Case Logs Research Articles

Discordance in current procedural terminology coding for pediatric orthopaedic surgeries between residents and attending surgeons: a retrospective comparative study

Background: The current procedural terminology (CPT) coding system is used in medical record maintenance and billing. CPT coding is a skill that residents should acquire through training. The purpose of this study was to assess concordance between attending and resident coding practices in pediatric orthopaedic surgery. Methods: Case log reports were collected from 14 residents on the pediatric orthopaedic surgery service over 2 yr, then compared to operating room billing records from three pediatric orthopaedic surgeons. CPT code concordance rates were generated between residents and attendings for individual cases. Results: Three attending surgeons performed 1,372 cases over the two years. To accommodate cases in which multiple residents participated, 38 cases were duplicated (1,410 total attending cases). There was no corresponding resident case entry for 31.3% of attending cases. Of the 968 cases logged by residents, a 78.2% concordance rate was observed. Residents who rotated on pediatric orthopaedics only as a post-graduate year (PGY) 3 during the study period exhibited 73.8% concordance rates, versus residents that rotated as both a PGY-3 and PGY-4 who exhibited 78.7% and those who rotated only as a PGY-4 who exhibited 82.0% (P<0.001). Closed reduction and percutaneous pinning of supracondylar humerus fractures had the highest concordance rate (93.5%) among ACGME-required minimum category cases. Conclusions: Residents and attendings demonstrate a relatively high CPT code concordance among pediatric orthopaedic surgeries. Concordance rates were significantly higher when reported by more experienced residents. Among minimum category cases, percutaneous pinning of supracondylar humeral fractures demonstrated the highest concordance rate. Level of Evidence: Level IV

Resident Vitreoretinal Procedure Volume: Effect of Intravitreal Injections, Region, Program Size, and Vitreoretinal Fellowship and Veterans Affairs Affiliation.

Purpose To analyze resident vitreoretinal procedure volume across Accreditation Council of Graduate Medical Education (ACGME) accredited ophthalmology residency programs. We assessed the effect of the increase in intravitreal injections (IVI), geographic region, program size, and Veterans Affairs (VA) and vitreoretinal fellowship affiliation on vitreoretinal procedures. Methods A request was sent to all residency programs in 2018 for their graduating residents' ACGME case logs. Vitreoretinal procedures were defined by ACGME case log categories and included vitreoretinal surgery, peripheral retinal lasers, and IVI. Procedures were categorized by Current Procedural Terminology (CPT) code. Programs were studied by geographic region, program size, and by VA and vitreoretinal fellowship affiliation. Results A total of 38 of 115 (33.0%) programs responded, and 167 residents logged 32,860 vitreoretinal procedures. The median number of retina procedures per resident was 146 (range 36-729). Programs with a vitreoretinal fellowship had a higher average number of vitreoretinal procedures per resident (208.3 vs. 125.0; p = 0.002), but there was no difference between the average number of non-IVI vitreoretinal procedures (60.0 vs. 64.2; p = 0.32). For IVI, VA affiliation (146.6 vs. 71.1; p = 0.02) and vitreoretinal fellowship (149.4 vs. 60.8; p < 0.001) were associated with a greater number. More IVI strongly correlated with a larger total volume of retinal procedures ( r = 0.98), and there was no difference across programs for total retinal procedures when IVI was removed. Conclusions The presence of a vitreoretinal fellowship at a residency program had a positive effect on resident total vitreoretinal case volume, but their residents performed more IVI. Programs without vitreoretinal fellowships completed on average more non-IVI procedures.

Dedicated Chalazion Clinic as a Tool for Early Surgical Education in Ophthalmology Residency.

