2023, Number 2
Academic proposal from the Mexican Association of General Surgery for establishing a referral program for the training of the general surgeon in Mexico
Full text
10.35366/111507
Language: English/Spanish [Versi?n en espa?ol]
References: 21
Page: 67-75
PDF size: 258.54 Kb.
ABSTRACT
Introduction: medical education has evolved from a topic-focused programs to one focused on the quality of outcomes and competencies. Different models and educational contents have been suggested for the training of doctors specializing in general surgery around the world. However, in our country there is no single program for all training venues for specialists in general surgery, which has resulted in a wide heterogeneity of levels of educational quality as well as clinical results in our country. Objective: to structure an academic program that serves as a reference for all academic institutions in our country training medical doctors specializing in general surgery. Material and methods: the development of the proposal of the reference program for the training of general surgeons (PRFCG) consisted of 5 phases: 1) review and integration of national and international programs better structured by a committee; 2) review and consensus by academic professors, experts and associates of the initial program; 3) review and consensus through the Delphi methodology (consensus > 75%) by working groups that worked remotely prior to the XVIII National Meeting of the Surgeon; 4) Presentation and discussion of the results of these tables in the XVIII Meeting and 5) Presentation and dissemination of the PRFCG in the XLVI International Congress of Surgery that took place in the city of Mérida, Yucatán. Results: the final product of this process was consolidated with the support and participation of more than 200 professors and experts on surgical education, 620 associates, 14 coordinators and 54 experts who worked for the creation of a program with 27 cognitive units, 9 transversal competencies, 8 attitudinal competencies, 21 rotations, 92 surgical procedures proposed in logbook as well as 5 APROCs as part of the PRFCG. The complete program is contemplated for a 4-year training with a flexible academic structure. Conclusions: PRFCG is herein presented as a reference with the intention of "standardizing" the minimum necessary academic elements for the training of a specialist in general surgery. The mission of this project is not to impose a program, but to facilitate through different means a surgical education of the highest quality and available to all Mexicans with the support of the Mexican Association of General Surgeons, A.C. (AMCG).ABBREVIATIONS:
- AMCG = Mexican Association of General Surgery, A.C.
- APROC = reliable professional activities.
- ATLS = life support to the polytraumatized patient.
- CMCG = Mexican Council of General Surgery, A.C.
- EPA = entrustable professional activities.
- FES = Fundamentals of Endoscopic Surgery.
- FLS = Fundamentals of Laparoscopic Surgery.
- IMSS = Mexican Social Security Institute.
- ISSSTE = Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado.
- PEMEX = Petróleos Mexicanos.
- PRFCG = reference program for the training of general surgeons.
- PUEM = unique program of medical specialties.
- SEDENA = Secretary of National Defense.
- ICU = Intensive Care Unit.
- UNAM = National Autonomous University of Mexico.
INTRODUCTION
The programs for the training of resident physicians in general surgery have evolved over the years as they have been impacted by pedagogical and didactic trends that have also been changing.1-3 These models have migrated from one centered on student learning or knowledge to models focused on quality patient care and reliable, high-quality professional activities.4-8 Medicine has shifted from being exclusively focused on diagnosis and treatment to being focused on the clinical outcomes of the patients that this professional practice impacts.9,10
In recent years, with the advent of the competency-based education model,10,11 training programs have been integrated in different parts of the world,12,13 as the USA,14,15 Canada,9 Europe,16 and Australia.17,18 The components of this model, which aims not only a significant learning in the cognitive area but also practical, emotional, motor, and disciplinary skills that integrate an optimal and pragmatic professional behavior of the specialist in general surgery.
A surgeon's competence to obtain good results is not only an educational element but a fundamental and moral commitment in the surgeon's relationship with his/her patient.19 Moreover, these competencies can be operationalized and evaluated objectively when linked to the results, quality of the procedure, as well as the professional activities of each surgeon.20,21
This program presents a flexible model based on competencies. It is structured based on the unique medical specialties (PUEM) program issued by the National Autonomous University of Mexico (UNAM) and 27 high-quality national and international programs for training specialists in General Surgery. This flexible model is based on four core competencies that every general surgeon should ideally have upon residency completion, in addition to a professional portfolio of evidence to support these competencies. The competencies and portfolio that make up this program are detailed below:
- 1. Disciplinary competencies (specific to the specialty or area of knowledge such as rotations in other services, hospitals, and areas of medical or biomedical specialty).
