The Churchill “Rectangular” Residency Program Transformed Surgical Education

July 1 is an honorary milestone in US medical education, when a newly minted class of aspirational and hardworking surgical interns arrive at their hospitals to begin their surgical education and professionalization.

This rite of passage has become formalized in the US through the standardization and accreditation systems overseen by the Accreditation Council for Graduate Medical Education, board certification processes administered by the American Board of Surgery (ABS), and the educational contributions of organizations such as the ACS and numerous surgical specialty societies.

In the twenty-first century, both the US public and the medical profession have come to expect board-certified general surgeons to have completed a rigorous and regulated residency program. However, throughout much of US history, this was not always the case.

From the eighteenth to the nineteenth century, colonial America experienced a rapidly growing population with an increase in medical problems. Few trained practitioners could perform even minor surgical procedures and apprentice-trained surgeons were rarely available to provide care.

Notably, the first US hospital was founded in Philadelphia in 1751, and shortly thereafter, apprenticeships were developed to provide training to medical doctors. Major US medical schools also were established. Despite these developments, there was a lack of standardized regulation governing the training or qualification of surgeons. Local medical societies began licensing physicians in an early effort to regulate practice and promote quality of care.

Seeking advanced medical education, many wealthy aspiring US physicians traveled to England, France, and Germany to pursue more advanced medical training before returning to their practices in the US.

The mid-to-late nineteenth century also brought increased scientific sophistication to the practice of medicine and surgery. The discovery and implementation of anesthesia (1846) and antisepsis (1867), as well as advances in physiology, radiography, hospital design, and professionalized nursing expanded the boundaries of surgical practice. And in 1880, Samuel Gross, MD, founded the American Surgical Association, with the goals to elevate the scientific rigor of surgery in the US and distinguish the roles of surgeons and physicians.

Building the Pyramid: The Halsted Model

William Stewart Halsted, MD, is recognized as a pioneer in US surgical education and was the first to establish an academic surgical residency in this country. Dr. Halsted completed his medical education at Columbia University College of Physicians and Surgeons in New York City, and his surgical training at New York’s Bellevue Hospital, followed by 2 years of clinical training in Germany and Austria. 

The Germanic model of surgical training made a strong impression on Dr. Halsted and would influence his reform of surgical education.

In 1880, he returned to the US to begin his surgical career, and in 1886, he was recruited to the newly founded Johns Hopkins Hospital in Baltimore, Maryland, where he founded the surgical department and established what would become the model of residency training programs in the US.

The model, based on the German approach to medical training, was strictly pyramidal. Eight interns enrolled each year and were guaranteed a position for 1 year. Four of the eight advanced to the next year, and ultimately only one attained the position of chief house resident, a role held for an indefinite period.  Advancement and graduation were determined solely by Dr. Halsted, leaving residents in training until he deemed them prepared for independent practice.

A report issued by a Hopkins committee noted the following: “The resident physician: It would be well to use for this officer the term ‘first assistant’ at the medical, surgical, and gynaecological [sic] clinics respectively. Ultimately, we should look forward to having second assistants, as at the German clinics. These men should, as now, be salaried. They should be selected with the greatest care by the staff, with the approval of the medical board and of the trustees. Though appointed annually, it is expected that these men remain for an indefinite period, so long in fact as they do their work satisfactorily.”

Advancement was not guaranteed, and the competition was “fierce and vigorous” while caring for patients, operating, and producing research.

This steeply pyramidal system was adequate for its time, because even residents who did not complete the full program but had 2–3 years of training could return to their communities as more knowledgeable and skilled surgeons.

Will C. Sealy, MD, speaking a century later through a contemporary lens, issued the following comment: “It is a strict pyramid with an autocratic chief…The period of training is long and indefinite.” This cutthroat and demanding approach to surgical education, with only one excellent winner, was meant to “produce not only surgeons, but surgeons of the highest type, men who will stimulate the first youths of our country to study surgery and devote their energies and their lives to raising the standard of surgical science.”

The Halstedian model was revolutionary for its time, and although it is flawed when viewed in retrospect, it rightfully established a strong framework of residency training in the US.

This model was instituted at a time when there was an emerging demand for standardized education, and with this goal in mind, the model replicated the highly recognized German-Austrian system. Dr. Halsted graduated 17 chief residents, and of these, 11 went on to establish similar residency training programs at other institutions.

Despite the proliferation of these pyramidal training programs, with graduated responsibility, and structured training of surgical residents, the bulk of US surgery in the early twentieth century continued to be performed by general practitioners who only had 1 year of medical internship training following medical school.