Objective Ophthalmology residency programs aim to improve resident surgical teaching through increased surgical exposure over a 4-year period. Resident-centric surgical clinics across various surgical specialties have been established to help develop surgical autonomy and experience. We present the first demonstration of a resident-centric chalazion incision and drainage clinic (chalazion clinic) in an ophthalmology residency with the goal of increasing early surgical exposure to residents. Design The chalazion clinic was founded in July 2019. It is a once weekly procedure clinic conducted by an ophthalmology resident and supervised by an ophthalmology attending. Patients with chalazia were referred directly to this clinic for evaluation and management, rather than the oculoplastics clinic as they were in the past. Retrospective review of Accreditation Council for Graduate Medical Education (ACGME) case logs of all residents per academic year before and after establishment of the chalazion clinic was performed in order to assess the impact on residents' chalazion procedures numbers per academic year. Setting The study involved a single academic ophthalmology department. Participants Ophthalmology residents of all years were present. Results A resident of any year performed an average of 3.0 chalazion procedures per year in the 2018 to 2019 academic year, 3.8 in 2019 to 2020, and 8.4 in the 2020 to 2021, which represents a 180% increase in procedure numbers per resident. Among post-graduate-year 2s (PGY)2s, the average number of chalazion procedures increased from 2.1 procedure per year to 22.3 per year (961.9% increase). Conclusion To the best of our knowledge, this is the first description of a dedicated resident-centric chalazion clinic in an ophthalmology residency program. PGY2s demonstrated the largest increase in procedural numbers. While chalazion incision and drainage is a minor procedure, increased exposure to surgical procedures early in training could help improve residents' skills and confidence. This clinic provides a proof of concept of a dedicated minor procedure clinic for ophthalmology residents to increase early procedural volume.

A Dedicated Simulator Training Curriculum Improves Resident Performance in Surgical Management of Pediatric Supracondylar Humerus Fractures.

The primary goal of including simulation in residency training is to improve technical skills while working outside of the operating room. Such simulation-related skill improvements have seldom been measured in the operating room. This is largely because uncontrolled variables, such as injury severity, patient comorbidity, and anatomical variation, can bias evaluation of an operating surgeon's skill. In this study, performance during the wire navigation phase of pediatric supracondylar humerus fracture fixation was quantitatively compared between 2 groups of orthopaedic residents: a standard training group consisting of residents who participated in a single simulator session of wire navigation training and an expanded training group consisting of residents who participated in a dedicated multifaceted wire navigation simulation training curriculum. To evaluate performance in the operating room, the full sequence of fluoroscopic images collected during wire navigation was quantitatively analyzed. Objective performance metrics included number of fluoroscopic images acquired, duration from placement of the first wire to that of the final wire, and wire spread at the level of the fracture. These metrics were measured from 97 pediatric supracondylar humerus fracture pinning surgeries performed by 28 different orthopaedic residents. No differences were observed between the groups for wire spread in the final fluoroscopic images (t(94) = 0.75, p = 0.45), an important clinical objective of the surgery. Residents who received the expanded simulator training used significantly fewer fluoroscopic images (mean of 46 vs. 61 images, t(85) = 2.25, p < 0.03) and required less time from first to final wire placement (mean of 11.2 vs. 14.9 minutes, t(83) = 2.53, p = 0.013) than the standard training group. A post hoc review of Accreditation Council for Graduate Medical Education case logs for 24 cases from the standard training group and for 21 cases from the expanded training group indicated that, at the time of surgeries, residents who received expanded training had completed fewer comparable cases than residents in the standard training group (mean of 13 vs. 21, t(42) = 2.40 p = 0.02). Further regression analysis indicated that the expanded simulator training produced an effect comparable with that associated with completing 10.5 similar surgical case experiences. This study demonstrates that training on a wire navigation simulator can lead to improved performance in the operating room on a critical skill for all orthopaedic residents. By taking fewer images and less time while maintaining sufficient pin spread, simulator-trained residents were objectively measured to have improved performance in comparison with residents who had not participated in the pediatric elbow simulator curriculum. As programs aim to provide safe and effective training for critical orthopaedic skills such as pinning a pediatric elbow, this study demonstrates a simulator curriculum that has demonstrated the transfer of skill from a learning environment to the operating room.

Cross-Sectional Study of Resident-Reported Surgical Experience in Female Pelvic Medicine and Reconstructive Surgery.

