Figure 1. Data on 43 residents' opinions of the quality of management skills instruction at their respective programs. The area under the curve represents the percentage of residents who held 1 of the 5 opinions before the course (black curve) and after the course (gray curve). A clear shift in opinions is seen, indicating that the residents felt the need for and benefited from such a management seminar.
Figure 2. Data on 43 residents' self-assessments of their knowledge of managerial skills before and after the conference. These graphs highlight the significant improvement in the percentage of residents who rated themselves “good” or “excellent” after the course (gray bars) vs before the course (black bars).
Figure 3. Data on 43 residents' self-assessments of their preparedness to perform managerial duties before and after the conference. These graphs highlight the significant improvement in the preparedness of residents to perform managerial duties after the course (gray bars) vs before the course (black bars).
Hanna WC, Mulder DS, Fried GM, Elhilali MM, Khwaja KA. Training Future Surgeons for Management RolesThe Resident-Surgeon-Manager Conference. Arch Surg. 2012;147(10):940-944. doi:10.1001/archsurg.2012.992
Author Affiliations: Department of Surgery, McGill University Health Centre, Montreal General Hospital, Quebec, Canada.
Objective To demonstrate that senior surgical residents would benefit from focused training by professionals with management expertise. Although managerial skills are recognized as necessary for the successful establishment of a surgical practice, they are not often emphasized in traditional surgical residency curricula.
Design Senior residents from all surgical subspecialties at McGill University were invited to participate in a 1-day management seminar. Precourse questionnaires aimed at evaluating the residents' perceptions of their own managerial knowledge and preparedness were circulated. The seminar was then given in the form of interactive lectures and case-based discussions. The questionnaires were readministered at the end of the course, along with an evaluation form. Precourse and postcourse data were compared using the Freeman-Halton extension of the Fisher exact test to determine statistical significance (P < .05).
Setting McGill University Health Centre in Montreal, Quebec, Canada.
Participants A total of 43 senior residents.
Results Before the course, the majority of residents (27 of 43 [63%]) thought that management instruction only happened “from time to time” in their respective programs. After the course, 15 residents (35%) felt that management topics were “well addressed,” and 19 (44%) felt that management topics have been “very well addressed” (P < .01). Residents noted a significant improvement in their ability to perform the following skills after the course: giving feedback, delegating duties, coping with stress, effective learning, and effective teaching. On the ensemble of all managerial skills combined, 26 residents (60%) rated their performance as “good” or “excellent” after the course vs only 21 (49%) before the course (P = .02). Residents also noted a statistically significant improvement in their ability to perform the managerial duties necessary for the establishment of a surgical practice.
Conclusions Surgical residency programs have the responsibility of preparing their residents for leadership and managerial roles in their future careers. An annual seminar serves as a starting point that could be built on for incorporating formal management training in surgical residency curricula.
Leadership and managerial skills are required for establishing a successful surgical practice after residency.1,2 There is also growing evidence that learning management tools can be used to enhance a trainee's experience during the senior years of surgical residency.3 Despite this, managerial training has traditionally been absent from formal surgical education, largely owing to its nonclinical nature.4- 6 With the recent reduction in resident work hours, there is even less time devoted to developing leadership and managerial skills. Program directors in surgery have acknowledged that their residents are not well prepared for future management roles and are in need of a formal business education.4 The aim of our study is to demonstrate that surgical residents will benefit from a focused management education in the form of an annual seminar given by expert professionals.
Surgical residents from all subspecialties at McGill University in Montreal, Quebec, Canada, were invited to participate in a 1-day management seminar entitled “The Resident-Surgeon-Manager Conference.” After institutional review board approval, 3 precourse questionnaires were circulated. The first aimed at assessing the residents' perceptions of how well topics of management were covered in their formal residency education. The answers were scaled on a 5-point Likert scale ranging from “not addressed at all” to “very well addressed.” The second questionnaire aimed to assess the residents' self-rating of their ability to perform the 9 managerial skills required for efficient management. The answers were scaled on a 5-point Likert scale ranging from “poor” to “excellent.” The third questionnaire aimed to assess the residents' self-rating of their preparedness to perform 4 managerial duties of early practice. The answers were scaled on a 5-point Likert scale ranging from “not prepared at all” to “very well prepared.”
The seminar was then given to the residents by surgeons, lawyers, tax specialists, and risk analysts with managerial expertise relevant to surgical practice. The material was delivered in the form of interactive lectures and case-based discussions. The methods of instruction used to cover the various topics included role-play, scenario simulation models, small-group problem-solving sessions, and live feedback sessions. Table 1 illustrates the objectives behind the discussion of each of the managerial skills and duties and how they were addressed during the seminar.
The 3 questionnaires were readministered at the end of the course along with an evaluation form. Precourse and postcourse data were compared using the Freeman-Halton extension of the Fisher exact test to determine statistical significance (P < .05).
A total of 43 senior residents from across surgical specialties participated in the seminar, and all 43 (100%) answered the precourse and postcourse questionnaires. Of the 43 senior residents, 32 (74%) were men and 11 (26%) were women. Thirty-two residents (74%) were between the ages of 25 and 30 years, 10 (23%) were between the ages of 30 and 35 years, and 1 (2%) was older than 35 years. The different senior postgraduate levels were represented, with 15 of 43 participants (35%) at the postgraduate year 3 (PGY-3) level, 12 (28%) at the PGY-4 level, and 13 (30%) at the PGY-5 level. Fellows at the PGY-6 level and higher constituted 3 of 43 participants (7%).
