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Original Investigation
March 24, 2021

A Framework for Understanding the Association Between Training Paradigm and Trainee Preparedness for Independent Surgical Practice

Author Affiliations
  • 1Division of Vascular Surgery, Department of Surgery, University of Utah, Salt Lake City
  • 2Division of Vascular Surgery, Department of Surgery, University of Wisconsin, Madison
  • 3Department of Medical Education, University of Illinois at Chicago, Chicago
JAMA Surg. Published online March 24, 2021. doi:10.1001/jamasurg.2021.0031
Key Points

Question  What factors are associated with surgical trainees’ perception of their preparedness for independent practice, and what are the differences between different training paradigms?

Findings  In this qualitative study of 22 recent graduates and program directors of graduate surgical training programs, 4 key domains were identified as factors that affect perception of preparedness for independent surgical practice: the structure of the training program, characteristics of the individual trainee, relationships between trainees and faculty members, and the clinical material and culture of the organization where the training occurs.

Meaning  Results of this study were used to create a framework for evaluating and improving existing residency and fellowship programs as well as for developing graduate surgical training paradigms that incorporate all 4 domains.


Importance  The sociopolitical and cultural context of graduate surgical education has changed considerably over the past 2 decades. Although new structures of graduate surgical training programs have been developed in response and the comparative value of formats are continually debated, it remains unclear how different time-based structural paradigms are preparing trainees for independent practice after program completion.

Objective  To investigate the factors associated with trainees’ and program directors’ perception of trainee preparedness for independent surgical practice.

Design, Setting, and Participants  This qualitative study used an instrumental case study approach and obtained information through semistructured interviews, which were analyzed using open-and-focused coding. Participants were recent graduates and program directors of vascular surgery training programs in the United States. The 2 training paradigms analyzed were the integrated vascular surgery residency program (0 + 5, with 0 indicating that the general surgery training experiences are fully integrated into the 5 years of overall training and 5 indicating the total number of years of training) and the traditional vascular surgery fellowship program (5 + 2, with 5 indicating the number of years of general surgery training and 2 indicating the number of years of vascular surgery training). All graduates completed their training in 2018. All interviews were conducted between July 1, 2018, and September 30, 2018.

Main Outcomes and Measures  A conceptual framework to inform current and ongoing efforts to optimize graduate surgical training programs across specialties.

Results  A total of 22 semistructured interviews were completed, involving 7 graduates of 5 + 2 programs, 9 graduates of 0 + 5 programs, and 6 vascular surgery program directors. Of the 22 participants, 15 were men (68%). Participants described 4 interconnected domains that were associated with trainees’ perceived preparedness for practice: structural, individual, relational, and organizational. Structural factors included the overall and vascular surgery–specific time spent in training, whereas individual factors included innate technical skills, confidence, maturity, and motivation. Faculty-trainee relationships (or relational factors) were deemed important for building trust and granting of autonomy. Organizational factors included features of the local organization, including patient population, case volume, and case mix.

Conclusions and Relevance  Findings suggest that restructuring training paradigms alone is insufficient to address the issue of trainees’ perceived preparedness for practice. A framework was created from the results for evaluating and improving residency and fellowship programs as well as for developing graduate surgical training paradigms that incorporate all 4 domains associated with preparedness.

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