The History of Surgical Education in the United States: Past, Present, and Future

Abstract

In just over 100 years, surgical education in the United States has evolved from a disorganized practice to a refined system esteemed worldwide as one of the premier models for the training of physicians and surgeons. But in the changing environment of health care, new challenges have arisen that could warrant a reform. To design our future, we must understand our past. The present work is not intended to be a comprehensive account of the history of American surgery. Instead, it tells the abridged history of surgical education in our country: the evolution from apprenticeships to residencies; the birth of hospital-based teaching; the impact of key historical events on training; the marks left by some preeminent characters; the conception of regulatory entities that steer our education; and, finally, how our process of training surgeons might need to be refined for the continued progress of our profession. Told in chronological order in a manner that will be memorable to readers, this story weaves together the key events that explain how our current surgical training models came to be. We conclude with a timely invitation to draw from these past lessons to redesign the future of graduate medical education, making a case for the transition to time-variable, competency-based medical education for surgical residency programs in America.

INTRODUCTION

In just over 100 years, surgical education in the United States has evolved from a disorganized practice to a refined system esteemed worldwide as one of the premier models for the training of surgeons.^1,2 But in the changing environment of health care, new challenges have arisen that could warrant a reform. To design our future, we must understand our past. Hereafter is an abridged story of surgical education in the United States: the evolution from apprenticeships to residencies, the transformation of hospital-based training, the conception of regulatory entities that steer our education, and how our process of training surgeons could be refined for the continued progress of our profession.

The comprehensive history of American surgery is rich and outside the scope of the present work. Due to space constraints, only broad historical and social events associated with the major changes in surgical education are provided for context. For in-depth information about a specific period or event, readers are directed to the many excellent references on each subject.

THE 18TH AND EARLY 19TH CENTURIES: FROM APPRENTICESHIPS TO MEDICAL SCHOOLS, STATE MEDICAL SOCIETIES, EARLY ASSOCIATIONS, AND THE CIVIL WAR

Surgery in Colonial America

While surgery in Europe was blooming by the 1700s—for example, with societies like The Company of Surgeons of London (1745) sprouting as the precursor of the Royal College of Surgeons³—medicine in the American Colonies was primitive. The rapidly growing population brought waves of disease without the doctors to treat it, as few formally trained European physicians were willing to settle in the New World. Informal medical care was provided by the educated individuals who had access to European literature of the day,⁴ like clerics and teachers, or by the rare barber-surgeon who could perform minor procedures. The colonial doctor was expected to be a “jack-of-all-trades,” unlike the well-demarcated lines separating surgeons from physicians and apothecaries in Europe.¹ Indeed, under these circumstances, few advances were made in the Colonies prior to 1750.⁴ Except for almshouses, there were no hospitals in America, until the Pennsylvania Hospital opened in Philadelphia in 1751. This was mostly thanks to the fundraising labors of Benjamin Franklin, who fought for an institution to care for the poor that would also serve as a place for American medical education.^1,5

Still, medical schools did not exist yet. By the mid 18th century, the apprenticeship model was the standard form of medical learning.⁴ Apprentices were indentured for 5–7 years starting around age 13 and, upon completion, would practice without regulation.^4,6 At the time of the American Revolution (1776), of an estimated 3,500 physicians, 10% had legitimate medical degrees.⁴ Only the wealthy aspiring physicians would travel to Europe to formalize their training under renowned masters, mainly in London and Edinburgh. This movement of physicians marked an important change in colonial medicine, as those who ventured abroad for training would return to become the pioneers in American Surgery and founders of its earliest medical schools by the late 18th century. The destinations of choice would change over the years, with England and France being the preeminent medical lands in the first half of the 19th century, and German-speaking countries taking the lead around 1850 until WWI.⁷

Founded largely by those Europe-educated leaders, medical schools at The University of Pennsylvania (1765), King’s College (1767, Columbia today), and Harvard University (1783) were the first to open in the country. Others followed in ensuing decades, including Dartmouth College (1797), the University of Maryland (1807), and Yale (1813). Strict admission requirements differentiated these institutions. For the University of Pennsylvania, prerequisites included: (1) 3 years of apprenticeship to reputable physician; (2) education in liberal arts, mathematics, and natural history; and (3) knowledge of Latin and, preferably, French.¹