Comprehensive surgical training is an essential component of obstetrics and gynecology residency, yet subspecialty experience may be declining. The objective of this study was to describe trends in reported obstetrics and gynecology resident experience in female pelvic medicine and reconstructive surgery (FPMRS). This study was a retrospective analysis of national case log reports from the Accreditation Council for Graduate Medical Education (ACGME) for obstetrics and gynecology residents. From 2013 through 2019, ACGME collected data from a median of 241 programs (range, 239-242) with a median of 1,259 residents (range, 1,213-1,286) reporting annually. There was a 26% decrease in resident-reported experience with incontinence and pelvic floor procedures from 74 ± 38 in 2013 to 55 ± 34 in 2019 ( P < 0.001). Cystoscopy increased by 19% from 43 ± 25 in 2013 to 51 ± 29 in 2019 ( P < 0.001). From 2014 to 2019, vaginal hysterectomy cases decreased by 12% ( P < 0.001). There was a significant decrease in resident-reported FPMRS surgical experience from 2013 to 2019, while cystoscopy numbers increased. After laparoscopic and vaginal hysterectomies were unbundled in 2013, resident vaginal hysterectomy cases decreased from 2014 to 2019. Given that the ACGME Incontinence and Pelvic Floor designation comprises a wide range of procedures, future investigation is needed to elucidate the gaps in FPMRS-specific surgical training during residency and its implication in comprehensive resident surgical training.

COVID-19 Elective Surgery Shutdown and Operative Experience for Graduating Plastic Surgery Independent Residents.

The initial wave of the COVID-19 pandemic led to a temporary shutdown of elective procedures. The purpose of this study is to evaluate how the elective surgery shutdown impacted case log numbers for graduating plastic surgery independent residents. The Accreditation Council of Graduate Medical Education graduate self-reported case logs were retrospectively compiled for graduating independent track plastic surgery residents for the year before the pandemic (2019), 4 months into the pandemic (2020) and 16 months into the pandemic (2021). Procedures were grouped into resident review committee area and totals for each area were used for analysis. Average number of cases and standard deviations were compiled. Percent change was calculated comparing each year to the prepandemic baseline. Statistical significance was determined with Student t tests comparing average number of cases. Coefficients of variation were calculated to assess for changes in interprogram variation. Average case numbers were then compared with minimum case requirements necessary for graduation. The Accreditation Council of Graduate Medical Education graduation case log statistics were available for 238 independent residents. There were no statistically significant differences in average case number for graduating independent residents for total reconstructive breast, trunk, hand and upper extremity, or total reconstructive procedures between graduation years. The average case number of total lower extremity reconstruction increased from 2019 to 2020 (average = 83-97.4, P = 0.02). The average total number of breast aesthetic cases increased between all years (average = 92, 98, 114), with the average increase from 2019 to 2021 being statistically significant ( P = 0.02). Differences in head and neck aesthetic deformities and trunk and extremity deformities between years were not statistically significant. The average case number for all graduating plastic surgery independent residents exceeded the minimum case log requirements. The temporary hold on elective procedures during the pandemic decreased the opportunity for plastic surgery trainees to meet minimum case log requirements. Case log data for graduating plastic surgery independent residents demonstrate that despite the temporary suspension, the pandemic did not greatly impact the average resident case numbers.

Case Volume Benchmarks During Residency and Fellowship Training for Pediatric Orthopedic Surgeons.

Higher case volumes correlate with improved clinical outcomes across surgical specialties. This study establishes case volume benchmarks after completion of pediatric orthopedic fellowship training. Case logs for orthopedic surgery residents and pediatric orthopedic fellows at accredited programs were analyzed (2017-2018 to 2020-2021). Case volumes for pediatric orthopedic surgery were compared using parametric tests. Case logs from 3,000 orthopedic surgery residents and 149 pediatric orthopedic fellows were analyzed. There was an increase in total pediatric cases among orthopedic surgery residents over the study period (273 ± 68 to 285 ± 76, 1.1% annual increase, P<0.001). On average, pediatric orthopedic fellows reported 276 cases: Spine deformity (55 cases, 20%), foot and ankle deformity (45 cases, 16%), hip reconstruction (34 cases, 12%), limb deformity (32 cases, 12%), trauma lower limb (24 cases, 9%), treatment of supracondylar humerus fracture (23 cases, 8%), trauma upper limb (19 cases, 7%), clubfoot (18 cases, 7%), soft tissue procedures (13 cases, 5%), open treatment of femoral shaft fractures (6 cases, 2%), and treatment of infection (7 cases, 3%). Pediatric orthopedic fellows effectively doubled their pediatric case volume from fellowship training. The distribution of pediatric orthopedic fellow case volume percentiles was: 10th - 191 cases; 30th - 237 cases; 50th - 275 cases; 70th - 318 cases; 90th - 382 cases. Case volume benchmarks can help inform orthopedic trainees, faculty, and patients about the impact of pediatric orthopedic fellowship training. More research is needed to elucidate optimal training environments for future pediatric orthopedic surgeons.

