voice in this. And that's published in Annals of Surgery. What are some of the obstacles that the committee is facing the second time around? Well, the first thing that Chris Ellison and Tim Flynn pointed out was there was no structure to see if the recommendations from BRC one got actually done. So they all sort of happened between the various groups, American College of Surgeons, American Board, and the RC, but there was no monitoring of that. So what Chris and I decided to do was. To ask for the American College of Surgeons to

provide some infrastructure to track and monitor the progress. So of the Final 10 recommendations that we had, we asked the American College of Surgeons would they let us do that. And they wanted a five year plan, and we had a much shorter timeline. So we said, well, why don't we pick out the top six and those six? We have formed an implementation committee, and then we assigned a leader to facilitate completion of that in 18 to 24 months. So the first one is to implement competency-based training, or really competency-based education. And we'd like to expand it beyond just general surgery. So we're gonna try and engage all the subspecialties to see if they're interested in that. And not all the surgical specialties have embraced competency-based assessment education. And Joe Bisky, the president of American Board of Surgery, is gonna head that up. Secondly, we would like to develop a better process for trainees to have a mentor transition into practice. Stan Den, who is

a outstanding surgical educator, has taken that on and we hope he will come up with a plan different than the colleges transition to practice they've had before. But my hope is that they will develop things that residents should accomplish during training to make them ready to go into practice or fellowship. Ron John Sudan from Duke has been asked to develop the national curriculum for faculty development in education that will include both EPAs and assessment, and we've asked Ron John to think about coming up with modular videos that could be made available to faculty that they could go through on their own time and learn about how to do education. I think that if we give busy surgeons some. That they could use, it could be helpful, I think because the American College of Surgeons has the resource to do this, to develop high quality. My hope is working with Dr. Satch Diva from the Division of

Education and Dr. Sudan. We will come up with something. Dr. Sudan has also been part of the certain educators course, so he has a long history of being able to work on these sorts of ideas. Jeff Matthews had worked for the BRC two on a surgeon scientist training pathway. Other surgical specialties in ENT and neurosurgery. Have training pathways to develop surgeon scientists. There're not very many of them. If you think about someone who wants to have a K award at the completion of their training, it's hard to do when you do your two years of research in the middle of residency, then you do your last two years of residency, then do your fellowship. You don't necessarily have the preliminary day to be able to apply for an NIH grant. It's available in all medical specialties, but it's not been very well adopted throughout the surgical specialties. And we will be submitting to the American Board of Surgery and the

RRC for surgery, an opportunity for flexibility and trading to have in select sites that have the resources to have. T 32 grants to have residents intersperse their research training with their clinical training and a clinical subspecialty training over probably seven or eight years. And that's not gonna be for everybody. My guess is there'll be probably maybe 10 places that will take advantage of this. And we've had some discussions with institutions that are interested in that, and I think that will be able to be written. And submitted to the board the RC within the 18 month time period. The last one, which is I think the most exciting. Ron Herschel from University of Michigan is a pediatric surgeon and he has worked on a promotion in place proposal that is ready to be submitted to the American Board of Surgery. So think about it and I don't have the exact details, but think about your

last six months of training where you act as an attending. So your last six months of your five year general surgery residency, you can be. Credential to be an independent surgeon, but have senior members down the hall in case she need help. The new A-C-G-M-E President, CEO, Deb Weinstein. Who was the Vice Dean of Education at University of Michigan got a grant from the double A MC to work on this, and we expect she will be supportive of this for the A-C-G-M-E working with the board to put this in place. So it is was written by Ron for pediatric surgery. The board wasn't ready for it. We think this could have application in general surgery. I know when I finished my residency at LA County, I did a super chief year. That also was a critical care year as well. But during that year, I had my own I supervised services. I was an attending fully credentialed. But

