JOINT BASE LEWIS-MCCHORD, Wash. -- Over the last 15 years, residents graduating from Madigan Army Medical Center's general surgery residency program have passed the exam for board certification on their first attempt at a nation-topping rate of 97.6 percent.

The American Journal of Surgery recently published a long-term study that ranks 231 general surgery residency programs across the country by this measure. By nearly two percentage points over the next ranked program, Madigan's residents taking exam over the 15-year duration of the study put the program in the number one spot. The pass rate that Madigan scored is well above the mean of 72.9 percent.

To become a board-certified general surgeon, passing a combination of a computerized multiple choice qualifying exam and an oral certifying exam is required.

Because of its value in the surgical field, this pass rate is seen as a significant measure of the success of a residency program. The study makes the overall success of military programs in achieving board certification apparent.

"I think we attract a special breed of residents," said Lt. Col. (Dr.) Vance Sohn, the residency program director and chief of general surgery. "That's the type of person that we recruit and retain -- the people who don't shy away from challenges. We want to be in the action," he added.

Of the 231 programs evaluated, eight were military, with six of those being Army. All of the military programs were ranked in the top half. Five of the six Army residencies were in the top third and two scored in the top three. Brooke Army Medical Center at Fort Sam Houston, Texas, occupies the third spot on the list.

Selecting Character and Promise

"The article divides it into military programs, academic programs, and civilian programs. The military programs were statistically better overall than any of the other two. And I think it has a lot to do with our selection process. They signed up for a military career and all the trappings that go with that -- the responsibilities and things. You're getting a different level of committed individual. That's part of it," explained Dr. Joseph Homann, a surgeon and key member of the faculty.

Sheer numbers also allow Madigan to be choosy when selecting its residents.

"You have more people that want to do general surgery than the Army has places to train people so you really get the best of the best," agreed Capt. (Dr.) Michael Lallemand, a chief resident currently in his sixth year in the program.

"If you get an 89 percentile in the nation, you're in the bottom quarter of Madigan in our annual in-training exam. That's unheard of in any program. In any other program, you get an 89 percentile in the nation, you are doing very well," Sohn said.

More than simply the supply and demand aspect is the vast difference between the selection process within the military and the civilian side.

As civilians apply to 1 of the 200+ programs, they submit their transcripts and possibly spend a day visiting a facility. That's the extent of visibility either candidate or faculty gets in determining whether the fit is right or not for the next five to six years.

In the military, a medical student does a full four-week rotation working within their prospective program. That makes the selection process much more informed, on both sides. The resident gets to interact with the faculty and staff within the program who, in turn, get to see the candidate in action.

"You get to work with them professionally. See how they work in clinic, see how they work on the wards," said Lallemand. "You get that time to figure out -- do we think this person is going to be successful or not," he said.

The military programs seem to have an advantage from the start. But, Madigan stands out even beyond that. A number of possible reasons come to the fore.

The Madigan Approach

When he attends meetings and conferences off base, Sohn gets asked the same question again and again. "'What is it that you guys do that makes you so different?' We don't have a separate book that only we study out of," he said.

Yet, there are things that are unique to Madigan's way of training general surgeons.

Every Thursday is dedicated to training. Every single one. There is also a full year dedicated to research. That is now common Army-wide, but wasn't when Madigan started doing it. It is not common in the typical civilian residency program.

Residents here also get some good preparation for that oral exam. As they work on-call in their second and third years, they are required to present in a morning conference on all their patients and activities. Then, during their last three years of residency, they work with a hospital in Seattle to do rounds of mock oral exams twice a year.

Being able to answer the questions of what to do in the oral exam situation is vital, but developing the surgical skills to perform in the operating room is clearly paramount.

"I think one of the big advantages to our program, especially compared to some of the civilian programs," commented Lallemand, "is that literally day one of intern year, the interns were in the operating room."

He noted that those initial procedures are minor things like draining an abscess, and are accompanied by intensive, over-the-shoulder supervision by faculty. Jumping right in and getting comfortable in the operating room is important, though.

"That's not necessarily the experience interns get everywhere in the country. That's one of the big strengths of our program is you get in the operating room right away and you get that experience."

As focused as faculty is on perpetuating the areas of strength in the program, they are also addressing weaknesses.

"Each year there are little incremental changes. We have discussions and we identify areas that are perhaps a little weak," said Homann.

Lallemand points to one area that has some room for improvement. "Anyone who's being honest isn't going to look at our program and say there's a lot of diversity. I think that's a weakness of our program," he said. In specific reference to the number of women in the program, he noted that, "the demographics are changing." The program has heard this concern from medical students doing their rotation and has added female faculty.

Stability and Sustainment

A number of the faculty, both current and throughout the study's length, did their residency here to include Sohn and Lt. Col. (Dr.) Matt Eckert, the trauma medical director and associate residency program director.

In addition to long-term dedication to the program by active duty surgeons, there is a contingent of former Madigan colonels who now work as civilian faculty.

"I came here in 2004 when most of the active duty people were deployed and they just needed help from people who were used to the system. That's 15 years ago. That covers the spectrum of this report," said Homann.

"I think having a stable staff really helps with the educational process," Homann said. Madigan was his last duty station before retiring from active duty.

"We've had a long-standing focus and intentional development of the faculty and the residency because we had a program that worked and we wanted to stick with it. That's a little unique in the military because typically even among surgical residencies in the military there's still a lot of movement among staff," said Eckert.

The Mission at Hand

"I really try to impress upon them what the mission for our training is," said Sohn. "We have a very defined role in that we are going to deploy to the most remote and austere environments. We're going to be given the least amount of resources and we're going to say, 'you have to succeed,'" he added.

Having been deployed numerous times himself, Sohn knows the skills and knowledge his residents will need in that situation. He works to nurture a drive in them.

"It's a long six years and they work very, very hard for six years. Our bar, our standards are very high because again, it's not something artificial; they will deploy," he said.

Lallemand, though he has not yet deployed, has clearly taken this mission awareness to heart.

"It's a very real possibility that six years from now when you're just finishing your residency and I've been out for six years and we deploy together and, you know, some Soldier's life depends on how well we can perform that day. To be able to perform your best, I have to rely on you to have gotten everything you can out of your residency," he said.

Culture of Excellence

Ultimately, the aspect faculty and residents bring forward as a key factor in the success of the program is that high-potential residents come into a program that is accustomed to success and, therefore, has very high expectations for them.

"We have a hard-wired culture of excellence here and I think that's really what sustains us," said Sohn.

High expectations exist for residents from the start of their first, or intern, year and they merely build from there.

Lallemand finds the expectation both intimidating and inspiring. By the final, or chief resident, year they are part of the mechanism that insists the bar is met.

"You have a team of medical students and residents looking up to you now. You have to be able to lead your people and get your people to want to be better for you because the people that were ahead of you made you better," said Lallemand. "You're always expected to be a teacher."

The staff and chief residents push until a resident doesn't know an answer. "Then, when you don't know the answer, that's where the opportunity to learn comes from. If you don't get to the point where you don't know something every day, I kind of get the sense that the faculty and the senior residents have failed the junior residents because we haven't taught them anything," said Lallemand.

Lallemand makes clear that all this pushing is borne of a passion for the craft, the program and those within it. "The faculty really care," he said.

"Being a surgeon is one of the greatest jobs in the world," concluded Homann. "And it's still fun, especially," he noted, "seeing the young people come along."

Editor's Note: The article relaying the study is entitled, "A 15-year residency program report card: Differences between the crème of the crop and the bottom of the barrel on the American Board of Surgery examinations," was written by John L. Falcone, and published in September.