Experience Of General Surgery Residents Research Articles

Assessment of Operative Experience of General Surgery Residents of Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia

Background: The Zwisch Score is a recognized tool for objectively assessing resident competency, particularly in measuring faculty guidance. However, there hasn't been a study in Ethiopia yet to assess surgical residents' operative experience using this standardized objective method. Objective: To assess the operative experience of general surgery residents’ using Zwish score in Yekatit 12Hospital Medical College. Methods: A cross-sectional study design was employed, involving all general surgery residents enrolled in the residency program at Yekatit 12 Hospital Medical College from January 2020 to January 2023. Primary data collection utilized online shared questionnaires, with data entry and analysis conducted using SPSS. Result: In Yekatit 12Hospital Medical College, there are 18 Surgeons and 44 surgery residents. Senior residents tend to give junior residents scores of show and tell (33.3% for year 1, 50% for year 2), while year 1 residents most commonly rate themselves as providing active help (18.4%), and year 2 residents rate themselves as show and tell (59.3%). When comparing senior residents' scores with their own, seniors commonly rate themselves as providing passive help (30% for year 3, 65.4% for year 4), and residents rate themselves similarly (31% for year 3, 62.1% for year 4). Conclusion: There are variations between scores given by junior residents and seniors, but senior residents' self-assessments align closely with those of the seniors. This suggests that residents tend to accurately evaluate their skills as they progress through their residency.

The Effect of Intersectionality on Attrition among US General Surgery Trainees.

To examine the association between intersectionality of race, ethnicity, and sex on retention of U.S. general surgery residents. There are limited data on the role that intersectionality plays on the US general surgery resident experience. Analysis was performed using Association of American Medical Colleges (AAMC) data for general surgery residents who started their training between 2005-2015 (followed through completion). Regression analyses were used to assess demographic associations with time to attrition or successful completion of residency training. Associations between faculty and resident demographics were assessed. 25,029 residents were included. Over the decade-long study period, the number of underrepresented in medicine (UIM) residents as a percentage of all residents remained similar from 17% to 19% (P=0.24). The percent of UIM males starting training in 2005 was 11% and 12% in 2015 (P-value=0.38). UIM females comprised 5.5% of trainees in 2005 and increased to 6.9% (P-value=0.003) in 2015; and female non-UIM residents increased from 23 to 28% (P-value<0.001). The overall rate of resident attrition was 15%. UIM females had the highest yearly attrition rate at 21% compared to non-UIM males at 13% (HR 1.7, P<0.001). UIM females were more likely to leave residency compared to UIM males (HR: 1.5; P<0.001). The percent of UIM faculty was positively correlated with percent of UIM residents (r=0.64, P<0.001). Increasing intersectionality is positively associated with attrition during surgery residency. The diversity of faculty appears to be associated with resident diversity.

A multi-institutional study from the US ROPE consortium examining factors associated with endocrine surgery exposure for general surgery residents

BackgroundPrior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not. MethodsWe analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period. ResultsOf the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8–12, P < .01), endocrine-trained faculty (+8, confidence interval 7–10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 –8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2–6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (–10, confidence interval –12 to –8, P < .01) and endocrine-focused otolaryngologists (–3, confidence interval –4 to –1, P < .01). ConclusionSeveral characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.

Trend of minimally invasive and open surgery experience of general surgery residents: Accreditation Council for Graduate Medical Education general surgery case log in Thailand.

Minimally invasive surgery (MIS) offers patients several benefits, such as smaller incisions, and fast recovery times. General surgery residents should be trained in both open and MIS. We aimed to examine the trends of minimally invasive and open procedures performed by general surgery residents in Thailand. A retrospective review of the Royal College of Surgeons of Thailand and Accreditation Council for Graduate Medical Education general surgery case logs from 2007 to 2018 was performed for common open and laparoscopic general surgery operations. The data were grouped by three time periods, which were 2007-2010, 2011-2014, and 2015-2018, and analyzed to explore changes in the operative trends. For Thai residents, the mean number of laparoscopic operations per person per year increased from 5.97 to 9.36 (56.78% increase) and open increased from 20.02 to 27.16 (35.67% increase). There was a significant increase in the average number of minimally invasive procedures performed among cholecystectomy (5.83, 6.57, 8.10; p < 0.001) and inguinal hernia repair (0.33, 0.35, 0.66; p < 0.001). Compared to general surgery residents in the United States, Thai residents had more experience with open appendectomy, but significantly less experience with all other operations/procedures. The number of open and minimally invasive procedures performed or assisted by Thai general surgery residents has slowly increased, but generally lags behind residents in the United States. The Thai education program must be updated to improve residents' technical skills in open and laparoscopic surgery to remain competitive with their global partners.