The Start of Regulation: State Medical Societies

Despite the foundation of major medical schools, there was no serious regulation governing the training or qualification of surgeons during the Early Republic of the 19th century. Medical schools along the Northeast started to educate a privileged minority, but lack of oversight allowed for many “informal” types of medicine. In a first attempt to regulate practice, local medical societies were created to examine and license their physicians. The first was the State Medical Society of New Jersey in 1776, conceived to address “[...] the matters of highest concern to the profession: regulation of practice; educational standards for apprentices; fee schedules; and a code of ethics.” Medical societies in Massachusetts (1781), Philadelphia (1787), and Maryland (1789) followed.⁴

Other smaller societies formed across the land. And as the local demands for physicians started to rise, societies started opening their own training programs. These “proprietary” medical schools sprouted everywhere with varying degrees of quality, doing away with any requirement for admission. No one who could pay their fee was turned down. They operated mostly in rural towns with meager facilities. Laboratory and clinical work were absent, and a typical “curriculum” consisted of two 16-week sets of lectures.¹ Unfortunately, the unhealthy competition impacted the more serious, established medical schools, forcing them to lower their admission standards when attendance dropped. The quality was so low, that some medical schools would resist evaluating graduates with tests because many were illiterate.^1,4,7 The local medical societies had failed at achieving regulation, while creating the problem of proprietary medical schools releasing unfit candidates into practice. The need for national oversight was becoming clear––although it would take nearly a century for significant changes to occur.

Birth of the American Medical Association

First attempting to address the issue in 1847, nearly 200 delegates from 40 state medical societies and 22 medical colleges met and formed the American Medical Association (AMA), with the primary goal of raising the standards of medical education in the country. Although the AMA would eventually become a crucial player in the development of medicine in the United States, they initially failed to achieve a reform.⁸ Their success in exerting change would not be evident until their reorganization the following century.⁷

Concurrent Advances During the 19th Century

The 19th century also brought increased scientific sophistication in medicine and surgery. The public advent of anesthesia (W. Morton, 1846) and antisepsis (J. Lister, 1867) expanded the boundaries of what had been achievable until then. These and other seminal developments during the second half of the century (X-rays, blood transfusions, the removal of restrictions in cadaveric anatomic studies, advances in experimental physiology, formal nursing education, etc.) allowed for the rapid development of new procedures in every surgical field around the world.⁴ The scope of the craft of surgery was rapidly changing.

The Civil War: A Hands-On Surgical Lesson

Albeit incredibly tragic, the Civil War (1861–1865) was a pivotal period in American surgery.⁴ With ballistic injuries came a demand for advancing surgical care, including the management of mass casualties with ambulance corps, battlefield aid stations, and field hospitals. The use of anesthesia shifted the operative focus from speed alone to technique and precision. Surgeons started keeping better records and pursuing scientific investigation, with American medical literature proliferating during the war. After this forced hands-on training, the postwar nation was provided with a core of experienced surgeons, and the American practice of surgery evolved rapidly (Figure 1).^4,9 The standardization and regulation of practice in the country was growing in parallel.

FIGURE 1.

One of the few existing photographs of an operation during the American Civil War taken in 1864 at Fortress Monroe, showing two uniformed Union surgeons about to perform a lower extremity amputation (taken from Rutkow⁴; p. 439). Reprinted with permission.

LATE 19TH CENTURY: STATE BOARDS, NATIONAL BOARD REGULATION, AND THE START OF A MEDICAL EDUCATION REFORM

State Medical Boards on the Rise

By the late 1800s, the harm of unqualified physicians was becoming a public concern. The medical diploma had been accepted as a license to practice, but the quality of education did not matter. Proprietary schools guaranteed degrees to anyone paying tuition,⁴ and fake medical diploma mills were being exposed in several cities (1860–1870).¹⁰ The practice of medicine was open to all who called themselves a “doctor.”⁴ A movement toward government involvement in medical licensing gained strength and, finally, between 1870 and 1880, 15 states passed medical licensing acts.¹¹ But highly variable laws and levels of scrutiny resulted in the formation of State Medical Boards, inspired by the pioneering efforts of the newly created Illinois Board of Health in 1877.¹¹ Led by Dr. John Rauch—a graduate of the University of Pennsylvania who would eventually cofound the American Public Health Association¹²—the Illinois Board forced nearly 3,600 individuals to leave practice within a year.^10,11 The Illinois Board acted as a catalyst, with other states following the lead and establishing systems for the evaluation of credentials and standards of medical schools.¹⁰ Once established, state medical boards focused on closure of the most corrupt proprietary medical schools.