As surgical sciences advanced, and surgical procedures became progressively more complex, there was a growing need to proliferate surgical skills among a broader generation of trainees.

The College, the Board, and Dr. Evarts Graham

At the turn of the twentieth century, fewer than half of US physicians pursued any postgraduate training. However, the increasing breadth of medical knowledge in the early 1900s required an increased focus on transition to practice. 

By 1923, US hospitals offered an internship position to every graduating doctor. Some institutions also offered short, 1-year residency programs that focused on a specific specialty, including surgery. 

The American Medical Association established guidelines to help regulate these residencies in the 1920s, but 12 months of training severely limited the scope and quality of this experience. By the 1930s, the practice of surgery had substantially changed, significantly increasing both the extent and variety of operations.

Leaders of the profession who were concerned about the quality of surgical practice initiated efforts to expand, evaluate, and certify training opportunities. Several academic leaders from the American Surgical Association, chaired by Evarts A. Graham, MD, FACS, convened the National Committee for the Elevation of the Standards of Surgery in February 1936. 

This committee proposed the establishment of a board of surgery following the organizational structure of other specialties. The requirements for board certification included specialty surgical training consisting of at least 3 years of graduate training following internship, sufficient graduate-level work in anatomy, physiology, pathology, and basic medical sciences, as well as adequate operative experience. The 3-year requirement was derived from the Mayo Clinic model developed in Rochester, Minnesota, in the 1920s. 

A two-part examination for board certification would be required: The first part was written, and the second part was oral or practical. The committee’s proposal was approved, and the ABS became the twelfth recognized specialty board in the US.

Dr. Graham was a driving force in the standardization of the US surgical residency. A classmate of Allen O. Whipple, MD, FACS, at Princeton University in New Jersey, Dr. Graham completed his medical education at Rush Medical College and his surgical training at Presbyterian Hospital (today known as Rush University Medical Center), both located in Chicago, Illinois. 

Following his service in World War I, he was recruited in 1919 to establish the Department of Surgery at Washington University in St. Louis, Missouri (WashU), and would serve as chair from 1919 to 1951.

At WashU, Dr. Graham standardized Dr. Halsted’s system into a set-length, graded curriculum with progressive responsibility and operative exposure as trainees advanced. He was the inaugural ACS Vice President (1932–1933) and would later serve as the ACS President (1940–1941) and Chairman of the Board of Regents (1951–1954). 

Changing standards of medicine and the creation of the ABS prompted the ACS to adopt and regulate residency training.

In November 1937, the ACS Committee on Graduate Training in Surgery first met and began developing standards for surgical residency programs. “There are really two problems that confronted us,” noted an internal report. “One was the ideal training for the surgeon and the other was the graduate training which is necessary for every man to have before he can become a member of the American College of Surgeons.” 

Thus, the College required residency training for all Fellows and took on the responsibility of inspecting and approving surgical residency programs. The inaugural 1937 ACS Residency Program Inspection evaluated 270 hospitals, and of these, 89 programs (33%) received full approval, 46 programs (17%) received provisional approval, and 135 programs (50%) were rejected.

The ACS published these results in a 1939 issue of the Bulletin of the American College of Surgeons that was distributed across the US. The publication of this report demonstrated the strict requirements for ACS residency program certification and a definitive list of the programs that satisfied these requirements. 

The ACS seal of approval became desirable for residency programs that wanted to attract more qualified residents. The applicants, in turn, trusted ACS-approved programs to ensure the quality of education necessary for entrance into both the College and ABS. 

From Pyramids to Rectangles: The Churchill Model

The rising standards for trainee instruction among the surgical societies led to increased scrutiny of the practicality of the Halsted pyramidal system. 

Although the Halstedian pyramid model produced a number of highly accomplished surgeons, many trainees received only a fraction of the intended education, with some completing as little as 1 year of formal surgical training. While incomplete training was adequate for the late 1800s, the changes in the ABS and ACS requirements in the 1930s meant that the many residents who did not complete the “pyramid” were ineligible to qualify for certification from either the College or ABS.

In 1940, Edward D. Churchill, MD, chair at the Massachusetts General Hospital (MGH) in Boston, publicly rejected the Halsted pyramidal system, commenting that “half a surgical training is about as useful as half a billiard ball.”

Dr. Churchill completed his undergraduate education at Northwestern University in Chicago, Illinois, and attended medical school at Harvard University in Cambridge, Massachusetts, and completed his surgical residency at MGH. He also completed a 2-year clinical fellowship in Germany and Denmark, where he was exposed to the German model of surgical training.