- a. Cognitive or theoretical competencies (or introductory and advanced knowledge that previously structured the academic programs of the residency).
- b. Motor or procedural competencies (which characterize the general surgeon when contrasted with other medical specialties and should be evaluated similarly to the cognitive level).
- c. Rotations (some rotations in different areas are suggested to acquire additional competencies).
- d. Attitudinal competencies (cognitive and motor skills specific to this specialty and other branches of medical sciences recommended to be included in general surgery resident training, such as ATLS, FLS, FES, and others).
- 2. Transversal competencies (which are not exclusive to the surgical specialty, but any physician or citizen should have, such as ethics, professionalism, and collaboration).
- 3. The professional portfolio should contain the evidence that proves the above competencies and periodic evaluations.
According to all the professionals who participated in structuring this program, these competencies are specific functions of the general surgeon. All the opinions were integrated into five phases within the collaboration between the Asociación Mexicana de Cirugía General, A.C. (AMCG) and the Consejo Mexicano de Cirugía General, A.C. (CMCG).
OBJECTIVES
- 1. To structure an academic program that serves as a reference to "standardize" the minimum educational elements necessary for all academic institutions that train medical specialists in general surgery in our country.
- 2. To reach a consensus among all the experts and professors associated with the AMCG (and some external advisors) on the areas of knowledge, disciplines, and competencies that a general surgeon should learn and master.
MATERIAL AND METHODS
The development of this proposal for the PRFCG had five phases:
Phase 1. In this phase, a committee composed of the presidents and coordinators conducted a careful, thorough, and extensive review of all the existing curricular programs for the training of resident physicians in the specialty of general surgery in Mexico (n = 15), USA, Canada,21 Australia, Europe, and other countries.6,13 These programs were contrasted with our country's most commonly used program, the PUEM, for general surgery, which served as a starting point and baseline reference. The programs were edited to eliminate redundancies, repeated topics, or topics that are no longer current.
Phase 2. The final proposal of the first phase was initially exposed to all invited professors, chiefs of teaching, and academic surgeons (who are known as opinion leaders in surgical education) from all academic units that train specialists in general surgery and from all over the country, to criticize and provide feedback on the survey. In an initial approach, these guests were selected by the university, faculty, or hospital, trying to seek federal and regional representativeness. Subsequently, the same survey was launched to all the associates of the AMCG, again seeking federal representativeness and representation of the private and public health sectors (Mexican Social Security Institute [IMSS], Ministry of Health, Institute of Security and Social Services for State Workers [ISSSTE], Ministry of National Defense [SEDENA] and Petróleos Mexicanos [PEMEX]). The database was cleaned with these experts' suggestions, comments, and corrections.
Phase 3. The program was divided into the different competencies proposed in the PRFCG, and seven working groups were formed, which met online or in person for three months to discuss each of the program sections to modify or correct it. The Delphi methodology was used as a strategy until a consensus of at least 75% of the experts invited to each working table was reached as a condition for the plan to be integrated.
Phase 4. The program proposed in phase three was reviewed by each of the coordinators of the working tables, four with the final decisions of each of the sections of the PRFCG in the XVIII National Meeting of the Surgeon, on May 11, 2022, within the facilities of the AMCG in Mexico City. The final observations were integrated into a definitive document.
Phase 5. The final edition of the document as a product of the XVIII National Meeting of Surgeons 2022, where the observations of all the participants in this meeting were integrated. The PRFCG was presented during the activities of the XLVI International Congress of Surgery held in the city of Merida, Yucatan, as well as to the competent authorities of the UNAM, to propose its integration into the PUEM for the teaching of general surgery in our country.
To collect the opinion of all associates and professors, we used online surveys through the Survey Monkey platform®. Each table worked on the different competencies and portfolio of pieces of evidence using the Delphi methodology, and included in the final program were only those elements voted by more than 75% of the members. The final consensus was presented by the coordinators of each working table at the XVIII National Meeting of Surgeons.
Each competency was structured according to a list of units, modules, topics, subtopics, and subtopic categories, for the four-year duration of the general surgery residency.
