General surgery resident education for the community surgeon

I still remember reading Dr. William Nolen’s book The Making of a Surgeon with great interest, dismay, but ultimately, awe. It felt quite informative, though the surgical content reflected an era of training that I could only partially connect with. As I started my training in general surgery in 2008, I picked up a copy of Dr. Craig Miller’s The Making of a Surgeon in the 21st Century. This felt more in line with the training I received. That said, in 2026, the training of general surgery residents looks very different and despite barely making it out of the “Young Surgeons” category of the SVS (I’m 10 years and three months into practice), I cannot say I fully understand what general surgery training entails in the current era.  

Working in a tertiary community hospital that runs a 100 year-old general surgery training program, we have the privilege of working with trainees during their internship, third year and chief resident year. I attend the morbidity and mortality conference for the entire department and every year I hear new acronyms, learn about new procedures and feel relief when certain surgical principles have not changed (we still do not mess with the pancreas). Our residents learn the pathophysiology, relevant anatomy, new classification systems and the role of different types of surgical interventions, its indications and complications. However, it seems that the repertoire of classifications and interventions has increased significantly. Moreover, when I review the curriculum on what’s expected for them to know about vascular surgery, or the specific tools we are given to evaluate them on our service, they do not really capture all the pathology and procedures that they are exposed to.  

Clearly, there has been a tremendous evolution in all surgical disciplines and we are all very familiar with the changes brought on by the endovascular revolution. With this change, I have heard over the years that general surgery trainees all “love open vascular surgery” (I mean, who wouldn’t?), but they do not enjoy the endovascular procedures. I believe that part of this is due to their lack of involvement. We sought to change this with our residents.  

In our program, I sit down with the trainees and discuss the goals of the rotation that go beyond the required curriculum. We have specific skills that they need to become proficient in during the rotation that are level appropriate. The skills are divided in different categories: endovascular, open and vascular imaging. Endovascular skills include getting ultrasound guided vascular access, getting “up and over,” the correct use of guidewires and catheters, etc. Open skills include operative exposure of arteries in the neck, abdomen, upper and lower extremities, use of a Fogarty catheter, etc. For vascular imaging we review non-invasive studies, as well as the correct identification of vascular pathology on CT and conventional angiography.  

As we go through the rotation we seek specific tasks where the trainee will have the opportunity to work on a step or steps of a case. Over the years I’ve had residents successfully gain difficult access (supine access of occluded popliteal veins for venous thrombectomy), cross arterial occlusions, correctly identify vascular pathology on imaging, safely get open vascular control in the abdomen and know what steps to take next. For those concerned with losing efficiency when operating with trainees, since we are working on very specific tasks, unless they have fully gained proficiency in all the steps needed for a given procedure, I am still doing most of it myself.  

There’s nothing like seeing a resident light up when they’re able to achieve a task they did not think they could perform, although we know better since the process typically leads to the desired outcome (trust the process). It has gotten some of our residents interested in pursuing vascular surgery fellowship. However, that is not our goal. We are interested in training safe and competent general surgeons. One of the highlights has been getting a call from a former trainee who went on to perform a breast surgery fellowship in New York, her attending got into an axillary vein and she was able to repair it with the skills she learned on our service.  

Finally, another important point I try to instill with the residents is that they are not allowed to say “I’m bad at X” in my operating room. Unless they are holding the micropuncture needle backwards, I reiterate that they are not yet proficient at a specific task. I also remind them that not being proficient at one specific step in a case does not mean they cannot perform other parts of the case.  

In summary, working with general surgery residents can be very rewarding to the vascular surgeon in community practice. When training is performed with intention by setting up expectations and goals, the results are great for the trainee, the attending surgeon and more importantly, for the patients they treat in the future, regardless of whether they pursue further training in vascular surgery.  

If anyone has interest in reviewing our curriculum, please feel free to reach out. I am not a professional educator (no formal pedagogical training), but I do perform my procedures the same way every time so it’s been relatively easy to come up with specific steps for each procedure. So go ahead and let go of that wire (well, after making sure the resident has it pinned).