Flexible Rotations Policy

Trainees may customize up to 12 months of rotations in the last 36 months of general surgery residency to allow for “early tracking” into their chosen specialty.

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 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.

Requests for ABS approval should be made in advance by letter (see next section). 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.

Requesting Flexible Rotations

To request flexible rotations for a resident, a letter should be sent via email to both the ABS (addressed to Dr. Jo Buyske, ABS President and Chief Executive Officer) and the executive director of the RC-Surgery of the ACGME (requests sent to the ABS must be initiated by first contacting the exam coordinator). The letter must be signed by both the program director and the designated institutional official (DIO) and be accompanied by:

  1. block diagram (see example below) outlining the specific resident’s individualized rotations
  2. A request to assign up to six months of chief experience in PGY-4, if necessary (RC approval only). See also section below regarding chief year rotations.

Refer also to this page on the ACGME website.

Please note that approval must be obtained for each individual resident, regardless if the program received approval in the past for the same arrangement. The ABS approval letter should be submitted with the resident’s application to the General Surgery Qualifying Exam.

The program will receive separate approval letters from the ABS and RC-Surgery; both must be received prior to implementation of flexible rotations.

Example of Block Diagram

Resident, PGY Level, Specialty of Interest Flexible Rotations In Lieu of:
Jane Smith, PGY-4, Transplant Transplant Surgery (3 months) Thoracic (1 month)
Endocrine/Oncology (2 months)
Aaron Jones, PGY-5, Surgical Oncology Colorectal Surgery (2 months) MIS (1 month)
Trauma Surgery (1 month)

Chief Year Rotations

In creating a plan for flexible rotations, programs should be aware that PGY-5 rotations that are not in the content areas of general surgery or (noncardiac) thoracic surgery, and/or where the resident is not the most senior resident involved with the direct care of the patient, cannot be considered a chief year rotation. If completion of such a rotation is desired, program directors must make certain that the resident will complete sufficient chief year rotations in his or her PGY-4 year, and obtain approval from the RC-Surgery in advance.

For the ABS to consider flexible rotations in the PGY-5 chief year, the program must include documentation of ACGME approval of chief rotations in the PGY-4 year. The ABS is unable to consider these requests without this documentation.

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 Area Recommended Training/Rotations
Acute Care Surgery / Surgical Critical Care Exposure in senior residency years to vascular surgery, cardiothoracic surgery and open abdominal surgery is recommended.
Cardiothoracic Surgery An elective PGY-3 rotation in cardiothoracic surgery is recommended. Program directors may also refer to the early specialization curriculum for guidance on suggested rotations.
Colorectal Surgery Specific 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 Oncology Senior-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 Surgery Program directors should refer to the early specialization program curriculum for guidance on suggested rotations.

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

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The links posted within resources are provided for informational purposes only. ABS assumes no responsibility for the content of these websites.

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