Lived Experiences of Mistreatment in a General Surgery Residency

Explore the lived experiences of General Surgery residents to identify how they perceive, define mistreatment, and which factors can contribute to or mitigate mistreatment within the Clinical Learning Environment. This is a phenomenological study conducted during 2019-2020 using Giorgi's psychological descriptive phenomenology methodology. Researcher bias, trustworthiness, and triangulation were addressed using bracketing, check-ins with program leadership, comparisons to resident survey, and team consensus based on Consensual Qualitative Research. General Surgery Residency program at Long School of Medicine, UT Health San Antonio, Texas. All residents in the general surgery program were invited to participate (n= 66, 43% female and 63% non-Hispanic). Specific demographic and identifying data for each participant was not collected. Approximately 50 (76% of program) residents from General Surgery participated. We were able to identify four themes that helped to delineate the lived experience of residents including program cultural factors, resident internal processing, and perceived effects of mistreatment by the residents. The resulting psychological structure and conceptual framework help clarify the interrelations between the themes and the Clinical Learning Environment. The scenarios discussed were adapted and depersonalized to use as prompts for the Forum Theater intervention. This project set out to explore resident's lived experiences and allow the data to reveal the main outcomes. The data was coded and analyzed following strict guidelines from descriptive psychological phenomenology and Consensual Qualitative Research with the aim of informing a later experiential intervention based on Forum Theater. The lived experience of general surgery residents helped identify cultural factors and behaviors that contribute to and/or mitigate mistreatment providing information to plan interventions at the resident and faculty level. Mitigating or stopping mistreatment can improve the Clinical Learning Environment and hence, the quality of training.

Trends in General Surgery Resident Experience with Colorectal Surgery: An Analysis of the Accreditation Council for Graduate Medical Education Case Logs

Colorectal surgery is a core component of general surgery. The volume of colorectal surgery performed by general surgery residents throughout training has not been studied. This study aims to analyze trends observed in colorectal-specific case numbers logged by general surgery residents over 16 years. Case number data for general surgery residents was extracted from the publicly available, annually published Accreditation Council for Graduate Medical Education (ACGME) database from 2003 to 2019. Cases were categorized as open or laparoscopic colectomy/proctectomy, colectomy with ileoanal pull-thru, abdomino-perineal resection (APR), transanal rectal tumor excision (TRE), anorectal procedure, colonoscopy, and total colorectal cases. The average case numbers per category was calculated for each year. Linear regression analyzed trends in case categories for all residents and those logged as surgeon chief and junior residents. ACGME accredited general surgery residency programs. Not applicable. General surgery residents reported increased numbers of all, chief, and junior resident colorectal cases over the study period (124.5-173.7 cases/yr; 38.4-53.0 cases/yr; 86.4-120.6 cases/yr, all p = 0.00). Average cases for all, chief, and junior residents have increased for laparoscopic colectomy/proctectomy (4.6-26.4 cases/year; 2.7-12.9 cases/year; 2.0-13.5 cases/year, all p = 0.00), anorectal surgeries (26.7-37.7 cases/year; 5.4-9.9 cases/year; 21.3-27.8 cases/year, all p = 0.00), and colonoscopies (35.9-70.6 cases/year, p = 0.00; 6.6-14.1 cases/year, p = 0.01; 29.4-56.5 cases/year, p = 0.00). Average cases for all, chief, and junior residents have decreased for open colectomy/proctectomy (52.0-34.9 cases/year; 21.2-14.3 cases/year; 30.9-20.6 cases/year, all p = 0.00), APR (3.3-2.7 cases/year, p = 0.00; 1.8-1.3 cases/year, p = 0.00; 1.5-1.4 cases/year, p = 0.02), TRE (1.9-1.1 cases/year; 0.7-0.4 cases/year; 1.2-0.6 cases/year, all p = 0.00). Ileoanal pull-thru did not demonstrate a linear trend. The increase in exposure to colectomies/proctectomies, anorectal procedures and colonoscopies is encouraging, as these common colorectal operations will be encountered in general surgery practice. The observed low case numbers for TRE, APR, and ileoanal pull-thru suggest a need for specialized training.

