Transition from Chief Residency to Specialty Training: Issues and Solutions

Three fourths of chief residents in general surgery receive further specialty training. The end to start-of-year transition can create administrative conflicts between the residency and the specialty training program. An Internet-based questionnaire surveyed general surgery and surgical specialty program directors to define issues and possible solutions associated with end to start-of-year transitions using a Likert scale. There was an overall response rate of 17.5 per cent, 19.6 per cent among general surgery directors, and 15.8 per cent among specialty directors. Program directors in general surgery felt strongly that the transition is an administrative problem (P < 0.001). They opposed extra days off at the end of the chief resident year or ending in mid-June, which specialty directors favored (P < 0.001). Directors of specialty programs opposed starting the year 1 or 2 weeks after July 1, a solution that general surgery directors favored (P < 0.001). More agreement was reached on whether chief residents should take vacation week(s) at the end of the academic year, having all general surgery levels start in mid-June, and orientation programs in July for specialty trainees. Program directors acknowledge that year-end scheduling transitions create administrative and patient care problems. Advancing the start of the training year in mid-June for all general surgery levels is a potential solution.

THE OUTSTANDING EVENT of the year in academic medicine is the wholesale turnover in trainees that occurs in late June or early July and traditionally has been recognized with the new medical school graduates on hospital wards. However, July 1 now also signals the transition of chief residents, who have completed their general surgery training, to move onto their individually chosen specialty training. More than three fourths of residents completing general surgery training pursue additional years of graduate medical education in surgery such as plastic surgery, pediatric surgery, thoracic surgery, and surgical critical care.1 Nearly half receive additional specialty qualifications from the American Board of Surgery.2 Despite recent changes in training paradigms toward integrated training in a single medical institution,3 most surgical trainees receive specialty training in a program that is distinct from their residency in general surgery, often in different hospitals in different communities.

Thus, the learning curve resets both for the demands of the new area of surgery as well as the unique policies, procedures, and routines of the new hospital. New plastic surgery residents and specialty fellows are under pressure to "hit the ground running" from the first day, often without the insulation of multiple layers of more experienced residents already familiar with the clinical and administrative demands. The residents and fellows before them, nearly fully trained at that point and comfortable with hospital routines, disappear as the new ones arrive without the benefit of continuity. The transition that occurs has been termed "the July effect," recognizing the hazard to patient care that may occur.4-8

General surgery and plastic surgery residencies and specialty training programs have adapted to the end to start-of-year transition with orientation programs that start several days before Julyl, anticipating that clinical coverage will start on that date. Medical school graduation typically occurs several weeks before July 1, allowing a smooth transition to internship. To further streamline this process, some general surgery programs begin their orientation procedures in late June. However, hospital residency schedules are 12 months long, and the end of the chief resident year officially ends at or close to June 30. This leaves little time for a transition to a new specialty program and hospital. Because this often involves moving to a different community, the resident has the added demands of finding a new residence and moving fantily and possessions.

Not surprisingly, this has led to friction. Program directors in general surgery have time requirements that specify the duration of the chief resident year. Those responsible for plastic surgery residencies and surgical specialty fellowships have the same time requirements and need their new trainees up to full speed at Day 1. We therefore polled program directors in residencies in general and plastic surgery and a number of surgical specialty fellowships to define whether a problem exists, what are the issues involved, how programs are currently addressing this issue, and to propose possible solutions.

Materials and Methods

We sent an Internet-based questionnaire (Zoomerang, San Francisco, CA) to the current members of the Association of Program Directors in Surgery (APDS), an organization that represents program directors in general surgery and surgical subspecialties. Current program directors in plastic, pediatric, colorectal, hand, critical care, thoracic, and vascular surgery, obtained from lists provided by the Residency Review Committee in Surgery, also received the questionnaire. The information technology department of the Mercer University School of Medicine (Macon, GA) coUected the results. We sent the questionnaire twice at a 1 -month interval to maximize responses.

We grouped the responses from program directors in plastic surgery residencies and specialty fellowships and compared them with those coming from program directors in general surgery. A 5-point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree) allowed comparison of the two groups using a 2X5 contingency table and [varkappa]^sup 2^ analysis with P < 0.05 considered significant.

