Framework for Post-Residency Surgical Education & Training

This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on Jul 2010.

I. PREAMBLE

The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) recognizes the discipline of surgery is dynamic and continues to evolve. Modifications of standard surgical procedures and completely new procedures are usually introduced gradually into clinical practice, a process that may require special training or privileges. Additional training will often be required to integrate techniques or procedures that are new to the individual surgeon. The same is also true for procedures that represent a substantial change in existing methods or practices or that require the mastery of new technology. The purpose of this document is to provide guidelines for post-residency surgical education (i.e. after completion of traditional residency or fellowship training).

THE PRIMARY PURPOSE OF POST RESIDENCY SURGICAL EDUCATION IS TO ENSURE SAFE, HIGH QUALITY PATIENT CARE.

II. OBJECTIVE

This document is a framework upon which post-residency training coursework may be developed. It provides both educational policy and practical guidelines for designing such programs, including those in which residents participate outside of their formal curriculum. Individual societies or institutions may wish to develop more detailed documents relating to specific techniques or procedures.

These guidelines seek to further define avenues by which appropriate post-residency training may be achieved, supplementing existing criteria mandated by accrediting bodies. In addition, mechanisms are proposed to assist educators, trainees and privileging bodies in assessing competence.

This document is advisory, and directed at surgical educators, institutions that grant privileges to surgeons, and surgeons who seek additional training after graduation from standard residency programs. As an advisory document, it does not intend to restrict or regulate practices, nor be used for the purposes of medical-legal actions.

III. DEFINITIONS

Some of the terms used in this document were carefully selected to indicate the specific meaning and relative weight attached to each statement. These terms are used in an educational context, not used for strict legal interpretation.

Must or shall: Indicates a mandatory or indispensable recommendation.
Should: Indicates a highly desirable recommendation.
May or Could: Indicates an optional recommendation; alternatives may be appropriate.
Competence: The minimum level of skill, knowledge and expertise, derived through training and experience, required to safely complete and proficiently perform a task or procedure.
Credentials: Documents provided following successful completion of a period of education or training.
Clinical Privileges: Authorization by a local institution (usually an accredited hospital) to perform a particular procedure.
Post-Residency Education: Coursework which is separate from formal residency or fellowship programs. While directed at the board certified surgeon, residents in training will often participate in such coursework.
Pre-test: A quantifiable examination of a trainee level of clinical knowledge, manual skills and/or technical proficiency prior to commencing a training course.
Post-test: A quantifiable examination of a trainee level of clinical knowledge, manual skills and/or technical proficiency upon completion of a training course.

IV. POLICY STATEMENTS

A. Inanimate training models: Inanimate, ex vivo models, or simulators are often preferable to animate models. Animate models may be necessary to simulate clinical situations when teaching certain surgical skills or techniques.

B. Educational grants: Educational grants provided by industry, or other organizations or sources, to support any educational program, course, skills course or preceptorship must be clearly noted in promotional and educational materials.

C.Investigational procedure: A procedure is considered investigational if 1) it has not been substantially accepted into general clinical practice, 2) it has not been critically assessed in peer reviewed medical literature, and/or 3) it has not been presented and discussed at suitable scientific meetings. Alternatively, a procedure is not investigational if sufficient studies are available to prove its efficacy and safety, or, if it has already been accepted into general clinical practice without existing rigorous scientific study.

Surgical progress would be impeded if every logical surgical innovation were required to be tested by randomized trials prior to clinical use. Furthermore, it is impossible to rigorously test every aspect of clinical practice. The surgeon should use his/her judgment to determine when such directed coursework and study is appropriate. Introduction of an investigational procedure may require the approval of the appropriate institutional review board (IRB). Self-training in new procedures must take place on a background of basic surgical skills. The surgeon should recognize when and how much additional training in each new procedure is necessary.

D.Certification: Certification is a symbol of successful completion of a program of study. Successful completion of any one or more training components or objectives does not necessarily signify an individual’s clinical competence in a specific procedure or technique.

V. COMPONENTS OF POST-RESIDENCY SURGICAL EDUCATION

Post-residency education assumes completion of a formal, recognized training program, such as an Accreditation Council for Graduate Medical Education (ACGME) or Royal College of Physicians and Surgeons of Canada accredited surgical residency training program in surgery.

A. COURSES & SKILLS LABORATORY SESSIONS

1. Definitions
a. A course is a limited period of instruction with defined objectives designed to educate participants in clinical skills, techniques and/or procedures. Course structure and duration may vary according to the specific course objectives. In addition, a skills lab session may teach one skill or the entire set of skills required to perform a procedure. A skills lab or course is usually a continuing resource that can be revisited. Every skills course must have a mission statement defining objectives, curriculum, eligibility for training, and an evaluation process.