RESULTS
In phase 1, four core competencies (cognitive/theoretical knowledge; disciplinary/rotations; motor/procedural; transversal and attitudinal) and a professional portfolio (containing evidence of competencies acquired at different levels of mastery) were integrated into a school-based academic program on a four-year calendar. Figure 1 shows the general distribution of a standard three-year program and "flexible" in the last fourth year. Both cognitive and procedural or motor competencies were classified according to Bloom's degree of difficulty or category for the digital age.
In phase 2, 204 teachers and teaching managers responded to the survey. In this same phase, the survey was also sent to all associates; approximately 770 responded to the study. The federal representativeness and by health care sector that responded to the survey is shown in Figure 2. This national representative consisted of 619 individuals (80.38%) who did respond to this question. As can be seen in Figure 2, most of the surgeons surveyed who responded were from Mexico City, followed by the State of Mexico, Jalisco, Nuevo Leon, and Guanajuato. The remaining states were represented by 5% or less of the total. As can also be seen in this figure, all the major health sectors of the country were represented in the survey.
In phases 3 and 4, the product of the working tables before and during the XVIII National Meeting of the Surgeon 2022 resulted in significant changes in the program. Approximately 60 experts were invited to this meeting, organized in seven working tables with an average of six surgeon educators, professors, or experts, plus two coordinators per table and nine general event coordinators. The complete list of participants in the event is in the acknowledgments at the end of the article.
Phase 5. The final edition of the document resulting from the XVIII National Meeting of Surgeons 2022 was completed, integrating all the observations of all the participants of this meeting. The PRFCG was presented during the activities of the XLVI International Congress of Surgery held in the city of Merida, Yucatan, as well as to the competent authorities of the UNAM to propose its integration in the PUEM for the teaching of general surgery in our country.
The general concept of this program includes standard competencies (previously considered mandatory) and "flexible" competencies (previously optional and now depending on the scope of each program and host hospital) that the residents themselves can select according to their plans for professional development after obtaining the degree of specialist in general surgery. This way, the residents will be able to adapt to the program depending on whether they want to conclude as general surgeons or enter some other sub or high specialty, in which they will not necessarily need to acquire all the available skills but the particular ones for the following academic degree. In general, they can be classified in the next final items in two professional competencies whose evidence is integrated into a portfolio:
- 1. Disciplinary competencies (which are subdivided into three competencies specific to the specialty or area of knowledge):
- a. Cognitive competencies.
- a.1. Systemic response to surgical trauma.
- a.2. Liquids and electrolytes.
- a.3. Hemostasis, bleeding, and transfusion medicine.
- a.4. The surgical wound.
- a.5. Surgical infectious diseases.
- a.6. General aspects of surgery and the surgical patient.
- a.7. Surgical nutrition.
- a.8. Professional profile and competencies of the general surgeon.
- a.9. Trauma surgery.
- a.10. Skin and subcutaneous adipose tissue surgery.
- a.11. Oncology surgery.
- a.12. Gastrointestinal surgery (upper gastrointestinal tract).
- a.13 Colorectal surgery (lower gastrointestinal tract).
- a.14. BPH (benign prostate hypertrophy) surgery.
- a.15. Endocrine surgery.
- a.16. Head and neck surgery.
- a.17. Spleen.
- a.18. Breast surgery.
- a.19. Urology.
- a.20. Bariatric surgery.
- a.21. Obstetrics and gynecology.
- a.22. Plastic and reconstructive surgery.
- a.23. Vascular surgery.
- a.24. Thoracic surgery.
- a.25. Neurosurgery.
- a.26. Transplant surgery.
- a.27. Pediatric surgery.
- b. Procedural or motor skills (92 procedures).
- b.1. Recommended procedure log at a minimum (P25).
- b.2. Recommended log of procedures as satisfactory (P50).
- b.3. Recommended procedure log as ideal (P95).
- b.4. Recommended procedure log as a total (P100).
- c. Attitudinal competencies.
- c.1. Priority decision-making in the polytraumatized patient (ATLS).
- c.2. Safety systems in surgical environments.
- c.3. Performance and care of ostomies in the Intensive Care Unit (ICU), emergency department, and hospitalization.
- c.4. Laparoscopic skills (FLS or analogous).
- d. Basic.
- e. Advanced.
- e.1. Basic skills of microsurgery.