In 1931, Dr. Churchill became the chief of the West Surgical Service at MGH. Based on his observations of the negative aspects of the pyramidal system during his time in Europe and early years at MGH, he sought to change the culture of American surgical education. Dr. Churchill fostered an educational environment led by a faculty of excellent surgeons, where no singular personality dominated the methods and technology of the institution, and he eliminated the authoritarian nature that developed as part of the master-apprentice relationship model.

Ultimately, his goal was to enhance the teacher-student relationship to improve resident education and growth. As Dr. Churchill wrote, ‘‘The conversion of the intellectually sterile master-apprentice situation into a mutually stimulating teacher-pupil relationship has been one of the goals of my professional life.”

Dr. Churchill established a “rectangular” surgical residency program in which all accepted residents completed the full training program. He limited the number of candidates per year from six to four but increased the length of training to 5 years for all accepted candidates. Individuals with an interest in academic surgery and research could continue for more years if desired. The program guaranteed residents a position throughout training and was designed to graduate surgeons capable of independent practice.

The educational potential of the hospital would be devoted to training several people, instead of just one or two exceptional trainees. This approach removed the constant competition between trainees for advancement and allowed the residents to focus on education. Dr. Churchill suggested that this arrangement would produce well-trained surgeons in a more collegial environment and that this structure encouraged cooperation among resident peers. 

In 1939, Dr. Churchill formally proposed the “rectangular” residency program to replace the competitive, “pyramidal” apprenticeship model. It was built on six underlying principles:

• Prevent exploitation of the residents by avoiding repetitious routine procedures
• Expose trainees to the foundations of basic science, including anatomy, physiology, bacteriology, and pathology
• Foster flexibility in training to tailor to individual interests and goals
• Select surgical faculty who meet the criteria for mature and well-qualified surgeons willing to devote time and effort to the training of residents
• Support progressive responsibility of the trainee that increases with time and competence
• Form an advisory board for graduate education to ensure the educational goals are met by residency training programs

The program would provide graded responsibility in patient care, operative complexity, and autonomy. Dr. Churchill recognized the importance of an institutional obligation to trainees, writing: “The willingness of this group [the residents] to deliver themselves up to an institution for 4 to 6 years of the most vital period of their life without any commitment for the ultimate future places a grave responsibility on the hospital to give them the best it has.”

While this was not the first rectangular training program, its association with Harvard and prominent surgeons such as Dr. Churchill provided the credibility necessary for wider adoption across the US. 

However, the transition from concept to practice was interrupted by global events. Implementation of Dr. Churchill’s proposed training structure was largely deferred by the onset of WWII. As a result, the entering MGH class of 1946 was the first to move through the new system completely in accordance with the rectangular residency. The model’s success was demonstrated by the increased number of surgeons trained for independent practice and the reduced competition among residents for limited training positions. This plan was widely adopted nationally, and the Halsted system became nearly obsolete following WWII.

Revisiting the Rectangle Through Competency-Based Education

Even as he was laying the foundation for his rectangular residency program in 1931, Dr. Churchill called for flexibility in tailoring training to individual needs, writing, “A frozen 5-year curriculum is unthinkable as it allows no latitude for the development of individual interests and proficiencies.” 

While Dr. Churchill may not have been directly referring to a competency-based surgical education model, his words are relevant when considering today’s residency training paradigm.

In February 2022, the ABS announced the move to competency-based assessment of surgical trainees with the introduction of the ABS Entrustable Professional Activities (EPA) Project. The EPA platform launched for general surgery residency programs in July 2023. It expanded in August 2025 to include vascular surgery, pediatric surgery, and complex general surgical oncology, followed by surgical critical care in September 2025.

The Churchill model has proven highly successful in training generations of general surgeons in the US and continues to evolve under the leadership of today’s surgical educators. This model provided comprehensive training for skilled surgeons while eliminating the inefficiencies of the pyramidal system.

In his presidential address to the Boston Surgical Society in December 1997, Hermes C. Grillo, MD, FACS, a world-famous thoracic surgeon, remarked, “I shall state a seemingly arrogant but, I think, defensible premise: The surgical residency training system in the US today is, at its best, the finest vehicle yet developed for the education of surgeons.”

Standing on the shoulders of Drs. Halsted, Graham, Churchill, and countless others, we welcome the next generation of surgeons to The House of Surgery^® as they begin their journeys.

Acknowledgment

The authors would like to acknowledge Justin Barr, MD, PhD, for his contributions to the field of surgical history, several of which are cited in this article. 

Dr. Aaron Delman is a transplant surgery fellow at Washington University in St. Louis, MO.

Dr. Brendan Lovasik is a transplant surgeon at the Mayo Clinic in Jacksonville, FL. 

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