Federation of State Medical Boards: A United Front for National Medical Examination and Licensing

Soon after State Medical Boards were created, they would realize the need for a national governing body. Between 1890 and 1902, at a time when there were conflicting licensing boards and examination bodies across states, two different confederations were created to unify licensing boards and medical examinations between all territories. With pressure from the AMA criticizing their duplicated efforts, the two confederations merged in 1912 to form the current Federation of State Medical Boards. The Federation of State Medical Boards (FSMB) has made significant contributions over time, including the formation of the Educational Committee for Foreign Medical Graduates (ECFMG), and the United States Medical Licensing Examination (USMLE).¹³

The Medical Education Reform of the 1870s and The Association of American Medical Colleges

In the decades that followed the Civil War, the state of medical education in the country was still dire. Concurrent with the medical licensing movement that had begun, educational reforms started to arise at a few institutions between 1870–1890—mainly Harvard, the University of Michigan, and the University of Pennsylvania. The stream of physicians returning from Berlin and Vienna had experienced the virtues of the medical education model used in German-speaking countries, where medical schools were associated with universities and the exchange of ideas was encouraged; learning was through experimentation in laboratories and medical research, instead of transmitted dogma through lectures and books. Although the leaders pushing for reform were met with significant opposition, they eventually prevailed.⁷

These reforms led to the creation of the Association of American Medical Colleges (AAMC) in 1876, by 22 deans of like-minded schools attempting to reform medical education curricula and standards.^14,15 The reform moved fast in the last two decades of the 19th century. Scientific courses were added to curricula and the academic year was expanded. By 1893, 90% of the medical schools offered 3 years, with leading schools demanding 4 years.⁷

Initially, the existing AMA and the new AAMC had conflicting ideas on how to achieve the goal of medical education improvement: the AMA represented the interests of medical professionals, and the AAMC those of educational institutions.⁷ However, they gained enormous strength during the 1900s, aligning their interests with those of the forward-thinking professors of leading schools to pursue a more widespread reform inspired by the German model.⁷ Together, they fostered a movement toward uniformity by publishing a suggested model curriculum for medical school adaptation in 1905.⁷ They would join forces again later on for medical school accreditation in 1919.¹⁴

TURN OF THE CENTURY: GROSS, HALSTED, AND FLEXNER

The Defining of “the American Surgeon”: Dr. Samuel Gross and the American Surgical Association

Contrary to European medicine, by the end of the 19th century, there was still no delineation between physicians and surgeons in the United States.⁴ In 1876, Dr. Samuel D. Gross wrote: “Although this article is designed to record the achievements of American surgeons, there are, strange to say, as a separate and distinct class, no such persons among us. It is safe to affirm that there is not a medical man on this continent who devotes himself exclusively to the practice of surgery… American medical men are general practitioners.”¹⁶ Dr. Gross saw the need for a surgical society that would enable those with similar interests to expand the boundaries of surgery, and in 1880, he founded the American Surgical Association (ASA)¹⁷ (Figure 2).

FIGURE 2.

The Gross Clinic, Portrait of Professor Gross (1875) by Thomas Eakins. The paining shows Samuel D. Gross with five assistants as he performs an operation in the amphitheater at Jefferson Medical College. Note surgeons operating in their suits with bare hands. To the left is presumably the patient’s mother, covering her face in horror. It was stipulated in charity cases that a member of the patient’s family be present. Dr. Gross was the founder of the ASA in 1880, paramount step toward the professionalization of surgery in the United States* (taken from Rutkow⁴; p. 320). Reprinted with permission.

A man from a humble background who eventually became Chair of Surgery at Jefferson Medical College in 1856,¹⁸ Gross had an abiding commitment to improve the quality of medical education and research. As a prolific writer of several surgical books translated to multiple languages, he was a restless advocate of the importance of developing American literature.^17,18 Besides cofounding and serving as President of the ASA, he was one of the only two surgeons to ever to serve as President of the AMA.¹⁷

The foundation of the ASA was a paramount step toward the professionalization of surgery in the United States, representing the first attempt to bring together those whose reputations and actions marked them as surgeons.¹⁹ The ASA still stands today as one of the country’s preeminent medical societies.¹⁹ In his inaugural speech, Dr. Gross stated their mission: “… to foster surgical art, science, education, and literature, to cultivate good teaching in the profession and to unite the prominent surgeons of the country in one harmonious body.” Three years later, the first volume of the Annals of Surgery was published—a fundamental record of the roots of American surgery. With a society and a journal, American surgeons were beginning to pursue the level of organization that European counterparts had long held.⁴ The next step in establishing the United States as a birthplace for surgical masters would come with Dr. William Halsted and his journey through The Johns Hopkins School of Medicine.