Surgical Training for a Disaster: Preparation of Surgical Trainees for Victims of Conflict.

With increasing global unrest and military physician shortages potentially leading to a surgeon draft, we sought to evaluate the readiness of graduating general surgery residents to care for casualties of war. We evaluated the National Data Reports of Surgery Case Logs for general surgery residents from 2009 to 2018 to quantify experience with key procedures that provide critical skills required for wartime surgery. Reported cases from the Accreditation Council for Graduate Medical Education for graduating residents from civilian and military residency programs were analyzed for 28 individual procedures determined to be critical for the care of combat casualties. These included central and peripheral vascular procedures, as well as neck, thoracic, abdominal, and peripheral interventions. From 2009 to 2018, there has been a significant decrease in wartime-relevant cases by graduating residents. Notably, these include aorto-iliac/femoral bypasses (50% reduction; 7.1%/year; P < .001), femoral-popliteal bypasses (60% reduction; 6.9%/year; P < .001), femoral-femoral bypasses (30% reduction; 2.6%/year; P < .001), upper extremity amputations (50% reduction; 6.4%/year; P = .016), fasciotomies for trauma (50% reduction; 4.5%/year; P = .013), open repair of ruptured infrarenal aorto-iliac aneurysms (70% reduction; 5.8%/year; P < .001), repair of traumatic aorta or vena cava injuries (70% reduction; 7%/year; P = .007), carotid endarterectomies (40% reduction; 4%/year; P < .001), lung resections (40% reduction; 3.7%/year; P = .001), trauma splenectomies/splenorrhaphy (30% reduction; 2.9%/year; P < .001), and repair of traumatic liver lacerations (30% reduction; 2.5%/year; P = .036). Graduating general surgery residents has limited exposure to wartime critical skills due to a significant reduction in open vascular, head and neck, thoracic, and operative trauma cases. As the threat of global war persists and new graduates continue to deploy worldwide, residency training must be augmented to ensure adequate preparation in case a surgeon draft is required to fulfill demand for military surgeons.

ACGME Program Requirements for Surgical Specialties: How Do Dermatology and MSDO Stack Up?

Dermatology and micrographic surgery and dermatologic oncology (MSDO) are two areas of medicine where surgical procedures play an important role both in training and practice. We sought to determine how dermatology and MSDO compare to ACGME surgical specialties with regard to surgical curriculum and case log requirements. We found that the surgical curriculums for dermatology and MSDO are similar to those of our surgical colleagues in ophthalmology, obstetrics, and gynecology. They are similar in that none require general surgery rotations, a general surgery postgraduate year 1 is not required, and all surgical experience can be obtained within each respective specialty residency training program. Regarding case log requirements, MSDO was found to have numerical case log requirements comparable to those of ACGME surgical specialties. Dermatology case log requirements were on the low end of the surgical spectrum. In dermatology and MSDO, surgical training is well integrated into the programs and case log requirements. They represent two of the many areas where medicine and surgery combine in the name of patient care. J Drugs Dermatol. 2023;22(1): doi:10.36849/JDD.6886.