Examining the impact of COVID-19 restrictions on the operative volumes of US general surgery residents

BackgroundIn March 2020, the COVID-19 virus global pandemic forced healthcare systems to institute regulations including the cancellation of elective surgical cases, which likely decreased resident operative experience. The objective of this study was to determine whether the COVID-19 pandemic affected operative experiences of US general surgery residents. MethodsThe operative experience of general surgery residents was examined nationally and locally. Aggregate Accreditation Council for Graduate Medical Education (ACGME) case logs for 2018 to 2019 (pre-COVID) and 2019 to 2020 (COVID) graduates were compared using national mean cumulative operative volume for total major and surgeon chief cases. Locally, ACGME case logs were used to analyze the operative experience among residents at a single, academic center. Average operative volumes per month per resident during peak COVID-19 quarantine months were compared with those the previous year. ResultsCompared with 2019 graduates, 2020 graduates completed 1.5% fewer total major cases (1055 ± 155 vs 1071 ± 150, P = .011). This was most evident during chief year, with 8.4% fewer surgeon chief cases logged in 2020 compared with 2019 (264 ± 67 vs 289 ± 69, P < .001). Institutional data revealed that during the peak of the pandemic, residents across all levels completed 42.5% fewer total major operations (12 ± 11 vs 20 ± 14, P < .001). This effect was more pronounced among junior residents compared with senior and chief residents. ConclusionThe COVID-19 pandemic was associated with decreased resident case volume. The ramifications of the COVID-19 pandemic for operative competency and autonomy should be carefully examined.

Are General Surgery Residencies Preparing Graduates for the Practice of Today's General Surgeon? An Analysis of American Board of Surgery Data From Applicants and Re-certifying Surgeons.

To compare the operative experience of general surgery residents and practicing general surgeons. The scope of general surgery has evolved, yet it remains unknown whether residents are being exposed to the right mix of operations during residency. A retrospective review of operative case logs submitted to the American Board of Surgery by US general surgery graduates and practicing general surgeons from 2013 to 2017 was performed. The operative experience of both cohorts was calculated as a proportion of total experience and ranked by frequency. The proportional experience between cohorts was analyzed using factorial analysis of variance. During the 5-year period, 5482 graduates applied for initial American Board of Surgery certification, and 4152 diplomates applied for recertification. Among all operative domains, the graduate experience was similar to that of diplomates in 6 of 12 areas (abdomen, alimentary tract, endoscopy, endocrine, other, skin/soft tissue; all P > 0.05). Residents have a greater experience in subspecialty areas (pediatric, thoracic, trauma, vascular, and plastic) at the expense of fewer breast procedures (all P < 0.05). The 30 operations most commonly performed by graduates comprised 67% of their total operative experience. Among these, residents performed 25 cases ≥10 times, 14 cases ≥20 times, and 7 cases ≥40 times. The operative experience of graduating US general surgery residents is largely similar to that of practicing general surgeons, particularly for core general surgery domains. These data offer reassurance that surgical training in the modern era appropriately exposes residents to the operations they may perform in practice.