The Beginnings of the Modern Surgical Residency: William Halsted and the Pyramidal Residency Paradigm

Born in 1852 in New York City, William Stewart Halsted was raised in privileged circumstances. After attending Yale, he graduated from the Columbia College of Physicians and Surgeons of New York in 1877,²⁰ followed by an 18-month long internship at Bellevue Hospital in New York. He then departed to Europe and spent 2 years in Austria and Germany. The scholastic German model of medical training made a strong impression on Halsted and would later influence his reform of surgical education.⁴ Halsted returned to New York in 1880 and was hired at his alma mater, where he started his research on topical anesthesia and cocaine. His experiments unfortunately resulted in addiction, leading to a slow health decline. He self-committed to an institution in Providence, where he was weaned off cocaine with morphine. Addiction ended his career in New York City. Faced with professional demise, he accepted an invitation from pathologist and friend William H. Welch, to move to Baltimore and work in his laboratory at The Johns Hopkins University. After convincing hospital authorities of his capabilities, he was appointed Surgeon-in Chief, and later, Professor of Surgery at the Johns Hopkins Hospital in 1892.²⁰

Of Halsted’s numerous contributions to surgery, the most salient was the introduction of a residency model of training surgeons marked by close patient contact, research, and graduated responsibility²⁰—a Germanic philosophy of training that he shared with Sir William Osler, Chief of Medicine at Hopkins at the same time.²¹ The Halsted model was strictly pyramidal, with 8 interns serving for 1 year but only 4 allowed to advance. Only one rose to the level of “house surgeon” for an indefinite amount of time,^1,21 while the others stood in line for preferment. The house surgeon would be allowed to graduate once he was cleared for independent practice by Dr. Halsted. Advancement was not guaranteed, and the competition was “fierce and vigorous” while caring for patients, operating, and producing research.^1,22 Halsted’s aim was to train not only surgeons, but teachers of academic surgery “…who will stimulate the youths of our country to study surgery and to devote their energies and their lives to raising the standards of surgical science.”^4,22 Eventually, many of his trainees went on to fulfill leadership positions at top institutions, including seven Chairs of Surgery. Even those who did not reach the top of the pyramid became prominent professors of surgery and subspecialties^4,22 (Figure 3).

FIGURE 3.

William Stewart Halsted in an oil painting from a photograph taken in 1922 by John H. Stocksdale. Halsted was a brilliant innovator and teacher who, as Dr. Ira Rutkow puts it, “he more than any other American surgeon created the foundation of which the American school of surgery rests” (from Rutkow⁴; p. 457). Reprinted with permission.

The foundation of the Johns Hopkins Medical School and its closely integrated hospital—with the trail-blazing individuals who passed through their halls, and the establishment of a revolutionary new residency training system—heralded the transformation of surgical education in the United States into the science-based model we know today.⁴

A Catalyst for Change: The Flexner Report

At the turn of the Century, the quality of the nation’s schools was widely variable, ranging from some of the finest universities to some of the “most atrocious schools in existence,”⁷ with for-profit medical education continuing to produce a surplus of poorly trained physicians.²³ The need to improve medical education had become a clear consensus in the medical profession. In 1908, the AMA’s Council on Medical Education commissioned the Carnegie Foundation for the Advancement of Teaching to conduct a survey on the state of medical schools in the country. Abraham Flexner, a Johns Hopkins University graduate and the headmaster of a private school in Louisville with a published book on education (The American College, 1908), was chosen to lead the survey and publish the results. The Council felt that an educator was better suited than a physician to criticize the dire status of American medical schools, hoping that the negative results would be better received coming from an external agent and institution.^7,23 Flexner traveled to and analyzed 155 medical schools in North America,²⁴ which he graded based on entry requirements, curricula, resources, faculty, and facilities. In 1910, “Medical Education in the US and Canada”—or “The Flexner Report”—was published, debuting with 15,000 copies.¹⁵ Using Johns Hopkins and the German and English systems as models of excellence, Flexner concluded that the majority of medical schools were of the poorest quality. As a result of the report and associated public outcry, 120 out of 162 medical schools were closed over ensuing years.^7,25 Flexner did not present anything conceptually new in medical education reform, but he brilliantly succeeded in making the transformation a broad social movement, accelerating a process that was already underway.⁷