Longitudinal trends in volume of oculoplastic procedures without ACGME minimum requirements among United States ophthalmology residents: an ACGME case log analysis

ABSTRACT Purpose To our knowledge, there have been no previous reports that investigate trends in ophthalmology residents’ exposure to oculoplastic procedures without Accreditation Council for Graduate Medical Education (ACGME) minimum requirements. To fill this knowledge gap, we investigated publicly available ACGME ophthalmology residency case logs from 2009 to 2021. Methods National resident averages and standard deviations were collected for the following oculoplastic procedures without minimum ACGME requirements: eye removal and implant, lacrimal surgery, other orbital surgery (e.g. orbitotomy), tarsorrhaphy, entropion/ectropion repair, temporal artery biopsy, and other oculoplastic surgery. We also collated average yearly surgical volumes of all oculoplastic procedures, “Total Oculoplastic Surgery,” which includes procedures with minimum requirements and procedures without requirements. Finally, we collected the average yearly volumes of all ophthalmic procedures. Linear regressions were used to characterize trends in resident oculoplastic surgical volume. Results We provide evidence that the average yearly volumes of all but one oculoplastic procedure without ACGME minimum requirements have been decreasing. The decreases in volume for these procedures are driven by residents having fewer cases both as primary surgeon and as assistant. In addition, while the total number of ophthalmic procedures logged by residents on average increased (β = 7.519, p = 0.0163), the average volume of total oculoplastic procedures did not demonstrate any statistically significant trends. Conclusions Volumes of oculoplastic procedures without ACGME minimum requirements between 2009 and 2021 have been decreasing among ophthalmology residents.

Performing research and publishing in the peer-reviewed medical literature should be a requirement for completion of post-graduate residency and fellowship training.

Graduate medical education (GME) in the USA is an increasingly organized and formalized process overseen by regulatory bodies, notably the American Council of Graduate Medical Education (ACGME), and associated specialty-specific Residency Review Committees (RRCs) to ensure that trainees, including residents and fellows, receive comprehensive, high-quality didactic education, clinical training, and research experience. Among the required elements of GME, performance of independent research is emphasized less than clinical and didactic education. In general, there are no ACGME requirements that trainees successfully publish papers in the peer reviewed. Indeed, unlike as is the case with procedure case logs, there are no minimum thresholds for specific numbers of abstracts presented, posters accepted, or manuscripts published. As such, while residencies and fellowships in certain disciplines or institutions may require considerable, documented research activity, others may not. Since future attending physicians are expected to be experts in their fields, able to digest relevant medical knowledge, critically evaluate emerging findings in the literature, and lead multi-professional healthcare teams, they must have a level of facility with the medical literature than can only be acquired by having performed research and having published papers themselves. Publishing one paper during training is easily attainable for all trainees. Having this be an ACGME requirement will necessitate protected time, research methods education, and mentorship for trainees. This can be accomplished without disrupting the other elements of resident and fellow training. From an ACGME perspective, required scholarly activity will support the competencies of practice-based learning and improvement as well as professionalism. In lay terms, benefits will be a higher level of education and attainment for trainees, and a potentially higher standard of health care for our patients.

Acute-onset postoperative endophthalmitis after cataract surgery performed by resident and attending physicians at a university teaching hospital.

To evaluate acute-onset postoperative endophthalmitis following cataract surgery and to compare rates between resident and attending physician-performed cohorts. Bascom Palmer Eye Institute, Miami, Florida. Retrospective chart review. Records of patients diagnosed with endophthalmitis within 6 weeks of surgery performed by attending and resident physicians between January 1, 2015, and December 31, 2020, were reviewed. Total cataract volume was obtained from institutional records, and resident case totals were obtained from case logs. Endophthalmitis cases were obtained from billing records and confirmed with chart review. There were 22 cases of endophthalmitis among 32 505 cases (0.068%). Endophthalmitis occurred in 6 of 6447 (0.093%) resident cases and 16 of 26 058 (0.061%) attending cases ( P = .55). The most common bacterial isolates were coagulase-negative Staphylococcus (8/22, 36.3%) and Streptococcus species (3/22, 13.6%), with negative cultures in 10 (10/22, 45.5%). Initial treatment with vitreous tap and injection of intravitreal antibiotics was performed in 21 eyes (21/22, 95.4%) and vitrectomy with intravitreal antibiotic injection in one (1/22, 4.5%). Vitrectomy was performed secondarily in 9 patients (9/22, 40.9%). Corrected distance visual acuity (CDVA) at last follow-up was ≥20/40 in 13 eyes (13/22, 59%) and ≤hand motions in 3 eyes (3/22, 13.6%). CDVA (logMAR mean ± SD) was 1.22 ± 1.16 in resident and 0.49 ± 0.79 in attending cases ( P = .11). In the current study, acute-onset postoperative endophthalmitis developed infrequently following cataract surgery. The rates and visual outcomes of endophthalmitis were similar in resident and attending cases.