B. SKILLS LABORATORY

1. A facility in which a practicing physician acquires, refines or improves his/her ability to perform specific medical/surgical tasks or procedures. Skills are the building blocks upon which procedures are constructed.

2. Objectives: The course must have a stated set of objectives. The objectives must be defined as tasks, successful completion of which can be quantitatively and qualitatively assessed. The method of assessment should be clearly stated. The objectives and assessment criteria of any course should include specific performance criteria to conclusively pass the course or skills lab.

3. Qualifications of faculty: The course director and the faculty members must have appropriate clinical and/or laboratory expertise to educate the participants in the stated objectives. When clinical procedures are taught, instructors must have clinical experience in those procedures. Proof of teaching expertise should come from qualitative and quantatative assessment from prior courses and participants. It should also include a faculty member own position on an assessed learning curve.

The director of a skills course has the overall responsibility for setting objectives, curriculum development, faculty and staff appointment, and development of evaluation criteria.

There must be an appropriate ratio of faculty to trainees in order to assure that progress is made and to enable documentation of achievement of objectives. The faculty should also be present for an appropriate quantity of time during the course to provide the learners adequate feedback.

The course must have a written policy on disclosure of faculty/industry relationships, according to ACGME/AMA guidelines for continuing medical education (CME).

4. Qualifications of participants: The skills course must define eligibility for participation. The trainee must have appropriate background knowledge, basic skills, and clinical experience relevant to the tasks to be learned.

Pretesting prior to the start of a course is strongly recommended.

5. Facility Operations: A course facility must be physically adequate to meet the stated objectives and to accommodate the course’s enrollment. A course may be conducted at an industry-sponsored facility, provided that it is operated in affiliation with a hospital, medical institution, or university or medical association which is qualified to grant continuing medical education (CME) credits.

6. Curriculum: A course must contain didactic instruction in the following areas as they may apply to the stated objectives:

  • Patient selection
  • Indications and contraindications
  • Instrumentation
  • Techniques
  • Documentation
  • Pre- and post-operative care
  • Follow-up
  • Outcome
  • Self assessment exercises
  • Complications and their avoidance and treatment
  • Course evaluations according to ACGME essentials

There must be a curriculum statement which should include a list of tasks, definitions of skill levels and a defined method of progressing from one skill level to the next. The curriculum must also include the learning components and their requirements. The curriculum may also include use and maintenance of medical instruments and equipment.

Components that should be included are

  • written materials (syllabus, reprints, bibliography)
  • pre- and post-testing

Components that may be included:

  • inanimate model practice
  • animate tissue/organ practice
  • animate laboratory instruction/practice
  • video instruction/practice
  • procedure observation
  • simulator models
  • computer-based instruction and simulation
  • interactive video simulation and testing
  • standardized patients
  • team training
  • cadaveric training
  • robotic training

Clinical case observation or clinical videos may be used to reinforce principles learned. Skills may also be developed using simulation technology such as virtual reality scenarios and/or tele-surgery or tele-conferencing.

The duration of skills training sessions may vary between individuals and should be criterion-based. This implies that the time for training should be sufficient for an individual to acquire the desired level of performance, based on objective metrics.

The post-test should quantitatively and qualitatively evaluate the participant’s acquisition of skills as defined by the program’s objectives.

The curriculum may need to be modified based on the trainee performance during participation in the skills course curriculum. Such modifications may include a series of exercises, tasks, or maneuvers which can be learned and later practiced outside the laboratory.

The instructor or laboratory director must document mastery of the defined objectives and provide both qualitative and quantitative descriptions of the trainee’s experiences.

7. Endorsement: Course directors should provide Continuing Medical Education (CME) credits and/or obtain endorsement by appropriate medical organizations.

8. Documentation: Documentation for certain courses consisting of only didactic instruction may consist of verification of attendance.

C. PRECEPTORSHIP

1. Definitions:

Preceptorship
An individual educational program in which the (graduate) physician (who is beyond residency and fellowship training) acquires additional skills and/or judgment to improve his/her performance of specific medical or surgical techniques and/or procedures. The preceptorship should define eligibility for participation and length of the training period.

Preceptor
An expert surgeon who undertakes to impart his/her clinical knowledge and skills in a defined setting to a preceptee. The preceptor must be appropriately privileged, skilled, and experienced in the procedure(s) and or technique(s) in question. In order to serve as a preceptor in a specific procedure or technique, the surgeon (preceptor) must be a recognized authority (e.g. publications, presentations, extensive clinical experience) in the particular field of expertise.