- e.2. Patient safety in complex situations in different surgical environments.
- e.3. Basic and advanced endoscopic skills (FES or analogous).
- e.4. Effective interactions with other clinical and surgical healthcare team members.
- a. Cognitive competencies.
- 2. Transversal competencies (not exclusive to the specialty or area of knowledge, but essential for the practice of the discipline).
- a. Surgical epidemiology and public health.
- b. Surgical research.
- c. Surgical ethics.
- d. Medical education and teaching.
- e. Professionalism and communication.
- f. Systems-based learning.
- g. Legal aspects of surgical practice.
- h. Economics and financial aspects for the surgeon general.
- i. Basic concepts of hospital and equipment management.
- 3. Professional portfolio (evidence that proves the acquisition of the different competencies that integrate the program).
- a. Cognitive or theoretical competencies.
- b. Transversal competencies.
- c. Attitudinal competencies.
- d. Motor or procedural competencies.
- e. Disciplinary competencies or rotations.
- f. Entrustable Professional Activities (APROC) or Entrustable Professional Activities (EPA).
- f.1. Inguinal hernia.
- f.2. Appendicitis.
- f.3. Cholecystitis.
- f.4. Trauma.
- f.5. General surgery consultation.
The complete details and contents of each of the competencies (cognitive, transversal, attitudinal, motor, and disciplinary), as well as the resident's professional portfolio, can be requested from the general coordinator of the meeting.
The authors authorize the unrestricted use of this information for academic purposes only.
CONCLUSIONS
The purpose of the XVIII National Meeting of the Surgeon AMCG 2022 was to structure and generate a curricular program that will serve as a reference for all the programs and centers that train specialists in general surgery in our country. The product of the working groups can be summarized in four competencies (cognitive, procedural, or motor, attitudinal, and transversal), as well as a professional portfolio of evidence of these integrated competencies. This academic program can be adjusted to educational and hospital levels and infrastructures. The primary intention is to try to "standardize" the minimum theoretical elements necessary for any medical specialist who wants to train in the specialty of general surgery by serving as a "reference" of the plans that must be covered before graduation to have an equitable national competitiveness in all the federal entities and academic centers. The mission of this work was not to impose a program, but to facilitate, through different means and programs, a surgical education of the highest quality for all Mexicans with the support of the AMCG.
ACKNOWLEDGMENTS
The authors would like to acknowledge and sincerely thank the participation of all the expert surgeons and professors from different parts of the country who actively participated in the working tables of the XVIII National Meeting of the Surgeon 2022:
PRESIDENTS
Miguel Francisco Herrera Hernández, MD, President of the Mexican Association of General Surgery.
Juan Pablo Pantoja Millán, MD, President of the Mexican Council of General Surgery.
GENERAL COORDINATOR
David Velázquez Fernández, MD, General Coordinator of the Program and Tables.
EXECUTIVE SECRETARY
Ms. Mónica Montes de Oca, Coordination and Review.
WORKING GROUP COORDINATORS
Rafael Humberto Pérez Soto, MD,
Gerardo Enrique Muñoz Maldonado, MD.
WORKING TABLES
Alejandra Gabriela Buerba Romero Valdés, MD, Program Coordinator.
Claudia Domínguez Fonseca, MD, Cognitive Competencies, first year.
Carlos Orlando Pacheco González, MD, Cognitive Competencies, first year.
Gustavo Félix Salazar Otaola, MD, Cognitive Competencies, second year.
Mariel González Calatayud, MD, Cognitive Competencies, second year.
Martha Patricia Sánchez Muñoz, MD, Cognitive Competencies, third year.
Jordán Zamora Godínez, MD, Cognitive Competencies, third year.
Óscar Chapa Azuela, MD, Cognitive Competencies, fourth year.
María del Carmen Barradas Guevara, MD, Cognitive Competencies, fourth year.
Alfonso Pérez Morales, MD, Motor or Procedural Competencies.
Marco Antonio Loera Torres, MD, Motor or Procedural Competencies.
Jorge Galindo Ordoñez, MD, Disciplinary, Attitudinal, and Transversal Competencies.
Enrique Jiménez Chavarría, MD, Disciplinary, Attitudinal, and Transversal Competencies.