I also had help if I needed it down the hall. I think many of those super chief years that used to exist in the eighties have gone away. But I think we would like to see if we could have residents credentialed, both by the hospital, also by insurance companies and that's a proposal that I think will go in place, which would allow. Complete autonomy. I think one of the big differences in training between when I trained and now for a number of reasons, including leapfrog criteria. Quality metrics and patient expectations. It's hard to give trainees full autonomy, but there's something I think to be learned without hurting patients by having qualified trainees have autonomy. One of the things that happens during fellowship training, because you work with the same group of people for, you know, a year. You are given more and more autonomy as they know more and more of your

capabilities. Lots of hospitals have different requirements. In previous hospitals I worked in, the resident could get started and they would call me when they were ready, when they isolate up the cystic duct and artery where I'd come in for the critical parts of the case, but didn't have to be there for the whole case nowadays because of. Institutional requirements and efficiency of the or. I'm there at the beginning of the case for the timeout. I stay to get the case moving along, and I think residents and fellows would benefit from more autonomy done safely. The last one is just we're gonna form an educational council of which we will monitor and we will have quarterly meetings with all the group leaders to make sure that we can get these five initiatives done in the 18 to 24 month time period. These are all phenomenal

initiatives. I think the promotion in place, as you said, is particularly exciting. Answering the question of what do we do with our trainees? They've hit all their EPAs. We all know they're ready for practice. Do we just release 'em into the world? This is a nice transition opportunity. I think it's not like, you know, July 1st after you finish your residency, you're automatically a better surgeon than you were on June 30th. I do not know what it's gonna be in the final proposal, but it may not be for everybody. There will be metrics that have to be met. One of them, you know, may be okay, you're required to take your, you know, qualifying exam at the end of your PG four year, which some residents do. I think if we go down this promotion in place, it is likely that not everyone will meet the metrics to be able to do this. And that's something that we have to be prepared for. It also gives us a direction of how to better prepare those residents for fellowship or for practice. So these are all outstanding initiatives. Were there things that you,

from your experience and leadership, that you wished had been included or thought would be included that didn't show up in the final recommendations? Of course, so when I was a early director on the American Board of Surgery, we had discussed having a shortened training program being available, a sort of a four plus two four years of journal surgery and two years of fellowship. That was brought to a vote and loss, I think in probably 2006 or oh seven when I was chair of the American Board of Surgery in 2010. We brought it up again and it lost on the, to the American Board of Surgery vote. So I think that's something which I believe we can do, but it did not get enough support in the BRC two to be put as one of our recommendations. I know Dr. Verman introduced me as a Pat Biliary surgeon. I used to be an hp, I'm a general surgeon now. I do believe that the.

Training I received allow me to still do the breadth of general surgery. I don't do breasts, I don't do, I do a lot of things, but I think it's vitally important for the training that we get in general surgery to prepare the trainees for fellowship as well. So the question which was not adopted by the group was, could we train a general surgeon four years? And when you think about what the general surgery training is, which currently takes five years. Are there things that not everybody has to do? I'll give you an example. If you're gonna be a breast surgeon, how much cardiac surgery do you need to do? How much trauma surgery do you need to do? I think you need to do some, because you may not be a breast surgeon forever, but 80% of the residents who train in general surgery do a fellowship, and there are good reasons in my mind of having fellowship trained people. If you're gonna subspecialize in colorectal surgery

or cardiac or thoracic or endocrine surgery. But I think we also have to recognize that many parts of the country, especially rural, need broadly trained general surgeons, but residents are voting with their feet. Most of them are doing fellowships and not just because they. Don't want to take general surgery or trauma call, but maybe they do it because they want to take better care of their patients, and I think we need to acknowledge that there are many reasons why people do fellowships. Curious if you could comment on what was the hesitation from individuals that voted against the four plus two model? Two things. First of all, there is a belief by many of my friends. That residents are not trained as well as they used to be, and they blame duty hours for that. Having served on the A CGE task force, which reaffirmed 80 hours being the standard, about 2000, I know,