Results

Table 1 summarizes the responses to our questionnaire. There was an overaU response rate of 17.5 per cent (155 of 885), 19.6 per cent (77 of 392) among general surgery directors and 15.8 per cent (78 of 493) among specialty directors. The highest response rate (33.7% [30 of 89]) came from residency directors in plastic surgery.

Does a Problem Exist?

Nearly hatf (44.2% [34 of 77]) of program directors in general surgery felt strongly that the year-end chief resident transition is an administrative problem (Table 2). Essentially the same percentage (46.8% [36 of 77]) felt strongly that the problem is in part created by specialty residency and fellowship orientation programs and start-of-year clinical expectations. Their view was not shared by specialty program directors, of whom half (50% [39 of 78]) disagree that the transition poses an administrative problem, and only sUghtly fewer (45.5% [35 of 77]) disagreed that their start-of-year programs and expectations create such a problem. The difference in response between general surgery and specialty program directors was highly significant (P < 0.001).

What Are the Issues Involved?

General surgery program directors felt strongly that any time allowance for a transition was not the responsibility of their residencies (85.7% [66 of 77]) but that of the postgeneral surgery training program (87.0% [67 of 77]) (Table 3). This differed significantly from the specialty program directors who showed less of a skewed distribution of responses to the statements ([varkappa]^sup 2^ = 73.7 and 82.5, respectively, P < 0.001 for both). The general surgery directors also had strong opinions that chief residents' professional commitment extended to the end of the academic year (93.5% [72 of 77]), a view shared by fewer of the specialty directors (46.1% [35 of 77], [varkappa]^sup 2^ = 60.9, P < 0.001). The former group did not think that a delayed start to specialty training posed a problem for sitting for board examinations, a view more specialty program directors thought was a potential factor ([varkappa]^sup 2^ = 34.4, P < 0 001). The two groups shared a general agreement that insurance coverage and lack of a salary over an extended transition period was problematic.

What Is Being Done

General surgery program directors did not support allowing extra days off at the end of the chief resident year (52.6% [40 of 76]), something that specialty directors favored (77.0% [57 of 74], [varkappa]^sup 2^ = 41.9, P < 0.001) (Table 4). Both groups noted that chief residents generally have not been allowed to begin after July 1 to accommodate year-end responsibilities and to address moving issues. A widespread observation is that chief residents cut down on their roles by the end of the academic year. General surgery directors disagreed that the "winding down" by chief residents makes transition issues moot (62.3% [48 of 77]), whereas specialty directors agreed (60.1% [45 of 74], [varkappa]^sup 2^ = 49.2, P < 0.001).

What Are Possible Solutions?

Nearl diametric disagreement occurred in suggesting that end of term of the chief resident should end early 69:7 per cent (53 of ?6) of gefleral surgery directors disagreed, whereas 77.9 per cent (60 of 77) of specialty directors agreed ([varkappa]^sup 2^ = 75.6, P < 0.001) (Table 5). Suggesting the counter solution, that the start of specialty training should begin after July 1, had the opposite but equally diametric responses: 81.8 per cent (62 of 77) of general surgery directors agreed, but 64 per cent (48 of 75) of specialty directors disagreed ([varkappa]^sup 2^ = 71.5, P < 0.001). Response patterns were more congruent in response to whether chief residents should take vacation week(s) at the end of the academie year, having all postgraduate year (PGY) levels start in mid- June, and having orientation programs in July for entering specialty trainees.

Many survey respondents commented on the statements in the survey. Anonymous summaries of the comments may be obtained from the corresponding author.

Discussion

Our most remarkable finding was the wide difference in responses between program directors in general surgery and those in surgical specialty training programs. Differences in response patterns were frequently highly significant with ? values often exceeding 30 and the associated P much less than 0.001. In several instances, both groups took diametrical stances with one group strongly agreeing, whereas the other strongly disagreeing with the statements. A frequent pattern was that the responses in one group were very lopsided, with many in the "strongly agree" and "strongly disagree" categories, whereas the other group had a more benign view of the question, responses being more evenly distributed.

There are a number of shortcomings to our study. The response rate (17.5%) is poor and limits the power of the study. Several survey studies involving the membership of the APDS have recently appeared in the literature. Many may have ignored the request for participation, symptomatic of "survey fatigue" that has been noted anecdotally by several. The responses may be skewed insofar as the most vociferous participants were likely to respond.

Our results show that the two groups are locked in their positions, a classic pitfall in bargaining.9 Fisher and Ury describe positional bargaining as a situation in which "each side takes a position, argues for it, and makes concessions to reach a compromise." They note that taking such a stance tells the other side what you want and may produce a settlement. However, they note that winning, losing, and saving face begin to assume greater importance than addressing the true needs of each party, which may be closer than either side realizes. They argue that positional bargaining is inefficient in coming to an agreement. Moreover, it endangers relationships because it engenders hard feelings among the participants. Thus, general surgery program directors and those leading surgical specialties are at loggerheads, in which the more general goal of quality in surgical graduate medical education may be lost.

We therefore feel that more productive questions are those in which there was common ground and where views converged. Table 3 summarizes responses to the general question of the issues involved. Although there was still a significant difference between the groups of program directors, they came closer together in questions of resident well-being during the transition (insurance coverage and lack of income). Table 4, in which current interventions are identified, the groups both identified that there was lack of time after July 1 and residents and fellows generally were not allowed time to attend to the details of a move. Table 5 shows that there is some "wiggle room" in the end of the academic year with suggestions that chief residents take their vacation weeks at the end of June to allow changeover to occur and that it might be a good idea for internships and all transitions at aU PGY levels occur in mid- June. Both agree that hospital orientations might accommodate new trainees in surgical subspecialties with an orientation program after July 1. Many already have gone through years of surgical training and would not need time-consuming events in a typical internship orientation, which often includes complete Advanced Cardiac Life Support and Advanced Trauma Life Support courses. So residents' needs are addressed, and some organizational rearrangements can be made to address practical matters like orientation. That we can agree on.

The core problem is the time crunch between the end of chief residency, scheduled to end on June 30, and the start of the new training program on July 1 . The question is where to put a 2-week or so period so that our residents can reasonably enjoy their graduation, move their families, and get started in their new position. In concentrating on the end of June and the beginning of July, we overlook a longer time period in which there is much more "wiggle room," the interval between the end of medical school and the beginning of internship. Medical students enjoy this last respite before they plunge headlong into surgical training with travel, relaxation, and other essentially time-killing activities before their residencies begin. A mid-June start for internships and having all PGY transitions at about the same time is an interval that may be more accommodating. The need for medical students to enjoy this "last chance of freedom" can be balanced more easily against the very real administrative and clinical challenges faced by program directors in surgery at the end of the academic year.

Such a solution was implemented for the Department of Internal Medicine at Tulane University by Jeffrey G. Wiese, M.D., Associate Dean for Graduate Medical Education, Designated Institutional Official, and Program Director of the Residency in Internal Medicine. The medicine residents start on June 23 with orientation beginning approximately one week earlier. Rotations change on or about the 21st of each month with the chief residents finishing their year on June 20.

Going forward, this would allow the preliminary residents 9 or 10 days to get to their new destinations and do orientations and the chief residents to do the same. Additionally, as noted, some general surgery programs already schedule their orientation programs for incoming interns toward the end of July. This rotational format could more effectively use the "wasted" time available to graduating medical students, alleviate problems associated with chief residents all grouping vacations at the end of the academic year, and assist fellowship programs and their residents in smoothing the turbulent period of the end to start-of-year transition for subspecialty training.

Acknowledgments

We thank Michelle Bliss and Tamrni Ford, Mercer University School of Medicine, for their assistance with information technology and collation of the data. Margaret Tarpley read and edited the manuscript.

[Reference]

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[Author Affiliation]

DON K. NAKAYAMA, M.D., M.B.A.,* LINDA G. PHILLIPS, M.D.,[dagger] R. EDWARD NEWSOME, Jr., M.D.,[double dagger] GEORGE M. FUHRMAN, M.D.,� JOHN L. TARPLEY, M.D.||

From the *Department of Surgery, Mercer University School of Medicine, Macon, Georgia; the [dagger]Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, Texas; the [double dagger]Division of Plastic and Reconstructive Surgery, Department of Surgery, Tulane School of Medicine, New Orleans, Louisiana; the �Surgery Residency Program, the Atlanta Medical Center, Atlanta, Georgia; and the ||Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee

[Author Affiliation]

Address correspondence and reprint requests to Don K. Nakayama, M.D., M.B.A., Department of Surgery, Medical Center of Central Georgia, 777 Hemlock Street, H.B. 140, Macon, GA 31201. E-mail: Nakayama.Don@mccg.org.