Did you know that Dr. Ben Kellogg joined USA after completing a Transition to Practice (TTP) program? TTP provides additional training that residents may not have received in medical school including practice building, billing, and administration. Dr. Kellogg, Dr. Burns and TTP were featured in the latest issue of General Surgery News. See the article below:
Lacking Confidence in Training? Program Provides Bridge to Practice
By: Monica J. Smith
Chattanooga, Tenn.—As one of the first participants in the American College of Surgeons (ACS) Transition to Practice (TTP) Program, Benjamin E. Kellogg, MD, said the program eased his transition from resident to a practicing general surgeon, and credited it with helping prepare him for a broad surgical practice.
“I saw TTP as a great opportunity for a number of reasons. The first, and perhaps most important for me in my residency, was to plan for a gradual increase in autonomy from resident to completely independent practice,” Dr. Kellogg said.
The other main benefit Dr. Kellogg described before the 2015 Southeastern Surgical Congress was the opportunity to explore the various types of surgical practices—academic, private, hospital employee, group—as well as different practice settings: metropolitan, suburban or rural.
“Often if you’re trained in a big academic center, you don’t get exposure to these other settings. I did not receive any rural surgery exposure in my training, but thought I might want to make my career in a rural setting,” he said. “In addition, I saw this year as an opportunity to hone skills in which I lacked expertise.”
Dr. Kellogg learned of TTP through R. Philip Burns, MD, FACS, with whom he had consulted about potential career opportunities in the Chattanooga, Tenn., area. Serendipitously, the two encountered each other just on the heels of the meeting of the ACS Board of Regents that approved the program. “Ben asked me if I knew of anyone who needed a practice associate and I said, ‘have I got a deal for you,’” Dr. Burns said.
Justification for the TTP
The question of whether residency prepares surgeons for practice is a matter of some debate, but there is widespread concern that the implementation of resident work-hour restrictions in 2003, among other things, had a deleterious effect on the training of general surgeons.
“Many of us felt this would ruin general surgery training by not allowing for continuity of care, by not allowing young surgeons to be in the operating room [OR] and take care of their patients,” said Frederick Greene, MD, former chair of surgery and general surgery program director at Carolinas Medical Center School in Charlotte, N.C. “Many of them do pursue fellowships because they don’t feel confident in general surgery.”
Multiple sources support this observation. A 10-year summation of a questionnaire about problems in surgery addressed by the ACS Board of Governors showed graduate medical education as being No. 4 on the list and moving to the third spot in the past two years.
“It’s been a concern reflected by the governors and fellows for a long time and continues to be so,” said Dr. Burns, chair of the Department of Surgery at the University of Tennessee (UT) College of Medicine in Chattanooga and director of the TTP program at that institution.
A survey of surgical educators and fellowship program directors also showed dissatisfaction with graduate medical education. “It indicated that residents are not ready at this point to operate independently, make decisions, suture and tie laparoscopically, recognize early signs of complications, or function independently in an OR or on call,” Dr. Burns said. “This is very disturbing information.”
A 2009 survey of 4,402 general surgery residents reflects this discomfort, showing that about 27% were not comfortable with performing procedures alone, and about 64% felt they needed specialty training to be competitive (JAMA 2009;302:1301-1308). “Basically, this showed that a significant percentage of categorical residents in programs did not think they would be able to function independently and confidently by the time they finished,” Dr. Burns said.
So if there is a problem, who is to blame? “I think most of us stand in awe at times of the intellectual ability, background and life experiences many of our residents have. We feel the system is to blame,” Dr. Burns said.
How TTP Came About
The TTP is an attempt on behalf of the ACS to address the perceived problem that surgeons are not ready to practice general surgery after residency, and also to encourage doctors to pursue general surgery rather than a subspecialty. The idea and concepts for the program brewed over several months in 2012, and the program was given the green light from the ACS Board of Regents at its September 2012 meeting.
A pilot for the program launched in 2013 at UT College of Medicine and the Mercer School of Medicine in Macon, Ga., and 14 other sites throughout the country were given preliminary approval by March 2014 to initiate their own TTP programs.
Essentially, the TTP program is like a fellowship in general surgery except that it does not adhere to strict fellowship criteria as established by the Accreditation Council for Graduate Medical Education; participants are associates rather than fellows. Stressing that TTP is not a remedial program, Dr. Burns described it as a flexible opportunity for education and the development of autonomy, directed by surgeons through the ACS to encourage residents to pursue a career in general surgery.