probably 18 or 19, I think that you can train someone in 80 hours. Most of the duty R violations occur in the PG one or two years. We were doing things which are, I don't wanna call it scut work, but it's necessary work, which is not necessarily adding to the education. I think there's a belief that residents were not getting as much training under 80 hours, but when you look at the RC case logs, gallbladders, colon, resections, thyroidectomies, residents do more case than they did now 10 or 15 years ago. So I categorically, historically disagree with that assertion that residents are not well-trained. One, one of my highlights of my career. I gave grand rounds probably 10 or years ago at Johns Hopkins. The title of my talk was, is it Time to Change How Steady and Training? And I put up a slide, which I use often, and I said, are the residents today as

good as the residents of 20 years ago? And John Cameron got up and said, no, they're better. And I think he was right. The residents that finished now. Because of the avalanche of information at their fingertips on their phone, the breadth of clinical experiences they have. I argue against some of my mentors that they're better trained, they may be differently trained. They have not had more autonomy through the famous paper by Samor Mattar. I think about 2008 or oh nine, they surveyed MIS program directors and they said that a third of them could not operate independently for 30 minutes in a rhetorical article by Kyle from Vanderbilt, she said it wasn't that they were not well trained, they were just more cautious because they had not had autonomy. So I think one of the important things we should try to do. Is put more

autonomy in the residents education and do that without compromising patient outcomes. So looking forward, you know, how can we ensure that surgical education is keeping up with the changing times, with technological advances, with time constraints, and you know, how does this start to form the agenda for whenever the next Blue Ribbon Committee convenes? I'm on the A CGE Board now, and I'm on the task force for the new common program requirements. I think we need to understand that the program requirements for every subspecialty are just guidelines that you have to stay within. All the program requirements state that the program director is responsible for their education. And I look at the program requirements that exist as just boundaries, and we should allow the program

directors to innovate and develop the best training for their trainees because they know the resources they have. They know what are the opportunities within their own institution to train residents. And I also think that, you know, the board's requirements, you know, case numbers are still very, very important. I believe you get better with repetition. I think that having robust case volumes at many of the best institutions training institution in the country you recognize that someone who comes out of those training programs has done a lot of surgery and taking care of a lot of patient, have a lot of clinical skills. So I think letting the program director, having maximum flexibility to provide the training individualized to the specific resident. Will allow the program to continue to, to produce the best trainees and give them the

flexibility to go into practice right after five years of general surgery, or making the best fellow candidates when they apply. I, I know when I was in Albany for 15 years, you know, we sort of had some guidelines. We wanted every resident to finish with general surgery, resident with at least 40 lap colons. If you're gonna go into a GI specialty, you had to do a hundred colonoscopies and at least 50 upper endoscopies. Those numbers are higher than what the board or the RSC requires, but I think the program directors should have the flexibility to tailor their resident experience to what their ultimate career goal is. We are incredibly grateful for all the time you've given us. This conversation's been fantastic and I am confident our listeners will be really grateful for your interpretation of these very important findings that are gonna shape surgical

education for at least the next 20 years. Would you provide us with a few key takeaways you'd like the listeners to have from all this work? Well, the only, the only thing I would add is that, you know, while. Lots of organizations have been helping with this. The American Board, the RC, and the American, but the American College of Services really stepped up and the executive committee of the Board of Regents are the ones who are. Who are approving us going forward and are gonna help provide the infrastructure to do these things. We are planning on having in July a summit with the RRC chairs and the board and all the surgical specialty board chairs and executive directors to see if there is endorsement of these initiatives across the house of surgery. I think the Ion College of Surgeons deserves, and Dr. Satch Diva specifically deserves lots of credit for allowing us

to do this. Well, thank you again so much. This has been a fantastic conversation and we look forward to hearing and reading more as the implementation process begins. Thank you very much for having me.