Ophthalmology Resident Oculofacial Surgery Case Exposure: An ACGME Case Log Analysis.

The authors quantified trends in resident oculofacial surgery exposure between 2009 and 2018, reviewed specific procedure volume, and correlated procedure volume with program characteristics. The authors requested de-identified case logs of residents graduating US ophthalmology residency programs in 2018 from all 118 programs. Current Procedural Terminology codes of all oculofacial procedures were analyzed. Current Procedural Terminology codes were grouped into 25 unique categories that the authors created in addition to the 11 Accreditation Council for Graduate Medical Education categories. One hundred and sixty-six of 488 (34%) US ophthalmology residents graduating in 2018 provided case logs (32.2% of programs). According to Accreditation Council for Graduate Medical Education case logs, residents graduating in 2018 completed significantly fewer eye removal/implant procedures, lacrimal surgeries, "other orbital" procedures, entropion/ectropion repairs, and temporal artery biopsies as primary surgeon than residents graduating in 2009, yet significantly more eyelid laceration repairs, chalazion excisions, tarsorrhaphies, ptosis repairs, and blepharoplasty/reconstruction procedures ( p < 0.05). No difference was found between the total number of oculofacial cases between 2009 and 2018 ( p = 0.051). The most frequently logged procedure per resident in the sample was blepharoplasty/reconstruction (17.2 ± 15) followed by "other oculoplastic" (12.7 ± 10.6). The least commonly performed procedures included temporal artery biopsy (1.5 ± 2.2) and "other orbital" (1.9 ± 3.1). Program size, location, and presence of oculofacial fellowship program all impacted case volume. Oculofacial surgery has the second highest case number requirement for residents per Accreditation Council for Graduate Medical Education guidelines. However, resident exposure to oculofacial surgery cases greatly varies in each ophthalmology residency program.

The Impact of the Maritime Deployment Cycle on the Surgeon's Knowledge, Skills, and Abilities.

The U.S. Navy routinely deploys aircraft carriers and amphibious assault ships throughout the world in support of U.S. strategic interests, each with an embarked single surgeon team. Surgeons and their teams are required to participate in lengthy pre-deployment shipboard certifications before each deployment. Given the well-established relationship of surgeon volume to patient outcome, we aim to compare the impact of land vs. maritime deployments on Navy general surgeon practice patterns. Case logs and pre-deployment training initiation of land-based (n = 8) vs. maritime-based (n = 7) U.S. Navy general surgeons over a 3-year period (2017-2020) were compared. Average cases per week were plotted over 26 weeks before deployment. Student's t-test was utilized for all comparisons. Cases declined for both groups in the weeks before deployment. At 6 months (26 weeks) before deployment, land-based surgeons performed significantly more cases than their maritime colleagues (50.3 vs. 14.0, P = .009). This difference persisted at 16 weeks (13.1 vs. 1.9, P = .011) and 12 weeks (13.1 vs. 1.9, P = .011). Overall, surgeon operative volume fell off earlier for maritime surgeons (16 weeks) than land-based surgeons (8 weeks). Within 8 weeks of deployment, both groups performed a similarly low number of cases as they completed final deployment preparations. Surgeons are a critical component of combat causality care teams. In this analysis, we have demonstrated that both land- and maritime-based U.S. Navy surgeons have prolonged periods away from clinical care before and during deployments; for shipboard surgeons, this deficit is large and may negatively impact patient outcomes in the deployed maritime environment. The authors describe this discrepancy and provide practical doctrinal solutions to close this readiness gap.

Do General Surgery Residents Begin Specializing Before Fellowship? A Multi-Institutional Study from the US ROPE Consortium.