The ups and downs of general surgery resident experience in endocrine surgery: Analysis of 30 years of ACGME graduate case logs

The aim of this study was to determine trends in the experience of general surgery residents with endocrine surgery cases. American Association of Endocrine Surgeons national general surgery case logs from 1989 through 2019 were reviewed. The numbers of individuals completing residency and the mean and median number of endocrine surgery cases by type and by level of operating resident surgeon were abstracted from annual data and analyzed. Descriptive statistics and linear regression analyses were performed modeling endocrine surgery cases over time and stratified by procedure type and resident level. The number of individuals completing general surgery residency each year increased from 981 to 1,219 (P < .001). The average total number of endocrine surgery cases performed increased from 17 to 33.2 (P < .001) but has declined since its peak at 36.9 in 2010 to 2011 (P= .014). Thyroid operations increased from 11.4 to 19.8 (P < .001) but peaked at 23.5 in 2010 to 2011 and have since declined (P < .001). Parathyroid operations more than doubled from 4.2 to 9.7 (P < .001). Adrenal operations increased from 1 to 2.2 (P < .001) and pancreatic endocrine operations increased from 0.2 to 1.5 (P < .001). Surgeon Chief endocrine surgery cases peaked at 14.4 in 2003 to 2004 but have since declined by 22.2% (P < .001). Surgeon Junior endocrine surgery cases increased overall (P < .001) but peaked at 22.8 in 2011 to 2012. There was increasing heterogeneity over time in trainee experience (P < .001). After having increased for 2 decades, the number of endocrine surgery cases performed by general surgery residents is currently in decline. Possible contributing factors include growth in the number of general surgery residents, variable and narrowed case mix, and encroachment by other learners.

Intersectionality of Gender and Visible Minority Status Among General Surgery Residents in Canada

Within medical specialties, surgical disciplines disproportionately and routinely demonstrate the greatest underrepresentation of women and individuals from racial/ethnic minority groups. Understanding the role that diversity plays in surgical resident training may identify strategies that foster resident resiliency, optimize surgical training, and improve patient outcomes. To examine the implication of gender and visible minority (VM [ie, nonaboriginal people who are not White individuals]) status for resiliency and training experiences of general surgery residents in Canada. In this survey study, a 129-item questionnaire was emailed from May 2018 to July 2018 to all residents enrolled in all Canadian general surgery training programs during the 2017-2018 training year. Survey responses were extracted and categorized into 5 major themes. The survey was designed by the Resident Committee and reviewed by the Governing Board of the Canadian Association of General Surgeons. French and English versions of the survey were created, distributed, and administered using Google Forms. Survey questions were formulated to characterize resident diversity and training experience. Self-perceptions of diversity, mentorship, and training experience were evaluated using a 5-point Likert scale (1 for strongly disagree, 2 for disagree, 3 for neither agree or disagree, 4 for agree, and 5 for strongly agree) and open-ended responses. The frequency of perceived unprofessional workplace encounters was evaluated using a 5-point scale (1 for daily, 2 for weekly, 3 for monthly, 4 for annually, and 5 for never). Of the 510 general surgery residents invited, a total of 210 residents (40.5%) completed the survey. Most respondents were younger than 30 years (119 [56.7%]), were women (112 [53.3%]), reported English as their first language (133 [63.3%]), did not identify as a VM (147 [70.0%]), had no dependents (184 [87.6%]), and were Canadian medical graduates (178 [84.8%]). Women residents who identified as VM compared with male residents who did not identify as a VM were less likely to agree or strongly agree that they had a collegial relationship with staff, (21 [63.6%] vs 61 [89.7%]; P = .01), to feel like they fit in with their training programs (21 [63.6%] vs 56 [82.3%]; P = .003), and to feel valued at work (15 [45.4%] vs 47 [69.1%]; P = .03). Both female residents and female residents who identified as VM described significant concerns about receiving fewer training opportunities because of their gender vs their male peers (54 [48.2%] vs 3 [3.0%]; P < .001). Ninety-one of 112 female residents (81.2%) reported feeling that their medical expertise was dismissed because of their gender at least once annually, with 37 women (33.0%) experiencing dismissal of their expertise at least once every week (P < .001). In contrast, 98% of male residents reported never experiencing dismissal of their medical expertise because of their gender. Similarly, residents with VM status vs those without VM status reported at least monthly dismissal of their expertise because of their race/ethnicity (9 of 63 [14.3%] vs 1 of 147 [0.7%]; P < .001). In this study, female sex and VM status appeared to be associated with adverse implications for the training experience of general surgery residents. These findings suggest that new strategies focused on the intersectionality of gender and race/ethnicity are needed to improve the training experience of at-risk residents.

