Flexibility in Surgical Training Does Not Affect American Board of Surgery Board Eligibility or Certification: Long-term Outcomes from a Prospective, Multi-Institutional Study of General Surgery Residents

Objective: In 2011, the American Board of Surgery (ABS) implemented a policy to permit greater flexibility in the structure of general surgery (GS) residency training. Our goal was to investigate the impact of flexibility in surgical training (FIST) on resident success in obtaining ABS board eligibility and certification.

Design: A prospective, multi-institutional study was conducted to examine the feasibility of incorporating flexibility tracks across residency programs and measure educational outcomes including ABS In-service Training Exam (ABSITE) scores, Accreditation Council for Graduate Medical Education (ACGME) Milestones, operative case log volumes, and ABS Qualifying (QE) and Certifying (CE) Examinations scores. We compared residents participating in flexibility tracks ("FIST residents") to contemporaneous residents not involved in subspecialty tracks ("non-FIST residents").

Setting: Seven academic GS residency programs.

Participants: GS residents at participating institutions were granted the opportunity to customize up to 12 of the final 24 months of residency with subspecialty rotations.

Results: From 2013 to 2019, 186 (52.2%) of 356 residents participated in a flexibility track. The most frequently selected subspecialty tracks were hepatobiliary (26.9%), gastrointestinal (15.1%), and cardiothoracic surgery (15.1%). There were no significant differences in ABSITE scores (573.0 vs. 562.0; p = 0.191) or total major operations performed (1056.5 vs 1018.0; p = 0.074) between FIST and non-FIST post-graduate year 5 residents. Residents participating in FIST scored significantly higher on 15 of 16 ACGME Milestones when compared to non-FIST residents. The first-time pass rate for the ABS QE was 92.2% and 91.1% for FIST and non-FIST residents, respectively (p = 0.756). The first-time pass rate for the ABS CE was 85.8% and 83.6% for FIST and non-FIST residents, respectively (p = 0.687). Overall, FIST residents had a higher first-time pass rate on both the QE (92.2% vs. 90.6%) and CE (85.8% vs. 81.7%), when compared to the national average.

Conclusions: Despite spending more time on subspecialty-focused flexible rotations, residents participating in FIST perform similarly to their peers in multiple measures, including on the ABS QE and CE. Incorporating integrated subspecialty training within GS residency does not interfere with the future success of trainees in obtaining ABS board certification. These findings could help inform modifications to the structure of surgical training, including allowing for earlier entry into subspecialty training.