Single-center data suggest that general surgery residents perform more cases related to their future fellowship compared with their peers. This study aimed to determine whether this experience was true for residents across multiple programs. Data from graduates of 18 Accreditation Council for Graduate Medical Education (ACGME)-accredited general surgery residency programs in the US Resident OPerative Experience (ROPE) Consortium were analyzed. Residents were categorized as entering 1 of 12 fellowships or entering directly into general surgery practice. Case log operative domains were mapped to each fellowship, and analyses were performed between groups. Of 1,192 graduated general surgery residents, 955 (80%) pursued fellowship training whereas 235 (20%) went directly into general surgery practice. The top 3 fellowships pursued were trauma/surgical critical care (18%), vascular surgery (13%), and minimally invasive surgery (12%). Residents entering minimally invasive surgery performed the most total cases, whereas residents pursuing breast performed the least (1,209 [1,056-1,325] vs 1,091 [1,006-1,171], p &lt; 0.01). For each fellowship type, graduates completed more total fellowship-specific cases in their future specialty compared with their peers (all p &lt; 0.05). This association was observed for all 12 fellowships at the surgeon chief level (all p &lt; 0.05) and for 10 of 12 fellowships at the surgeon junior level (all p &lt; 0.05). General surgery residents perform more cases related to their future specialty choice compared with their peers. These data suggest that the specialization process begins during residency. This tendency among residents should be considered as general surgery residency undergoes structural redesign in the future.

A Decade of Surgery Aboard the U.S. Naval Ship COMFORT (T-AH 20).

The U.S. Naval Ship COMFORT has performed six humanitarian assistance and disaster relief mission since 2007. This paper describes the surgical volume per surgical specialty for five missions spanning 19 countries. Raw surgical case logs were analyzed for total case volume, total operating days, unanticipated return to operating room, and percentage of pediatric cases (<18 years old) for each country visited. Total surgical volume for the five missions was 5,142. The countries most frequently visited were Columbia and Haiti with seven and five visits, respectively. General surgery, ophthalmology, and plastic surgery have had consistent volume over time. Orthopedic surgery volume has steadily decreased with the exception of the 2018 mission. As volume in military treatment facilities declines, alternative sources of surgical volume for military surgeons are being examined. This paper highlights the historical volume which can inform future personnel planning requirements of U.S. Naval Ship COMFORT missions. With the exception of orthopedic surgery, surgical volume has remained consistent over the last decade. For future best practice, historical case data should be used to determine staffing needs on hospital ships and case logs and operating procedures and follow-up protocols should be standardized.

The Impact of Relocating a Trauma Center: Observations on Patient Injury Demographics and Resident Volumes.

Introduction Changing the physical zip code location of an academic trauma center may affect the distribution and surgical volume of its trauma patients. General surgical residency case log requirements may also be affected. This study describes the impact of moving a level I trauma center to a different zip code location, on the hospital and resident trauma case volumes. Methods This retrospective analysis included all patients within the local trauma registry across two fiscal years representing the pre- and post-move timeframes. Variables collected included patient basic sociodemographic and injury information, trauma activation level and transfer status, management (operative management [OPM] versus non-operative management [NOPM]), and resident case logs. Results During fiscal years 2016-2017 and 2017-2018, 3,025 patients were included. Pre-move and post-move trauma volumes were 1,208 and 1,817 respectively. Post-move changes demonstrated differences in basic sociodemographics, with differences in age (six years older), a shift towardwhite and away from black (12.89%), and males being seen more frequently (11.87%). Injury severity score distribution shifted (7.72%) towards less severe trauma scores (<15), the percentage of patients with blunt trauma (4.19%) and falls increased (ground level and greater than 1 meter, 9.78%) while the number of patients considered full activations were decreased (15.67%). Proportions of OPM and NOPM trauma cases remained unchanged with the exception of a reduction in emergent operative trauma (3.1%). Resident case logs requirements were met both pre- and post-move. Conclusion Relocating the trauma center to a different zip code location did not negatively impact our resident case volumes. Total trauma volumes were increased, with a shift in the demographics and severity distribution of injuries.