Preceptee/Trainee
A surgeon with appropriate basic knowledge and experience seeking individual training in skills and/or procedures not learned in prior formal residency or fellowship training. The trainee must have appropriate background knowledge, basic skills, and clinical experience relevant to the proposed curriculum. The trainee should be board eligible or certified in the appropriate specialty or possess equivalent board certification from outside the United States.

2. Objectives: The preceptorship must have stated objectives. The objectives must include a program outline and a proposed list of tasks and skills to be addressed during the training period.

3. Role of Preceptor: The preceptor has the overall responsibility for setting objectives, developing curriculum, overseeing instruction and practice of skills, demonstrating technique and clinical procedures, and evaluating the trainee.

The preceptor has primary patient care responsibility and is obliged to supervise not only procedures in which the trainee participates but also the appropriate perioperative care. This relationship must be reflected in the informed consent documentation.

4. Role of Trainee/Preceptee: The trainee must be involved in:

  • developing an adequate fund of knowledge about the disease process for which the technique or procedure is intended to treat.
  • learning the skills required to perform a technique or procedure
  • both pre-operative and post-operative patient care

Completion of a preceptorship denotes adequate exposure to the patient’s complete pre-operative, operative, and post-operative care.

5. Site/Operations: The preceptorship site must have sufficient clinical material and facilities to adequately educate the trainee. The preceptorship may be operated by or in affiliation with an accredited hospital, medical institution, university, or a medical association which is qualified to grant continuing medical education (CME) credits.

6. Curriculum: The preceptor-trainee relationship should be analogous to residency training and include: factual, technical, and judgmental components. This training is based on clinical experience. However, the experience may be supplemented with teaching tools at the preceptor’s discretion. Teaching aids utilized by the preceptor may include:

  • inanimate models/simulators
  • ex vivo tissues
  • videos
  • self assessment exercises
  • animate laboratories
  • telementoring

7. Documentation: The preceptor must document in writing both qualitative and quantitative descriptions of the trainee’s experiences. This should include skills acquired and the number of procedures in which the trainee assisted or served as primary operator. Documentation stating that the procedures were satisfactorily performed must be provided to the preceptee. A certificate of training should be provided by the preceptor.

8. Insurance It is the dual responsibility of the preceptor and the trainee to secure appropriate authorization and indemnity through their own institution(s) or through independent sources in order to protect themselves and the patient.

VI. PROGRAM ASSESSMENT

Each program must regularly evaluate the degree to which its goals are being met through a formal assessment process. Such evaluation should be ongoing and systematically documented. The goal of each program should be to prepare qualified surgeons. The assessment process should include faculty evaluation by trainees. For programs granting CME credit, ACCME guidelines should be followed.

VII. PRIVILEGING

A. Credentialing/Privileging Committee: The trainee’s local hospital or institutional body is charged with granting of privileges as defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In conjunction with standard JCAHO guidelines for granting hospital privileges, the structure and process remain the individual responsibility of each institution. Having completed formal residency and post-residency training, privileging guidelines may include:

  • consideration of clinical experience and post-residency training/education
  • privileging in comparable alternative procedures
  • appropriate ability and experience to manage common complications

B. Appeals Mechanisms: As part of its responsibility, the privileging committee must establish appropriate mechanisms of appeal for individuals denied privileges.

C. Renewal of Privileges: Surgeons’ experience and skills vary. Therefore, clinical privileges must be periodically re-evaluated. The hospital privileging committee must have written policy concerning renewal of privileges. The written policy should indicate if renewal of privileges is a part of, or separate from, hospital re-appointment. It is suggested that privileges be renewed every two years. Renewal should be contingent upon a stated level of clinical activity in specific procedures, in addition to satisfactory performance as assessed by quality assurance monitoring.

D. Documentation of Continuing Education: Continuing medical education related to the field should be required as part of the periodic renewal of privileges. Attendance or participation at appropriate local, national, or international meetings and courses should be encouraged and documented.