Unfortunately, a disproportionate casualty of the closures were the predominantly Black medical schools, with only two surviving after the Flexner report (Howard University College of Medicine and Meharry Medical College).^26,27 And although Flexner did recommend the coeducation of women and men, he accepted segregation in medical schools and noted that Black physicians should be trained differently.²⁸

Over the next few years until around WWI, the model of the “modern American medical school” was born with the combination of securing a solid financial base with an outpouring of philanthropy,²⁵ the maturation of academic medicine, a drive for research, and the establishment of teaching hospitals. The elimination of proprietary schools occurred with the slow enactment in all states of stringent licensing laws.⁷

Segregation by the Turn of the Century and Effects on African American Physicians

Segregation plagued America and organized medicine at the time. African American physicians had been struggling for decades to counteract exclusion from medical schools, regulatory bodies, and medical societies. After 1888, all members of State medical societies were automatically included in the AMA; however, strict racial bars on membership in many state and local societies (especially in the South) precluded most African American physicians from joining the AMA.²⁸ And since membership became mandatory for hospital admitting privileges, and the latter was required for specialty training, for years African American physicians were functionally excluded from specialty training.²⁷ The unsuccessful attempts of Black physicians to join the AMA led to the creation of the National Association of Colored Physicians, Dentists, and Pharmacists in 1895 in Atlanta, Georgia—which changed its name in 1903 to the National Medical Association, including a policy of nonexclusion based on race. The plea of the National Medical Association leaders for inclusion into the AMA would continue for decades, intertwined with the national movement for Civil Rights that strengthened after WWII. Following passage of the Civil Rights Act in 1964 and Medicare in 1965, discrimination was prohibited in public accommodations and federally funded programs, making segregation in hospitals finally illegal.^27,28 These effects reverberated slowly into medical and professional associations. Although the AMA failed for decades to take a stance on issues of physician discrimination, it has since changed its code of ethics, taken strong action on inclusion, and issued a public apology in 2008.²⁹

THE 20TH CENTURY: POST FLEXNER ERA, CHANGES IN SOCIETIES AND REGULATION, AND A NEW MODEL OF RESIDENCY

Post Flexner Era and Interplay Between Societies, Boards, and Organizations

In the wake of the Flexner report, the cry of medical educators and the public for strict regulation was finally heard. At the same time, The Council of Medical Education and Hospitals of the AMA became the first professional organization to set standards for graduate medical education (GME), by publishing in 1914, a list of hospitals approved for medical internships. By 1927, the list also included all approved hospitals with GME programs in all specialties, called “Essentials of Approved Residencies and Fellowships.” This was considered the foundation for the evolving standards for residency training. At the same time, the movement for surgical specialization was becoming stronger, and by the mid-1930s some specialty boards had been founded (American Board of Ophthalmology in 1916, Otolaryngology in 1924, Obstetrics and Gynecology in 1931). In parallel, the recently formed American College of Surgeons would be making strong efforts to standardize surgery in the same manner.³⁰ By 1931, there would be approximately 25,000 specialty board-certified physicians in the United States. Notably, only 2 of them were African American: Dr. Daniel Hale Williams (Surgery), and Dr. William Harry Barnes (Otolaryngology).²⁷

Franklin Martin and the American College of Surgeons

In the early 20th Century, most American doctors received no GME. Since medical schools did not provide surgical instruction, physicians who were interested either became self-taught, took short unofficial courses, or pursued an internship—a formal year of hospital education after medical school that provided some surgical training. Few hospitals offered one-year residencies after internship year to focus on a specialty. Although the difference between these shorter programs and those at major universities was stark, the bulk of the surgical care in the United States was in the hands of practitioners with little instruction. But as sophistication in surgery increased, so did the need for more specialized training. The formation of the American College of Surgeons (ACS) was, in part, a response by surgeons themselves to this need for better surgical postgraduate training.^7,21

Founded by Franklin H. Martin, the ACS played a key part in events of the following decades.³¹ Martin attended Chicago Medical College (later Northwestern University) until 1880 and, followed by a 2-year internship, opened a practice in gynecology and obstetrics. The death of a patient after performing his first oophorectomy fueled his drive to improve GME. After obtaining an appointment in the Women’s Hospital of Chicago in 1887, Dr. Martin cofounded the Postgraduate Medical School and Hospital in 1889.³² He then founded the practical publication Surgery, Gynecology and Obstetrics (1905)—an overnight success that later became the Journal of the American College of Surgeons. In 1910, Dr. Martin organized the first national postgraduate surgical meeting, The Clinical Congress of Surgeons of North America, inviting surgery practitioners to observe and discuss technique and demonstrations.³² At their 1912 meeting, a Committee on the Standardization of Surgery was formed, with the goal “to formulate a minimum standard of requirement which should be possessed by any authorized graduate in medicine who is allowed to perform independently operations in general surgery or any of its specialties.”¹ The Clinical Congress of Surgeons went on to become the ACS in 1913, establishing professional, ethical, and moral standards for every authorized physician who practiced surgery.⁴ Martin founded the college to elevate the quality of surgery for both the elite academicians and the community practitioners who had proven themselves competent surgeons (Figure 4).²¹ Of its 17 founding regents, only 5 had college degrees and only one had postgraduate training and certification (mostly from Europe), reflecting the varied and inconsistent backgrounds of surgeons of the period.³³ Initially, surgeons who were female, immigrants, or other minorities were granted fellowships into the college sparingly. Of the new 1,057 fellows welcomed to the ACS in 1913, only five were identified as female ³⁴, and one was black. It was mostly after WWII that the ACS became the inclusive body we know today.⁴

FIGURE 4.

Franklin H. Martin (1857–1935) was the founder of Surgery, Gynecology and Obstetrics (1905), the Clinical Congress of Surgeons of North America (1910), and the American College of Surgeons (1913) (from Townsend³²).

The newly formed ACS realized early-on the importance of hospital standardization, forming in 1917 a program that suggested a “minimum standard” was needed by hospitals to ensure safe patient care (e.g., enforcing medical record-keeping, and hiring only licensed staff).³⁵ The effort to enforce these standards would continue over the years with periodic visits, and ultimately become a fundamental precursor to the Joint Commission on Accreditation of Hospitals in 1951, and the Joint Commission on Accreditation of Healthcare Organizations in 1987.^36,37

The ACS also took the lead in reforming surgical education, aiming to set standards for GME in surgery. After years of discussions on how to address this, their Committee on Graduate Training in Surgery met in 1937 and outlined expectations for surgical residency programs.²¹ Given that the AMA had already established criteria and an inspection system for hospitals offering GME, the ACS asked to collaborate, but the AMA declined.^1,21 The ACS proceeded to independently survey and inspect each program that same year. The results showed the state of surgical education: “One of the most striking impressions as a result of this study is the complete lack of a basic standard of uniformity in the methods of graduate training.”²¹ As a result, the “Fundamental Requirements for Graduate Training in Surgery” were published in the 1939 Bulletin of the ACS, including a list of approved hospitals for GME in surgery.^21,25 The report was well received, with deans of academic institutions pledging to raise their programs to the proposed standards. The ACS seal of approval became desirable for programs who wanted to attract more qualified residents. The applicants, in turn, trusted ACS-approved programs to ensure entrance into the College—and, with the concurrent establishment of the American Board of Surgery, also to improve their chances of passing their boards.²¹

The American Board of Surgery

After years of disagreements and unsuccessful attempts between the ASA and the ACS to create a united front to evaluate surgeons and ensure their competency,¹ they started to recognize that their efforts were interdependent. The American Board of Surgery (ABS) was created in 1937 as a result of a committee created a year earlier by the ASA (National Committee for the Elevation of the Standards of Surgery), with representatives from the ACS, AMA, and regional surgical associations.³⁸ With surgery maturing into a full-time specialty, they saw the need to create a national certifying body to differentiate formally trained surgeons from doctors in general practice.³⁸ As such, the Board established a certification process for surgeons practicing in the United States, to protect the public by ensuring that only graduates from approved programs who met acceptable standards could become certified in surgery.^1,21,38 The ABS demanded three years of residency following internship—a requirement derived from the then new Advisory Board of Medical Specialties (ABMS, est. 1933) applying to all boards.²¹ This event transitioned surgical education from highly variable experiences around the country to a more unified national standard.²¹

