Flexible Rotations During General Surgery Residency

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Introduction
  • The American Board of Surgery approved in 2011 a new policy to permit greater flexibility in the structure of general surgery residency training.
  • With advance ABS approval, program directors may customize up to 12 months of a resident's rotations in the last 36 months of general surgery residency to allow for "early tracking" into the resident's chosen specialty. No more than six months of flexible rotations are allowed in any one year. This is an entirely voluntary option for program directors and may be done on a selective, case-by-case basis.

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Approval Process
  • Requests for ABS approval should be made in advance by letter (see next section) and outline the plan for the flexible rotations. The requirement that no more than four months in the chief year be devoted to one area will be extended to six months, if necessary, upon approval. This policy does not affect any of the ABS' other requirements for certification.
  • To take advantage of this unique educational opportunity, programs may wish to assign residents up to six months of chief experience during PGY-4 with advance approval from the ABS and RRC-Surgery.
  • Approval will be sent by letter from the ABS office. The letter of approval must be retained and submitted with the resident's application to the General Surgery Qualifying Exam.

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Required Information
  • To request flexible rotations, a letter should be mailed (no e-mails or faxes) to both the ABS (addressed to Dr. Jo Buyske, ABS associate executive director) and the executive director of the RRC-Surgery. The letter must be co-signed by both the program director and the designated institutional official (DIO) and be accompanied by:
    1. A block diagram (see example below) outlining the specific resident's individualized block diagram, with chief rotations identified
    2. A request to assign up to six months of chief experience in PGY-4, if necessary
  • The program will receive separate approval letters; both must be received prior to implementation of flexible rotations.
  • Example of Block Diagram
  • Resident, PGY Level, Specialty of InterestFlexible RotationsIn lieu of:
    Jane Smith, PGY-4, TransplantTransplant Surgery (3 months)Thoracic (1 month)
    Endocrine/Oncology (2 months)
    Aaron Jones, PGY-5, Surgical OncologyColorectal Surgery (2 months)MIS (1 month)
    Trauma Surgery (1 month)
    Kate Walsh, PGY-5, Pediatric SurgeryHPB Surgery (1 month)
    Neonatal ICU (1 month)
    Critical Care (1 month)
    VA Surgery (1 month)

  • See also: ABS-RRC Flexible Rotations Policy (pdf).

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Specialty-Specific Guidelines
  • The guidelines below are not intended to be prescriptive. They were created by the ABS to assist program directors in the design of flexible rotations for residents interested in a specific specialty. However, regardless of a resident's future specialty, the development of leadership skills and the ability to make independent decisions are critical for all residents and should be the hallmark of the surgical chief resident year.
  • Flexible Rotations vs. ESPs: While the guidelines below mention the curricula of early specialization programs (ESPs) as a reference, ABS approval is not required for ACGME-accredited ESPs. The approval process above relates solely to flexible rotations within a five-year general surgery residency.

Specialty AreaRecommended Training/Rotations
Acute Care Surgery / Surgical Critical CareExposure in senior residency years to vascular surgery, cardiothoracic surgery and open abdominal surgery is recommended.
Cardiothoracic SurgeryAn elective PGY-3 rotation in cardiothoracic surgery is recommended. Program directors may also refer to the early specialization program curriculum for guidance on suggested rotations.
Colorectal SurgerySpecific training in all aspects of abdominal surgery, including open and advanced minimal invasive surgery, should be emphasized. Proficiency in open colon resection, laparoscopic colon resection and endoscopy are essential to the entering colorectal fellow.
Gastrointestinal Surgery
  • Specific procedures to be emphasized are open and laparoscopic incisional hernia repair, laparoscopic inguinal hernia repair, Nissen fundoplication, laparoscopic colectomy, and laparoscopic small bowel procedures, as well as extensive training in endoscopy.
  • Experience in the last two years of residency should include:
  • Open abdominal surgery
  • Complex minimal invasive surgery with an emphasis on proficiency in anti-reflux procedures and hernia repair
  • Hepatobiliary surgery
  • Colorectal surgery
  • Endoscopy (if not previously proficient)
Pediatric Surgery
  • A senior rotation in pediatric surgery is recommended for residents to gain exposure to advanced pediatric surgery and demonstrate capabilities critical for selection to pediatric surgery programs.
  • The following surgical rotations are also felt to be of benefit:
  • Thoracic/esophageal
  • Surgical oncology
  • Head and neck/endocrine surgery
  • Hepatobiliary
  • Advanced minimal invasive surgery
  • Colorectal surgery
  • Surgical critical care
Surgical OncologySenior-level experience in the six areas of the surgical oncology curriculum (upper GI, hepatobiliary, colorectal, endocrine, breast, and melanoma/sarcoma) is recommended.
Transplantation
  • For general surgery residents with an interest in transplant surgery, it is recommended that additional time be spent on the following rotations during the last 24 months of residency to better prepare them for their fellowship training:
  • Vascular surgery (open and catheter based cases, dialysis access, vascular trauma)
  • Cardiothoracic surgery (open and close thoracotomies and median sternotomies, lung resections)
  • Critical care
  • Urology (laparoscopic and open nephrectomy, cystoscopy)
  • Pediatric abdominal surger
  • Endocrine surgery (parathyroid, open and laparoscopic adrenalectomy)
  • Gastrointestinal surgery (Whipple and other pancreatic resections, gallbladder and bile duct resections, liver resections
Vascular SurgeryProgram directors should refer to the early specialization program curriculum for guidance on suggested rotations.

For questions regarding this policy, please contact the ABS coordinator.

Updated: July 2014

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