E. Proctoring:

  1. Definition: Traditionally, a proctor is a person who supervises or monitors students. As defined here, a proctor differs from a consultant or a preceptor in that s(he) functions as an observer and evaluator, does not directly participate in patient care, and receives no fees from the patient. Proctoring may be an element of the privileging process.
  2. Qualifications of the Proctor: A proctor must be a physician/surgeon who has recognized proficiency or documented expertise in the specialty area being proctored. The proctor should be free of perceived or actual conflicts of interest, which might create a bias against, or in favor of, the applicant. A proctor may work at the same or at another institution.
  3. When a proctor may be required: A proctor should be available to the privileging committee when a surgeon requests initial or extended privileges, during the review process, or for special quality assurance situations.
  4. Proctoring process: The proctor must serve as an agent of the medical staff privileging committee. The privileging committee should determine the extent of the proctoring. It is the hospital responsibility to indemnify the proctor and so advise in writing.
    It may be necessary to have more than one proctor evaluate the candidate at different times. The proctor must certify the trainee’s competence in the procedure’s performance. The proctor’s(s’) evaluation(s) must be documented in writing and submitted directly to the privileging committee. The evaluation should include the type and number of procedures observed and whether these were sufficient to enable the proctor to render an opinion concerning the applicant’s performance. The committee should develop a formal written protocol and maintain detailed records. The proctoring document must be kept confidential.

Criteria of competency should be established in advance. These should include:

  • patient selection
  • pre-operative evaluation and preparation
  • familiarity with instrumentation
  • surgical skills/judgment
  • safe, expeditious completion of the procedure
  • post-operative plan
  • complication avoidance

5. Proctor’s responsibility: The proctor sole responsibility is to the medical staff privileging committee. There must be no financial obligation to the proctor from the surgeon or the patient.

6. Intervention: The issue of whether and to what extent a proctor should intervene in a procedure is complex and unsettled. Certain clinical situations, or simple humanitarian concerns, may dictate that the proctor become a consultant to the applicant or actually intervene to assist in a procedure gone awry. The proctor must realize that if s(he) goes beyond merely observing the procedure, s(he) has undertaken a duty to the patient which can result in liability arising from sequelae of the procedure. The proctor’s involvement should be disclosed on the patient’s chart and in the proctor’s confidential report to the privileging committee. In situations where an applicant has an associate who holds privileges in the procedure being proctored, some hospitals have encouraged the associate to be present to assist (if necessary) in the procedure and to avoid the necessity for the proctor to become involved. The proctor may or may not be included in the patient’s informed consent, recognizing that such inclusion may expose the proctor to risk beyond that of mere proctoring.

VIII. SUMMARY STATEMENT

The practicing surgeon may recognize or a privileging committee may mandate when additional formal training is required. Examples include, but are not limited to: a procedure new to the surgical community at large or a procedure or technique which is not part of the surgeon’s current repertoire. Regardless of the impetus, the components of training must result in a surgeon who is comfortable performing a new procedure. In addition, training must be uniformly structured to provide sufficient information to objectively document the results of training.

This document outlines a framework for post-residency surgical training, provides consistent definitions of key terms and roles, and suggests educational programs appropriate to JCAHO guidelines.

REFERENCES

  1. Cheifetz RE, Phang, PT: Evaluating Learning and Knowledge Retention after a Continuing Medical Education Course on Total Mesorectal Excision for Surgeons. Am J Surg 2006;191:687-90.
  2. Chekan EG, Muryama K, Provost D, et al. Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Guidelines on Continuing Medical Education and Financial Relationships. Surg Endosc 2006;20:1168-1170.
  3. Hori Y, SAGES Guidelines Committee. Granting of privilege for gastrointestinal endoscopy. Surg Endosc 2008;22:1349-52.
  4. Kurt ER, Bell RL, Duffy AJ. Evolution of Surgical Skills Training. World J Surg 2006:12: 3219-32.
  5. Rogers DA, Elstein AS, Bordage G. Improving Continuing Medical Education for Surgical Techniques: Applying the Lessons Learned in the First Decade of Minimal Access Surgery. Ann Surg 2001; 233:159-166, 2001.
  6. Rosser JC, et. al. Telementoring and Teleproctoring. World J Surg 2001;25: 1438-1448.
  7. Sachdeva AK, Russell TR. Safe Introduction of New Procedures and Emerging Technologies in Surgery: Education, Credentialing, and Privileging. Surg Clin N Am 2007; 87: 853-866.
  8. Sachdeva AK. Acquiring Skills in New Procedures and Technology: The Challenge and the Opportunity. Arch Surg 2005;140: 387-389.

This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on Jul 2010.

This is a revision of SAGES publication #17 printed Jan 1994, revised Apr 1998, Jun 2003, and Jul 2010.

For more information please contact:

SOCIETY OF AMERICAN GASTROINTESTINAL ENDOSCOPIC SURGEONS (SAGES)
11300 West Olympic Blvd., Suite 600
Los Angeles, CA 90064
Tel:
(310) 437-0544
Fax:
(310) 437-0585
Email:
publications@sages.org

Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.

Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of its production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice.