Vascular Surgery Residency Research Articles

Interview experience, post-interview communication, and gender-based differences in the integrated vascular surgery residencymatch.

Integrated vascular surgery residency (IVSR) applicant perspective about the match process has been rarely studied, yet this has important implications on trainee recruitment. We sought to better understand the nature of the interview process and post-interview communication and its impact on students' ranking choices. A voluntary and anonymous survey was sent to students who matched to IVSR in 2020, inquiring about interviews, post-interview communications, and factors influencing students' rank lists. Seventy of the 73 matched students completed the survey (96% response rate; 23 female and 47 male respondents). Applicants reported they were asked questions about other programs of interest (81.4%), top choice programs (65.7%), marital status (32.9%), family planning (7.1%), and religion (1.4%) during interviews. Female applicants were more frequently asked questions about family planning (17.4% vs 2.1%; P< .01) and marital status (52.5% vs 23.4%; P< .01) compared with male applicants. After interviews, 92.9% of applicants notified their top choice program of their ranking preference. Of applicants, 61.4% received post-interview communication with regards to ranking from at least one program, initiated by program directors in 81.3% of instances. Among these applicants, 58.1% reported that the post-interview communication had an impact on their rank list, and 46.5% matched at a program by which they were contacted. Of applicants, 5.7% were asked by a program to reveal their ranking of the program, and 11.4% were promised by a program to be ranked first if the applicant reciprocally ranked them first. Female and male applicants weighed program culture, operative volume, mentorship, and prestige equally in making their rank list. Male applicants weighed the sub-internship experience more significantly; however, female applicants weighed the sub-internship experience, personal relationships in certain cities, dedicated professional development years, and large female representation in the program more heavily (P< .02). This study provides insight into the interview experience and impactful factors for the vascular surgery match. Both female and male applicants were asked a high number of questions about personal matters unrelated to medical school performance. Female applicants, however, experienced a higher proportion of these instances, particularly regarding family planning. These findings demonstrate the factors that are important to applicants in the matchprocess and raises awareness of potential challenges in the interview and recruitment process.

Medical Student Perspectives on Choosing a Career in Vascular Surgery

Vascular surgery is facing an impending workforce shortage as the population ages and the demand for vascular surgical services increases. The integrated vascular surgery residency (0+5) paradigm is well-established and provides a mechanism to increase the number of board-certified vascular surgeons. Recruitment of medical students to these programs has proven challenging with unfilled positions in each of the past 2 years. The aim of this study is to explore factors that influence medical students' interest in vascular surgery and their decision to ultimately pursue a career in the field. Medical students listed on the Society for Vascular Surgery "Find a VSIG (Vascular Surgery Interest Group)" webpage were contacted via email to participate in the study. A snowball sampling technique was employed to recruit additional participants, including recent medical school graduates who had matched into a 0+5 program. Fifteen students participated in 5 focus groups. Directed content analysis was employed to qualitatively analyze focus group transcripts. Five domains were identified as influencing students' decision to pursue vascular surgery. Experiential learning facilitated early exploration of the field. The intellectuality of the specialty was a feature that attracted students to vascular surgery. In addition, the professional identify of vascular surgeons as comprehensive care providers was appealing. Students identified with their mentors' relationships as observed during clinical encounters. Long-term mentorship was important in sustaining students' interest. Medical students pursue a career in vascular surgery based on early exposure to the specialty, experiential learning through hands-on VSIG events, clinical experiences, and longitudinal faculty mentorship. The unique aspects of the specialty, including professional identity and intellectuality, should be highlighted to both attract and maintain students' interest in the field. These findings can be used by national vascular surgery leaders, practicing vascular surgeons, and faculty and student leadership of VSIGs to optimize recruitment programs and increase the vascular surgery workforce.

The Use of Learning Analytics to Enable Detection of Underperforming Trainees: An Analysis of National Vascular Surgery Trainee ACGME Milestones Assessment Data.

This study aims to investigate at-risk scores of semiannual Accreditation Council for Graduate Medical Education (ACGME) Milestone ratings for vascular surgical trainees' final achievement of competency targets. ACGME Milestones assessments have been collected since 2015 for Vascular Surgery. It is unclear whether milestone ratings throughout training predict achievement of recommended performance targets upon graduation. National ACGME Milestones data were utilized for analyses. All trainees completing 2-year vascular surgery fellowships in June 2018 and 5-year integrated vascular surgery residencies in June 2019 were included. A generalized estimating equations model was used to obtain at-risk scores for each of the 31 subcompetencies by semiannual review periods, to estimate the probability of trainees achieving the recommended graduation target based on their previous ratings. A total of 122 vascular surgery fellows (VSFs) (95.3%) and 52 integrated vascular surgery residents (IVSRs) (100%) were included. VSFs and IVSRs did not achieve level 4.0 competency targets at a rate of 1.6% to 25.4% across subcompetencies, which was not significantly different between the 2 groups for any of the subcompetencies ( P = 0.161-0.999). Trainees were found to be at greater risk of not achieving competency targets when lower milestone ratings were assigned, and at later time-points in training. At a milestone rating of 2.5, with 1 year remaining before graduation, the at-risk score for not achieving the target level 4.0 milestone ranged from 2.9% to 77.9% for VSFs and 33.3% to 75.0% for IVSRs. The ACGME Milestones provide early diagnostic and predictive information for vascular surgery trainees' achievement of competence at completion of training.

Trends in operative case volumes of Canadian vascular surgery trainees

ObjectiveVascular surgery has evolved with increasing use of endovascular therapies and a decline in open surgery. The influence of these changes, in addition to a new vascular surgery training program introduced in 2012, on case volumes of vascular trainees is not known. We sought to evaluate trends in operative case volumes of Canadian vascular surgery trainees. MethodsA survey was administered to graduates of the Canadian Royal College-accredited Vascular Fellowships (VFs) and Integrated Vascular Surgery Residency (IVSR) programs (2007-2019) to record cases performed during their final 2 years of training. Procedures of interest were open abdominal aortic aneurysm (oAAA) repair, open thoracic/thoracoabdominal aortic (oTAA/TAAA) repair, lower extremity bypass (LEB), carotid endarterectomy (CEA), lower extremity endovascular intervention (LEEI), and endovascular abdominal, advanced, and thoracic aortic repair (EVAR, aEVAR, and TEVAR). Case volumes were analyzed overall, and by graduation year, type of training program, and resident demographics. ResultsA total of 60 participants (10% female) from all the 10 Canadian training institutions responded (response rate, 63%). There was a declining trend in overall procedures performed since the introduction of IVSR in 2012 (median, 427 [interquartile range (IQR), 304-496] in 2007-2012 vs median, 342 [IQR, 279-405] in 2013-2019; P = .055), driven by a significant decline in open vascular surgery cases (median, 273 [IQR, 221-339] in 2007-2012 vs median, 156 [IQR, 128-181] in 2013-2019; P = .001). Case volumes of oAAA, LEB, and CEA declined by 44%, 40%, and 45%, respectively. Compared with vascular fellows, IVSR residents logged ∼2.5 times more aEVARs (median, 8; IQR, 2-11 vs median, 19; IQR, 8-27; P = .001) and ∼1.5 times more LEEIs (median, 60; IQR, 40-99 vs median, 93; IQR, 69-120; P = .018). Trainees were most confident (range, 90%-100%) in performing oAAA, EVAR, LEB, LEEI, and CEA after training, and least confident in performing oTAA/TAAA and aEVAR (20% and 49% confidence, respectively). ConclusionsOperative case volumes of Canadian vascular surgery trainees since the introduction of IVSR program in 2012 have decreased, driven by declining exposure to open cases. However, trainees continue to receive adequate operative exposure to perform most standard vascular procedures confidently upon graduation.

Validity Evidence for Vascular Skills Assessment: The Feasibility of Fundamentals of Vascular Surgery in General Surgery Residency

As the Fundamentals of Laparoscopic Surgery (FLS) and Fundamentals of Endoscopic Surgery (FES) have been used for general surgery assessment, the Fundamentals of Vascular Surgery (FVS) has recently been developed to evaluate core operative skills for vascular trainees. This study examines the 3 year implementation of FVS for general surgery residents and it gathers validity evidence using Messick's framework. We hypothesized that the curriculum and assessment tool enhance general surgery resident training and assessment. This is a retrospective review of FVS assessments of residents using descriptive and multivariate analyses. This study was conducted at an academic institution, where simulation-based teaching sessions occur in coordination between the general surgery and the integrated vascular surgery residency programs. Seventeen general surgery residents were assessed in FVS skills by an expert rater from 2018 to 2020. Overall, 86 assessments were completed. Assessment focuses on 3 open vascular skills (End-to-Side Anastomosis, Patch Angioplasty and Clockface Suturing). Response Process: 7 items comprise a graded rating for a skills score. Additionally, a global summary score is designated. Internal Structure: The assessment tool has a Cronbach's alpha of 0.87, demonstrating good internal consistency. Addition of the second rater correlated with Cohen's kappa -0.69 (p < 0.001), indicating poor interrater reliability. Relationships to other variables: The most significant improvement occurred in total scores between PGY2s (17.4 ± 2.37) and PGY4s (23.2 ± 3.00), p < 0.001, indicating adequate level discernment. The validity evidence of FVS assessment in this study supports its use in general surgery residency at a time when opportunities for open vascular skills assessment may be decreasing due to case availability and shifting paradigms. Further study into quality rater training is needed to optimize national implementation of FVS and ensure consistency in grading.

Factors Contributing to Attrition in Vascular Surgery Residency

Factors Contributing to Attrition in Vascular Surgery Residency

Radiation Exposure in Vascular Surgery Trainees

We evaluated the radiation safety practices among vascular surgery residents (postgraduate year [PGY] 4-7) enrolled in Accreditation Council for Graduate Medical Education vascular surgical residency programs across the United States.

Case Logging Habits of Integrated Vascular Surgery Residents

Current research has suggested a significant discrepancy in integrated vascular resident (IVR) vs vascular fellow case numbers by the completion of training. Our objective was to understand how IVRs log cases and whether they log cases correctly, assess whether IVRs receive any formal training on case logging, and gauge their understanding of IVR graduation requirements.

Effect of New Integrated Vascular Surgery Programs on Vascular Case Volumes of Residents in Associated General Surgery Programs: Observations from a Retrospective Multicenter Study

The impact of integrated (0+5) vascular surgery residency programs (IVSRPs) on the associated general surgery (GS) resident program vascular case volume has not yet been clearly evaluated. We aim to assess the effect of introducing a new IVSRP on the vascular surgery operative experience for trainees in the associated general surgery (GS) program.

Women Representation in Academic Vascular Surgery: Leadership, Education, and Research

There has been an increase in the proportion of registered women vascular surgeons in the past 5 years. It is unclear whether these changes have been reflected within leadership positions within vascular surgery. The purpose of our study was to quantify and highlight women representation within academic vascular surgery, specifically among editorial boards, the Society for Vascular Surgery (SVS), and in training program directors. Data on program directors and department or division leadership was determined by visiting the individual websites of all active vascular surgery residencies (n = 63) and fellowships (n = 116). Data on committee involvement was obtained from the SVS website (https://vascular.org/about/councils-and-committees). Demographics on editorial boards was determined from the top three vascular surgery-specific journals with the highest impact factors: Journal of Vascular Surgery, Journal of Vascular and Endovascular Surgery, and Annals of Vascular Surgery. Gender was assumed from the use of pronouns in surgeon biographies. The proportion of women vascular surgeons in the above leadership positions was compared with the demographics of the 2019 active physician's data available through the Association of American Medical Colleges using χ2 tests. Our analysis revealed significant disparities between men and women in vascular surgery leadership. Among active vascular surgeons, women account for 14.6% (575/3941) of the total workforce. Among the three highest impact vascular surgery journals, women comprised only 8.6% (25/291) of the editorial board, which was significantly lower than the proportion of active women vascular surgeons (P = .006). In contrast, 45.16% (14/31) of the SVS committee leadership positions were held by women (14/31), which was significantly higher than the proportion of active women surgeons (P < .001). Within vascular surgery training programs, women account for 14.52% (9/62 positions) of program directors in the integrated residency programs and 12.07% (14/116 positions) of program directors in fellowship programs (P = 1.0 and P = .487, respectively). Among division chiefs in the same academic institutions, women comprised only 4.81% (5/104 positions; P = .007) (Fig). Our results suggest that women are well-represented among SVS committee leadership but underrepresented among journal editorial boards and division leadership. Of note, our analysis may over-represent women in leadership as some individuals held multiple positions both within their institution and nationally. Leadership positions should evolve with the changing demographics of vascular surgeons, and additional research is needed to understand attitudes and barriers to a more balanced representation. In addition, gender was assumed based off pronoun usage, and self-reported data is needed to capture gender identity more accurately.

Representation of Women Physicians in Editorial Roles With in the Highest-impact Vascular Surgery Journals

In 2020, 28% (46/164) of newly board-certified vascular surgeons, and 29% (136/471) of vascular surgery residency applicants were women. Despite the increases in women in vascular surgery practice, most leadership positions in the field are still held by men. We evaluated the state of gender equity among editorial board membership and senior editorial leadership within the top 10 clinical journals in vascular surgery, as well as their corresponding companion journals.

Evaluating the Virtual Presence of Integrated Vascular Surgery Residencies in 2020 and Beyond: Are Programs Showing Future Vascular Surgeons What They Want to See?

Because of cancellation of in-person interviews, sub-internships, and live meetings during the COVID-19 era, official integrated vascular surgery residency program (IVSR) websites and social media have become increasingly important sources of information for potential applicants. This study seeks to evaluate the virtual presence of IVSRs and to determine if it emphasizes what is valued by future vascular surgeons.

The Italian vascular surgery residency program during COVID-19 emergency

The Italian vascular surgery residency program during COVID-19 emergency

Trends in General Surgery Operative Experience Obtained by Integrated Vascular Surgery Residents

When the integrated vascular surgery training pathway was introduced, training was comprised of nearly equal amounts of core general surgery and vascular surgery experience. However, specific requirements for case numbers or types were not defined. Over time, the time spent on core general surgery requirements has been reduced, most recently in 2018, from 24 to 18 months. We sought to determine trends in general surgery case volume and type over the past 10 years for vascular surgery residents. We conducted a retrospective review of the Accreditation Council for Graduate Medical Education case log data for integrated vascular surgery graduates from 2012-2018. We evaluated trends in mean numbers of cases, categorized as general surgery open (GS-open), general surgery laparoscopic (GS-laparoscopic), vascular surgery open (VS-open), and vascular surgery endovascular (VS-endo). Cases were also categorized by anatomic region as head/neck, thoracic, or abdominal. The mean number of total head/neck, thoracic, or abdominal cases logged by graduating integrated vascular surgery trainees was 263.5. This total, as well as the proportion of general surgery cases (35%-38%, p = 0.99) has remained constant over time. The type of general surgery cases has changed significantly, with an upward trend in the mean number of GS-open cases and downward trend in mean GS-laparoscopic cases (GS-open p = 0.006, GS-laparoscopic p = 0.048). Among head/neck and thoracic subgroups, no significant changes were observed, while in the abdominal subgroup, there has been a significant increase in GS-open over time (p = 0.005). Additionally, the number of open vascular abdominal aortic cases has remained stable, with an average of 36.82 per graduating trainee per year. In the 10 years since the introduction of integrated vascular surgery programs, total case volume and proportion of general surgery cases have remained remarkably stable. The type of general surgery cases has shifted though, with a decrease in GS-laparoscopic cases, replaced primarily by open abdominal cases. These changes likely reflect integrated vascular residents actively seeking out these opportunities during their core rotations and a willingness by general surgery partners to provide these opportunities. At the program level, these data may help guide program directors' choices about the specific core rotations they incorporate into their curriculum. At the national level, this information may contribute to future discussions regarding the optimal number of core general surgery rotation requirements.

The Changing Demographics of Surgical Trainees in General and Vascular Surgery: National Trends over the Past Decade

Recent initiatives have targeted the issue of gender and ethnic/racial disparities in general surgery and vascular surgery. However, the prevalence of these disparities in general and vascular surgical training programs is unknown. A retrospective analysis was conducted using data from three separate sources, including the US Graduate Medical Education annual report, Electronic Residency Application Service database, and National Resident Matching Program annual report. Demographic information regarding gender distribution and ethnic/racial identity was collected from 328 general surgery residency programs, 59 vascular surgery residency programs, and 100 vascular surgery fellowship programs across the US. The primary outcomes of this study were to evaluate national trends in gender and ethnic diversity in general surgery and vascular surgery training programs, including both traditional fellowship and integrated residency paradigms. From 2011-2020, general surgery residency programs showed a positive trend towards both female applicants (from 31.9%-41.5%) and trainees (from 36.2%-43.1%) (p < 0.0001 each). The proportion of minority trainees decreased, primarily among Black (from 7.2%-5.4%) and Asian trainees (from 21.5%-19.2%) (p < 0.0001 each). Concurrently, the number of vascular integrated residency programs grew from 27 to 59, resulting in a fivefold increase in trainees (from 64-335). Despite this growth, there was no change in the proportion of women applicants or trainees for both vascular integrated residency (24.9% applicants; 36.2% trainees) and fellowship programs (27.4% applicants; 25.9% trainees) over the study period (p = 0.11, 0.89, 0.43, and 0.13 respectively). Moreover, there was no significant change in proportion of minority trainees in both vascular integrated residency and fellowship programs. While general surgery programs have expanded in proportion of both female applicants and trainees, racial diversity has decreased. Gender and racial diversity in vascular training has not changed. Future initiatives in general and vascular surgery should focus on recruitment and promotion of proficient women and minority trainees.

Factors influencing medical student choices in the integrated vascular surgery match: Implications for future post-pandemic residency matches

ObjectiveIntegrated vascular surgery residency is among the most competitive specialties, but little is known about the applicant perspective. The coronavirus disease 2019 outbreak impacted the 2021 integrated vascular surgery residency match because of travel restrictions. We sought to better understand pre-pandemic applicant recruitment strategies, logistics of away rotations, and the residency interview process to identify areas for improvement in the application process. MethodsAn anonymous survey was sent to matched students in 2020, inquiring about motivations for pursuing vascular surgery (VS), logistic of away rotations and interviews, and factors influencing students' rank lists. ResultsSeventy of the 73 matched students completed the survey (95.9% response rate). The median age was 27 (range, 25-41); 32.9% were female, 91.4% were U.S. medical students, and 77.1% were from institutions with a VS training program. Factors most strongly influencing the decision to choose VS as a career were interest in open vascular procedures, endovascular procedures, perceived job satisfaction, emerging technologies, and influence of a mentor. The prospect of the job market, future salary, and competitiveness of the application process had the least impact. Of the matched students, 82.9% completed an away rotation (median, 2; range, 1-4), with 51.7% of students paying a total cost of more than $2500. Fifty percent of students matched either at their home institution or where they had performed an away rotation. Students reported application submissions to a median of 50 programs (range, 1-70) and interviewed at 17 (range, 1-28), with 40% of students paying a total of more than $4000 for interview costs. The most significant factors affecting students' rank lists included program culture, open aortic surgical volume, geography, and complex endovascular procedure volume. Tours of facilities, resident salary, and male/female distribution had the least importance. ConclusionsSuccessfully matched applicants in 2020 prioritized operative case volume and program collegiality when ranking programs. Despite their high cost, away rotations played an important role in the Match, suggesting that time spent at potential institutions allowed ideal assessment of factors for students. The high average number of away rotations and in-person interviews performed in 2019-2020 was limited for the 2021 Match due to coronavirus disease 2019 restrictions. Programs will have to continue developing creative alternatives or additions to away rotations and the application processes to assure continued success in future post-pandemic Match cycles.

Open Abdominal Aortic Aneurysm Surgery Among Vascular Surgery Trainees: On the Verge of Extinction?

Objective: In the past decade, treatment of abdominal aortic aneurysm (AAA) has shifted dramatically from open aneurysm repair (OAR) to an endovascular approach (EVAR). The decreasing number OARs has raised concerns regarding future vascular surgeons’ competence to perform this complex and high risk procedure. The main goal of this study was to evaluate AAA repair trends among vascular surgery residents over the last 15 years on a national level.

Diversity and Inclusion on General Surgery, Integrated Thoracic Surgery, and Integrated Vascular Surgery Residency Program Websites.

Increasing diversity in medicine is receiving more attention, yet underrepresented in medicine (UiM) surgeons remain a small fraction of all surgeons. Whether surgical training programs attempt to attract UiM applicants to their programs, and therefore their specialties, through program website information is unclear. To analyze the scope of diversity and inclusion (D&I) related information on US allopathic and osteopathic general surgery, integrated thoracic surgery, and integrated vascular surgery residency program websites. Residency programs were identified through the Electronic Residency Application Service (ERAS) in July 2020. We searched surgical program websites and collected data on the presence or absence of variables labeled "diversity & inclusion" or "underrepresented in medicine." Variables found on program websites as well as sites linked to the program website were included. We excluded programs identified in ERAS as fellowship training programs. Programs without webpages were also excluded. We identified 425 residency programs and excluded 22 from data analysis. Only 75 of the 403 included programs (18.6%) contained D&I-related information. The presence of individual variables was also low, ranging from 4.5% for opportunities related to early exposure to the specialty to 11.1% for a written or video statement of commitment to D&I. In 2020, as recruitment and interviews moved entirely online, few US allopathic and osteopathic general surgery, integrated thoracic surgery, and integrated vascular surgery residency programs provided D&I-related information for residency applicants on their program websites.

Self-Perceived Comfort Performing Vascular Surgery Procedures among Senior Vascular Surgery Trainees and Recent Graduates

In the last two decades, vascular surgery training evolved from exclusively learning open skills to learning endovascular skills in addition to a functional reduction in training duration with 0+5 residency programs. The implications for this on trainee evolution to independence are unknown. We aimed to assess self-perceived comfort performing open and endovascular procedures and to identify predictors of high comfort among senior vascular surgery trainees and recent graduates. Junior and senior 0+5 vascular surgery residents, traditional fellows, and attendings in their first 4 years of practice were asked to complete a survey assessing the number of vascular procedures performed to date, comfort performing these procedures on a Likert scale, and validated scales of self-efficacy and grit. Groups were then matched by training level and age. Logistic regression identified independent predictors of the top quartile of self-perceived comfort performing procedures. Surveys were completed by 92 trainees and 71 attending surgeons in their first 4 years of practice. After matching, completing ≥7 open juxtarenal aortic repairs (OR = 4.73, 95% CI = 1.59-14.07) and a higher self-efficacy score (OR = 3.24, 95% CI = 1.20-8.76), were independent predictors of top quartile comfort performing open vascular procedures. 0+5 residency training inversely correlated with top quartile comfort performing open vascular operations (OR = 0.12, 95% CI = 0.03-0.47). Completing ≥7 complex EVARs (OR = 3.94, 95% CI = 1.61-9.59) and a higher self-efficacy personality score (OR = 2.76, 95% CI = 1.09-7.02) were predictors of top quartile comfort performing endovascular procedures. In this nationally representative survey, both trainees and junior attendings completed a paucity of complex open vascular cases, which corresponded to reduced comfort performing these procedures. Furthermore, 0+5 residency training was associated with lower self-perceived comfort performing open vascular surgery, a trend that persisted through the first years of practice. Endovascular comfort did not show a similar correlation.

A Framework for Understanding the Association Between Training Paradigm and Trainee Preparedness for Independent Surgical Practice

The sociopolitical and cultural context of graduate surgical education has changed considerably over the past 2 decades. Although new structures of graduate surgical training programs have been developed in response and the comparative value of formats are continually debated, it remains unclear how different time-based structural paradigms are preparing trainees for independent practice after program completion. To investigate the factors associated with trainees' and program directors' perception of trainee preparedness for independent surgical practice. This qualitative study used an instrumental case study approach and obtained information through semistructured interviews, which were analyzed using open-and-focused coding. Participants were recent graduates and program directors of vascular surgery training programs in the United States. The 2 training paradigms analyzed were the integrated vascular surgery residency program (0 + 5, with 0 indicating that the general surgery training experiences are fully integrated into the 5 years of overall training and 5 indicating the total number of years of training) and the traditional vascular surgery fellowship program (5 + 2, with 5 indicating the number of years of general surgery training and 2 indicating the number of years of vascular surgery training). All graduates completed their training in 2018. All interviews were conducted between July 1, 2018, and September 30, 2018. A conceptual framework to inform current and ongoing efforts to optimize graduate surgical training programs across specialties. A total of 22 semistructured interviews were completed, involving 7 graduates of 5 + 2 programs, 9 graduates of 0 + 5 programs, and 6 vascular surgery program directors. Of the 22 participants, 15 were men (68%). Participants described 4 interconnected domains that were associated with trainees' perceived preparedness for practice: structural, individual, relational, and organizational. Structural factors included the overall and vascular surgery-specific time spent in training, whereas individual factors included innate technical skills, confidence, maturity, and motivation. Faculty-trainee relationships (or relational factors) were deemed important for building trust and granting of autonomy. Organizational factors included features of the local organization, including patient population, case volume, and case mix. Findings suggest that restructuring training paradigms alone is insufficient to address the issue of trainees' perceived preparedness for practice. A framework was created from the results for evaluating and improving residency and fellowship programs as well as for developing graduate surgical training paradigms that incorporate all 4 domains associated with preparedness.