Carlos Arturo Hinojosa Becerril, MD, Professional Electronic Portfolio.
Hugo Sánchez Aguilar, MD, Professional Electronic Portfolio and Video Library.
PARTICIPANTS
Abilene C. Escamilla Ortiz, MD, Cognitive Competencies, first year.
Humberto Arenas Márquez, MD, Cognitive Competencies, first year.
Juan Pablo Avila Ruiz, MD, Cognitive Competencies, first year.
Javier Carrillo Silva, MD, Cognitive Competencies, first year.
Luis Juan Cerda Cortaza, MD, Cognitive Competencies, first year.
Gerardo Gil Galindo, MD, Cognitive Competencies, first year.
José Lorenzo de la Garza Villaseñor, MD, Cognitive Competencies, second year.
María Norma Gómez Herrera, MD, Cognitive Competencies, second year.
Angélica Hortensia González Muñoz, MD, Cognitive Competencies, second year.
Alejandro González Ojeda, MD, Cognitive Competencies, second year.
José Raúl Hernández Centeno, MD, Cognitive Competencies, second year.
Luis Mauricio Hurtado López, MD, Cognitive Competencies, second year.
Erick Otto Paul Basurto Kuba, MD, Cognitive Competencies, third year.
Adriana Josephine Jauregui Soto, MD, Cognitive Competencies, third year.
José Luis Lara Olmedo, MD, Cognitive Competencies, third year.
David Alberto López Herrera, MD, Cognitive Competencies, third year.
Gustavo Martínez Mier, MD, Cognitive Competencies, third year.
Arturo Vázquez Mellando Díaz, MD, Cognitive Competencies, third year.
José Luis Martínez Ordaz, MD, Cognitive Competencies, fourth year.
Julio César Naranjo Chávez, MD, Cognitive Competencies, fourth year.
María Eugenia Ordoñez Gutiérrez, MD, Cognitive Competencies, fourth year.
Sergio Ulises Pérez Escobedo, MD, Cognitive Competencies, fourth year.
Luz María Rivas Moreno, MD, Cognitive Competencies, fourth year.
Álvaro Tomás Ruz Concha, MD, Motor or Procedural Competencies.
Jesús Tapia Jurado, MD, Motor or Procedural Competencies.
Sergio Francisco Uhthoff Brito, MD, Motor or Procedural Competencies.
Rubén Gabriel Vargas de la Llata, MD, Motor or Procedural Competencies.
Elena López Gavito, MD, Motor or Procedural Competencies.
Roberto Sandoval López, MD, Motor or Procedural Competencies.
Jorge Alfredo Zendejas Vázquez, MD, Disciplinary, Attitudinal, and Transversal Competencies.
María Nayví España Gómez, MD, Disciplinary, Attitudinal, and Transversal Competencies.
Francisco Campos Campos, MD, Disciplinary, Attitudinal, and Transversal Competencies.
Luis Montiel Hinojosa, MD, Disciplinary, Attitudinal, and Transversal Competencies.
Mauricio Sierra Salazar, MD, Disciplinary, Attitudinal, and Transversal Competencies.
Ismael Domínguez Rosado, MD, Professional Electronic Portfolio.
Abraham Pulido Cejudo, MD, Professional Electronic Portfolio.
Elisa Delgadillo Márquez, MD, Professional Electronic Portfolio.
María Paulina Sesman Bernal, MD, Professional Electronic Portfolio.
Jorge Arturo Vázquez Reta, MD, Professional Electronic Portfolio.
Eduardo Prado Orozco, MD, Professional Electronic Portfolio.
As well as to all the associate members of the AMCG who answered the survey, to the directors and administrative staff of the same association, who allowed and helped in the final realization of this great project.
REFERENCES
AFFILIATIONS
1 General Coordinator of the Program.
2 Table Coordinator.
3 Former President of the Mexican Association of General Surgery, A.C.
Ethical considerations and responsibility: data privacy. According to the protocols established in our work center, we declare that we have followed the protocols on patient data privacy and preserved their anonymity.
Funding: no financial support was received for the preparation of this work.
Disclosure: none of the authors have a conflict of interests in the conduct of this study.
CORRESPONDENCE
David Velázquez-Fernández. E-mail: asociados@amcg.org.mxReceived: 11/01/2022. Accepted: 12/16/2022