Microsurgical Management of Vestibular Schwannoma (Acoustic Neuroma): Facial Nerve Outcomes, Radiographic Analysis, Complications, and Long-Term Follow-Up in a Series of 420 Surgeries

The purpose of this study is to retrospectively evaluate the clinical and surgical outcomes of a large surgical series of vestibular schwannoma from North America over 20years. After institutional review board approval a retrospective review of the senior author's personal case logs to identify patients who had operations for vestibular schwannoma was performed. The clinical notes, operative record, preoperative and postoperative imagings, and long-term clinical follow-up notes were evaluated. A total of 415 patients who underwent 420 surgeries were identified from the years 1998-2021. The average length of follow-up was 3years and 9months. Overall, at last follow-up the rate of "good" facial nerve outcomes (House-Brackmann [HB] score I and II) was 86% and "poor" facial nerve outcomes (HB III-VI) was 14%. The amount of cerebellopontine angle extension (P= 0.023), tumor volume (P= 0.015), facial nerve consistency (P < 0.001), preoperative HB score (P < 0.001), and FN stimulation threshold at the end of the procedure (P < 0.001) were correlated to facial nerve function at the last follow-up. This study represents one of the largest recently reported surgical series of vestibular schwannoma in North American literature with available long term follow-up. Facial nerve outcomes correlated with cerebellopontine angle extension, tumor volume, facial nerve stimulation threshold, facial nerve consistency, preoperative facial nerve function, and history of a prior resection. Tumor recurrence remains significantly higher after subtotal resection. We believe the data supports a continuation of a strategy of general intent of gross total resection, greatly modifiable by intraoperative findings and judgment.

Automating Anesthesiology Resident Case Logs Reduces Reporting Variability.

The Accreditation Council for Graduate Medical Education (ACGME) case log system for anesthesiology resident training relies on subjective categorization of surgical procedures and lacks clear guidelines for assigning credit roles. Therefore, resident reporting practices likely vary within and between institutions. Our primary aim was to develop a systematic process for generating automated case logs using data elements extracted from the electronic health care record. We hypothesized that automated case log reporting would improve accuracy and reduce reporting variability. We developed a systematic approach for automating anesthesiology resident case logs from the electronic health care record using a discrete classification system for assigning credit roles and Anesthesia Current Procedure Terminology codes to categorize cases. The median number of cases performed was compared between the automated case log and resident-reported ACGME case log. Case log elements were identified in the electronic health care record and automatically extracted. A total of 42 individual case logs were generated from the extracted data and visualized in an external dashboard. Automated reporting captured a median of 1226.5 (interquartile range: 1097-1366) total anesthetic cases in contrast to 1134.5 (interquartile range: 899-1208) reported to ACGME by residents (P = .0014). Automation also decreased the case count interquartile range and the distribution approached normality, suggesting that automation reduces reporting variability. Automated case log reporting uniformly captures the resident training experience and reduces reporting variability. We hope this work provides a foundation for aggregating graduate medical education data from the electronic health care record and advances adoption of case log automation.

Low Ankle Arthroscopy Procedural Volume Amongst Graduating Orthopedic Surgery Residents

Category: Ankle; Arthroscopy; Sports Introduction/Purpose: The purpose of this study was to evaluate trends in graduating orthopedic resident case volume and variability for ankle arthroscopy. Methods: The Accreditation Council for Graduate Medical Education surgical case log data from 2016 to 2020 for graduating United States orthopedic surgery residents was assessed. Arthroscopy procedures of the leg/ankle were identified. The average number of cases performed per resident was compared from 2016 to 2020 to determine the percent change in case volume. The 10th, 30th, 50th, 70th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability. Results: There was no significant change in the average number of leg/ankle arthroscopy cases from 2016 to 2020 [6.2 +- 5 [range 0 to 35] vs. 6.1 +- 6 [range 0 to 76] [p=0.732], despite a 19% increase in the average number of total leg/ankle procedures performed over time (168.4 +- 47 [range 55-414] in 2016; 200.8 +- 57 in 2020 [range 67-601], p &lt;0.001). There was wide variability in ankle arthroscopy case volume amongst residents. The 90th percentile of residents performed 13 cases in 2020, compared to 5 in 50th percentile, and 1 in the 10th percentile. Conclusion: Despite the growing popularity of ankle arthroscopy, orthopedic resident exposure to this technical procedure remains generally low. Understanding trends in case volume and variability is important for programs to ensure that orthopedic residents are gaining adequate exposure to increasingly popular procedures. Implementing minimum case requirements for ankle arthroscopy during orthopedic residency may be helpful to increase exposure to ankle arthroscopy and reduce variability in experience.