A Timely Residency Structure Reform: Churchill and The Rectangular Residency Paradigm

Although the approved list of sites for surgical training was growing, the number of competent surgeons was still insufficient for the needs of America at the time. In 1939, Dr. Edward Churchill proposed a new surgical training model to the Board of the Mass General Hospital in Boston. Churchill criticized Halsted’s pyramidal model in that, while creating a few superb surgeons, it produced more who were incompletely educated, with as little as 1 year of formal surgical training. As he put it, “half a surgical training is about as useful as half a billiard ball.”³⁹ The pyramidal system perpetuated the apprenticeship model with a dominant master and a docile learner, which he considered “anti-intellectual and a-scientific.”³⁹ Instead, Churchill proposed a “rectangular program,” where 6 individuals were selected each year to complete training in surgery. Provided satisfactory performance, they would all complete 5 years of training, becoming eligible for the ABS Qualifying Examination.²² Two could stay for an additional 1–2 years on a path to become surgery professors at academic institutions. His model was rooted on graded responsibility in clinical care, a broad operative experience, physiology courses, and research support during training. By removing the brutal competition for survival, it allowed residents to focus on their education while working cooperatively with peers and preceptors.^1,22,39 The new model emphasized the formation of competent surgeons for the community and not only academicians, aiming to producing the number of well-trained surgeons that the country needed.²¹ With minor modifications, his system became the core structure of the current residency training system in America.³⁹

World War II and the Federalization of Residency Funding

World War II affected surgical training in profound ways. The war created a massive exodus of surgical staff from residencies. Although doctors initially required scant experience to go to war as “surgeons,”²¹ the Armed Forces eventually recognized the superiority of fully trained surgeons, providing higher ranks and pay to those holding Board (ABS) certification. By the end of the war, there was a flood of returning veteran doctors who wanted to finish surgical training. The nation accommodated them by creating training opportunities at VA hospitals—which associated themselves with medical schools and academic institutions under a broad initiative to improve the quality of care, also providing female and pediatric exposure for trainees. The ACS helped by increasing postwar program inspections for approval. At the same time, residency training was declared eligible for funds under the GI Bill of Benefits for veterans, making it a paid educational benefit for veteran doctors. In 1965, under the Lyndon B. Johnson presidency, the US Congress approved the Medicare Bill, which provided training hospitals and GME with federal funding support. With that, the entirety of residency training was raised to the level of public policy, including a stipend for GME trainees.^21,40

The Formation of Residency Review Committees, their Oversight, and Further Standardization in GME

As the 1950s arrived, despite advancements in training, there were still no coordinated standards for accreditation of residency programs. Residencies were burdened with two parallel processes for accreditation: one by the AMA, approving hospitals with GME programs; and another by the specialties themselves (i.e., ACS), approving hospitals and establishing training standards. The redundancy came to resolution in 1950, when the AMA, the ABS, and the ACS formed the Conference Committee on Graduate Training in Surgery, which assumed accreditation authority for surgery programs.^15,30 This committee was the forerunner of the Residency Review Committee (RRC) in surgery.^25,41 The model of the Surgery RRC quickly spread to other specialties, serving as a guide for national residency reform. With this, there was finally a separation of function between the specialty boards—which examined candidates, and the RRCs—which accredited training programs.²⁵

Although each RRC worked well for independent specialties, different RRC standards gave hospitals multiple sets of requirements, sometimes redundant or conflicting. The need for an oversight body for the RRCs across all disciplines was recognized, and five organizations (AMA, ABMS, American Hospital Association, AAMC, and Council of Medical Specialty Societies) came together in 1972 to form the Liaison Committee for Graduate Surgical Education (LCGME), to coordinate and oversee independent RRCs.^25,30,41 Due to political and governance issues, the LCGME dissolved after 9 years, and it was recreated under the same 5 parent organizations as the Accreditation Council for Graduate Medical Education (ACGME). Still plagued by the same political problems, that initial ACGME also failed. A new organization with the same goals but independently governed was created in the year 2000. The ACGME name was kept to avoid issues with federal funding being tied to the old organization’s name.³⁰

The ACGME’s mission is “to improve health care by assessing and advancing the quality of resident physicians’ education through exemplary accreditation.”⁴² Within a few years, the newly independent ACGME effected several key initiatives and reforms that are in play today, including the Six Core Competencies, the Outcomes Project, Duty Hour Reform, the Next Accreditation System, and the Milestones Project.⁴³ Today, medical schools, residency programs, physicians, and hospitals work together within this complex system of accreditation and certification systems, striving to ensure that every patient can be confident in their medical (and surgical) care.

