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A Framework for Understanding the Association Between Training Paradigm and Trainee Preparedness for Independent Surgical Practice

Educational Objective
To identify (1) factors associated with trainees' perceptions of their preparedness for independent practice, using qualitative analysis, and (2) differences between different training paradigms.
1 Credit CME
Key Points

Question  What factors are associated with surgical trainees’ perception of their preparedness for independent practice, and what are the differences between different training paradigms?

Findings  In this qualitative study of 22 recent graduates and program directors of graduate surgical training programs, 4 key domains were identified as factors that affect perception of preparedness for independent surgical practice: the structure of the training program, characteristics of the individual trainee, relationships between trainees and faculty members, and the clinical material and culture of the organization where the training occurs.

Meaning  Results of this study were used to create a framework for evaluating and improving existing residency and fellowship programs as well as for developing graduate surgical training paradigms that incorporate all 4 domains.


Importance  The sociopolitical and cultural context of graduate surgical education has changed considerably over the past 2 decades. Although new structures of graduate surgical training programs have been developed in response and the comparative value of formats are continually debated, it remains unclear how different time-based structural paradigms are preparing trainees for independent practice after program completion.

Objective  To investigate the factors associated with trainees’ and program directors’ perception of trainee preparedness for independent surgical practice.

Design, Setting, and Participants  This qualitative study used an instrumental case study approach and obtained information through semistructured interviews, which were analyzed using open-and-focused coding. Participants were recent graduates and program directors of vascular surgery training programs in the United States. The 2 training paradigms analyzed were the integrated vascular surgery residency program (0 + 5, with 0 indicating that the general surgery training experiences are fully integrated into the 5 years of overall training and 5 indicating the total number of years of training) and the traditional vascular surgery fellowship program (5 + 2, with 5 indicating the number of years of general surgery training and 2 indicating the number of years of vascular surgery training). All graduates completed their training in 2018. All interviews were conducted between July 1, 2018, and September 30, 2018.

Main Outcomes and Measures  A conceptual framework to inform current and ongoing efforts to optimize graduate surgical training programs across specialties.

Results  A total of 22 semistructured interviews were completed, involving 7 graduates of 5 + 2 programs, 9 graduates of 0 + 5 programs, and 6 vascular surgery program directors. Of the 22 participants, 15 were men (68%). Participants described 4 interconnected domains that were associated with trainees’ perceived preparedness for practice: structural, individual, relational, and organizational. Structural factors included the overall and vascular surgery–specific time spent in training, whereas individual factors included innate technical skills, confidence, maturity, and motivation. Faculty-trainee relationships (or relational factors) were deemed important for building trust and granting of autonomy. Organizational factors included features of the local organization, including patient population, case volume, and case mix.

Conclusions and Relevance  Findings suggest that restructuring training paradigms alone is insufficient to address the issue of trainees’ perceived preparedness for practice. A framework was created from the results for evaluating and improving residency and fellowship programs as well as for developing graduate surgical training paradigms that incorporate all 4 domains associated with preparedness.

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Article Information

Accepted for Publication: December 30, 2020.

Published Online: March 24, 2021. doi:10.1001/jamasurg.2021.0031

Corresponding Author: Brigitte K. Smith, MD, MHPE, Division of Vascular Surgery, Department of Surgery, University of Utah, 30 N 1900 E, SOM#3C344, Salt Lake City, UT 84132 (brigitte.smith@hsc.utah.edu).

Author Contributions: Dr Smith had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Smith, Yudkowsky, Hirshfield.

Acquisition, analysis, or interpretation of data: Smith, Rectenwald, Hirshfield.

Drafting of the manuscript: Smith.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Smith.

Supervision: Smith, Rectenwald, Hirshfield.

Conflict of Interest Disclosures: None reported.

Disclaimer: The views expressed herein are those of the authors and do not reflect the official policy or position of the APDVS.

Additional Contributions: The Association of Program Directors in Vascular Surgery (APDVS) provided contact information for the recruitment of study participants.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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