The first questionnaire aimed to elucidate the degree to which residents felt that management topics were covered in their curriculum of instruction. Before the course, the majority of residents (27 of 43 [63%]) thought that management instruction only happened “from time to time” in their respective programs, whereas 6 residents (14%) thought they had “no exposure” to management topics. Only 2 of the 43 residents (5%) thought that management topics were “well addressed” in their programs, and none (0%) felt that they were “very well addressed.” After the course, 15 residents (35%) felt that management topics were “well addressed” during their seminars, and 19 (44%) felt that they have been “very well addressed” (P < .01) Figure 1.
The second questionnaire asked the residents to rate themselves on a 5-point Likert scale from “poor” to “excellent” on their perceived ability to perform the 9 managerial skills required for efficient management of a surgical team (Table 2). Different exercises were used to introduce and build on each of those skills.
Residents noted significant improvement in their ability to perform the following skills after the course: giving feedback, delegating duties, coping with stress, effective learning, and effective teaching (P < .05) (Figure 2). Managing time had a trend to improvement (P = .07). On the ensemble of the 9 managerial skills combined, 26 residents (60%) rated their performance as “good” or “excellent” after the course vs only 21 (49%) before the course (P = .02) (Figure 2).
The third questionnaire asked the residents to rate their preparedness to face the 4 managerial duties of independent practice on a 5-point Likert scale from “not prepared” to “ready.” There was a statistically significant improvement on all 4 duties (negotiating employment, managing personal finances, hedging malpractice risk, and managing a private practice) after the course compared with before the course (P < .05) (Figure 3).
Preparedness for independent practice is not a new topic in clinical research. In an article that surveyed 2626 residents from different specialties across the United States, Blumenthal et al7 concluded that residents were well prepared for independent practice. However, their surveys did not include any questions about managerial skills, financial knowledge, or the business aspects of medical practice. In another study, Cantor et al6 conducted telephone interviews with 6053 young physicians who had recently graduated from residency and were established in practice between 2 and 9 years, and they6 found that only 3% were prepared to face the business aspects of their practice. Residents' preparedness for managerial tasks, either during their senior years or during early independent practice, remains a topic that is not well studied in the surgical literature.4
Residency programs in pediatrics, psychiatry, and internal medicine have recognized the need for managerial training and have initiated educational initiatives to enhance the quality of their curricula.8- 12 Sockalingam et al10 reported not only a deficiency in management knowledge among trainees but also considerable gaps between the trainees' real level of knowledge and their desired level of knowledge of management topics. Our data reveal that surgical programs at our university provide very limited management education. Residents may acquire certain managerial skills such as building teamwork and making rounds by virtue of the nature of surgical training, but we have shown that they are still deficient in other skills that are essential to being an effective manager, such as delegating duties and giving feedback. We have also shown that, before attending a management seminar, the majority of graduating residents were not prepared to perform the basic managerial duties of independent practice.
Most importantly, our research demonstrates that providing them with managerial concepts serves as an important starting point to kindle interest in learning about management. In the business literature, management education has been shown to be predictive of better managerial performance and is closely tied to an increased competitive advantage.13,14 Although formal management curricula have been successfully designed and implemented in the corporate world, they are still under exploration in the surgical community.15,16 At our institution, we will undertake the design and application of a longitudinal management program that can be integrated in the formal residency curriculum. In concert with various departments at our university, we are developing a pilot project that will allow residents to have firsthand exposure to the concepts of quality improvement, patient flow management, medical cost analysis, and evaluation of guidelines. We are also collaborating with national partners to enhance management training of surgical residents and to promote further research on this important topic.
Our study is limited by its small sample size and the subjective nature of self-assessment. The change noted in the residents' own perceptions of management knowledge after the course serves to highlight their need for a formal management curriculum, but it is not an indicator of whether they will actually turn out to be better managers. For that end, objective tools to measure management proficiency for surgeons should be developed and validated. Until then, a formal management curriculum should be instituted and assessed, before determining whether it can produce better surgeon-managers.
Surgeons are at the forefront of hospital administration, health policy, quality-control measures, and global health initiatives. Surgical residency programs are starting to recognize their responsibility to prepare their residents for leadership roles in their future careers. An annual 1-day seminar is a starting point that could be built on for incorporating formal management training in surgical residency curricula.
Correspondence: Kosar A. Khwaja, MD, MBA, MSc, FRCS, FACS, Department of Surgery, McGill University Health Centre, Montreal General Hospital, 1650 Cedar Ave, L9.411, Montreal, QC H3G1A4, Canada (email@example.com).
Accepted for Publication: March 26, 2012.
Published Online: June 18, 2012. doi:10.1001/archsurg.2012.992
Author Contributions:Study concept and design: Hanna, Mulder, Elhilali, and Khwaja. Acquisition of data: Hanna and Khwaja. Analysis and interpretation of data: Hanna, Mulder, and Fried. Drafting of the manuscript: Hanna and Khwaja. Critical revision of the manuscript for important intellectual content: Hanna, Mulder, Fried, Elhilali, and Khwaja. Statistical analysis: Hanna. Obtained funding: Hanna. Administrative, technical, and material support: Hanna, Mulder, and Khwaja. Study supervision: Mulder, Fried, Elhilali, and Khwaja.
Financial Disclosure: None reported.