THE 21ST CENTURY: RETHINKING OUR WAYS

Moving Toward Competency-Based Medical Education: Back to the Future?

Back in 1931, Churchill called for flexibility in tailoring training to individual needs, by pointing out how “a frozen five-year curriculum is unthinkable as it allows no latitude for the development of individual interests and proficiencies.”^1,39 Should we reconsider this?

The Josiah Macy Jr. Foundation (est. 1930) is the only national foundation dedicated to improving the education of health professionals. Their reports have highlighted how despite massive amounts of federal funding for GME, there is no public accountability that physicians are adequately trained to meet the needs of a changing demographic and health system. In fact, studies have shown that a high percentage of surgical graduates in different fields feel unprepared for independent practice after training.^2,44 The foundation has also noted excessive emphasis on time-based training as a surrogate for competency.⁴⁵ Instead, their recommendation is to move toward a competency-based, time-variable educational system.^2,46 Under this system, the length of training is determined by an individual’s readiness for independent practice—demonstrated by mastery of all required competencies and skills, and by fulfillment of nationally endorsed, specialty-specific standards—rather than tied to a given number of years. Competency-based medical education (CBME) aims to create a process that is learner-centered, fostering individual abilities, a self-drive for life-long learning, and addressing both the trainee’s shortcomings and inherent talents. This concept is not new: in fact, the ACGME changed the method for measurement of residency training outcomes with the establishment of the Six Core Competencies in 1999, followed by the Next Accreditation System and Milestones Project in 2013.⁴⁷ These initiatives have already started to shift the focus of training toward achievement of individual educational milestones as a parameter for training success.⁴⁸

The concept of a time-variable, CBME system in surgery takes after the Halstedian model in that surgeons train until proving competence instead of a set number of years, while following Churchill’s paradigm in ensuring that all trainees leave the system as fully trained surgeons ready for independent practice. Are we in a way going back to the future?⁴⁹

Following the successful experimental program in CBME by the Department of Orthopedic Surgery in Toronto in 2009, the Royal College of Physicians and Surgeons of Canada in 2017 determined that all GME programs would adopt such a format.⁵⁰ First in the United States, with approval by the American Board of Plastic Surgery and the ACGME, the Consortium for CBME in Plastic Surgery was established in 2016 between programs at University of Pittsburgh, Johns Hopkins Medicine, The University of Michigan, and Baylor Scott and White. This experimental program is ongoing since 2018 and, if successful, could become a model to replicate in other surgical fields around the country.⁵¹

There are many challenges in establishing a time variable, CBME system in surgery, including defining outcomes that truly constitute competency; creating reliable assessment tools that are repeatable and objective; and making changes to credentialing, assessment, and accreditation. Additionally, although there have been significant strides to make surgery a more inclusive and diverse field, the fact remains that there are still concerns about underrepresentation in medicine for certain groups (especially in leadership),^52–54 as well as bias when it comes to resident assessment related to gender or ethnicity.^48,55 If we are to move toward a system where competency is the sole basis for advancement, then it must be ensured that potential bias will not influence the outcome.^48,56 Fine-tuning these aspects will be an ongoing process as CBME is implemented.

Although challenging, it may be time to reexamine the concept of residency training that has served us well for the past 100 years.

In his delivery of the Annual Address in Medicine at Yale in 1904, “The Training of the Surgeon,” Halsted said: “A warning for all time against satisfaction with present achievement and blindness to the possibilities of future development is the imperishable prophecy of the famous French surgeon, Baron Boyer, who over a hundred years ago declared that surgery had then reached almost, if not actually, the highest degree of perfection of which it was capable.” We must continue to heed this warning and not settle for the status quo, being blind to the possibilities of evolution in our surgical training. We have a responsibility to critique and rethink our ways of shaping surgeons, by drawing lessons from the past for the betterment of surgical education in the future.