Before establishing Dr. Kellogg in the TTP program, Dr. Burns needed to consult with faculty to be sure that the program would not compete with other programs, including a number of fellowships.
“A TTP program cannot conflict with your existing general surgery program; you can’t bring in a new graduate and have [him or her] compete for cases,” Dr. Greene said. “That’s not the concept.”
He also needed to bear budget in mind. “We had to look at where we were going to get the research and development dollars for this,” Dr. Burns said.
The curriculum is flexible, but mainly follows its original design of five to six months of monitored practice, in which residents work closely with a faculty member in the OR, outpatient area or on call, followed by six or seven months when the associate works in independent practice, becoming completely autonomous with assistance from those faculty members.
A resident’s participation begins with an intake assessment and discussion of the goals of the program, the resident’s professional and personal goals for the year and how the program can help the resident attain those goals.
“At my initial intake assessment, we reviewed my case logs from residency to see where I might benefit from some additional training, and also considered where I felt I would benefit from additional training,” Dr. Kellogg said.
From this assessment, all parties determined that a significant component of Dr. Kellogg’s program should be based in a rural setting and that he could benefit from additional experience in breast and anorectal surgery, endoscopy and advanced laparoscopic surgery.
Additionally, the program took advantage of certain ACS resources to address practice management issues that are crucial to running a practice but tend to receive little attention during residency. For instance, Dr. Kellogg attended a two-week coding and billing workshop at the beginning of his program.
“I also attended a practice management seminar conducted by the University of Tennessee, and underwent a curriculum run by the chief executive officer of the University Surgical Associates’ group to cover business administration over several sessions.”
Dr. Kellogg was board-eligible and became board-certified three months into the program, which allowed him to obtain unrestricted privileges at the hospitals where he worked, allowing him to gradually increase his patient care responsibilities and eventually have his own clinic, with back-up supervision when needed.
He spent his first few months in the program working in more of an apprenticeship model with general surgeons in clinics, OR and on call, gradually gaining more independence. Dr. Kellogg later had the opportunity to work with Craig Swafford, MD, at a practice in rural Dayton, Tenn., that is affiliated with the faculty of the UT College of Medicine, Chattanooga. Dr. Kellogg joined the Dayton practice in 2014. Both Drs. Swafford and Kellogg are assistant professors with the UT College of Medicine.
“I was well trained in a very good residency program, but when I finished I lacked confidence in my abilities,” Dr. Kellogg said. “Now that I’ve completed the program and have some perspective, I think the program benefited me best by increasing my autonomy as a surgeon from resident to independent practitioner,” Dr. Kellogg said.
Where the Program Stands Today
At this point, more than two years since it started, there are 18 TTP programs across the country and six more pending approval, with 11 associates confirmed for participation this year and possibly as many as 15 starting in July.
Budget, however, is a problem, and some institutions that have initiated a TTP program, including the University of Tennessee in Chattanooga, have opted out or chosen not to run the program consecutive years.
“We’ve run two TTP programs now. But we have an adequate number of surgeons, and we don’t have enough of an excess caseload to support the $125,000 to $150,000 it costs to run the program,” Dr. Burns said.
The costs include the associate’s salary, plus health insurance, malpractice insurance and incidentals such as travel to meetings and workshops. Dr. Kellogg was able to generate about $100,000 in revenue through his caseload, but that still left the program $50,000 in the red.
“Our faculty is very supportive of the program, but they don’t necessarily want to pay for it out of their own pockets,” Dr. Burns said. “I see this long term as an opportunity for hospitals that want to partner with a general surgeon who wants to do the program in lieu of starting immediately. If we can get half of it paid for, I think we can get enough compensation back in the flex in the system to pay for part of it. But I don’t want our faculty to have to eat a $50K loss every year.”
Of course, no one is suggesting that all surgeons finishing residency need further training. “I have seen, even in recent years, some very good surgical trainees who finish their chief resident year with all the confidence and skill to go into a practice without something like this program,” Dr. Greene said.
“What needs to happen is for program directors to identify individuals who they feel are not ready and recommend that they do something like this,” he added.
Originally from: General Surgery News