More of less: General Surgery Resident Experience in Biliary Surgery

The scope of operations performed by surgery residents has progressively narrowed. This analysis was undertaken to determine the degree to which that narrowing has occurred in one particular operative domain-biliary surgery. The total numbers of major cases and biliary cases by resident role were abstracted from annual ACGME national case log reports from 1989 to 1990 through 2017 to 2018, as were the number of total operations performed by residents in each biliary case category. Trends were analyzed. The total numbers of major cases and biliary cases performed throughout residency have increased considerably. For chief residents, the total number of major cases has declined, but the total number of biliary cases has increased slightly. The increase in the total number of biliary cases performed is due entirely to laparoscopic cholecystectomy. All other types of biliary operations have decreased substantially in number and are now performed rarely. For 2018 graduates, laparoscopic cholecystectomy accounted for 11.2% of all major operations throughout residency and 11.7% of chief resident operations. Resident operative experience in biliary surgery has increased considerably both in absolute numbers and as a proportion of overall operative experience, but is increasingly limited to laparoscopic cholecystectomy.

A review of general surgery resident experience in common bile duct exploration in the ERCP era

BackgroundUse of minimally invasive techniques for management of common bile duct (CBD) stones has led to declining number of CBD explorations (CBDE) performed at teaching and non-teaching institutions. We evaluate the impact of this decline on surgery training in bile duct procedures. Study designNational operative data for general surgery residents (GSR) were examined from 2000 to 2018. Biliary operations including, cholecystectomy open and laparoscopic, and CBDE open and laparoscopic were evaluated for mean number of cases per graduating GSR. ResultsDespite increases in number of GSR, case numbers for laparoscopic cholecystectomy increased 39% from 84 to 117, p < .00001, per GSR. Mean number of cases for open CBDE, however, decreased 74% from 2.7 to 0.7, p < .00001, per GSR and laparoscopic CBDE declined 22% from 0.9 to 0.7 per resident. ConclusionGSR operative case volume in CBDE has declined significantly creating a training deficiency for this complex skill. Novel simulation, including fresh cadavers, may offer the best option with high-fidelity, dynamic training to mitigate the loss of low volume, high acuity procedures.

Review of General Surgery Resident Experience in Common Bile Duct Exploration in the ERCP Era

Warner, Rachel DO; Bardes, James MD; Borgstrom, David C. MD, MBA, FACS; Grabo, Daniel J. MD, FACS Author Information

Trends in resident operative trauma: How to train future trauma surgeons?

BackgroundTrauma is an essential content area of general surgery residency. The objective of this study was to assess trends in the operative trauma experience by general surgery residents. MethodsThis was a retrospective review of available ACGME case log reports (the past 29 years) for general surgery residents. ResultsOver the study period, the total operative trauma cases as surgeon decreased from 79.6 to 29.9, (p < 0.001), gastrointestinal cases decreased from 10.6 to 4.0, (p < 0.001), and vascular cases decreased from 8.6 to 4.5, (p < 0.001). The median number of trauma cases in which residents reported a teaching assistant role fell from 5 to 1 (p < 0.001) and as a first assistant declined from 17 to 1 (p < 0.001). ConclusionsOver the past 29 years, the operative trauma experience of general surgery residents has dramatically decreased. The decline is multifactorial but brings sharp focus on resident education in operative trauma.

General surgery resident experience with anorectal surgery

BackgroundPrevious studies have suggested that general surgery residents graduate with suboptimal anorectal experience. However, competence in anorectal procedures is an important part of general surgery training. MethodsACGME general surgery resident case logs from 1999 to 2017 were reviewed. Mean number of anorectal procedures were evaluated, comparing Period 1 (1999–2008) and Period 2 (2009–2017). ResultsBetween 1999 and 2017, the mean number of all anorectal procedures performed by each general surgery resident has increased from 25.9 to 32.4 (by 25%). Between Period 1 and 2, mean numbers of total anorectal procedures, abscess drainage, fistula repair, hemorrhoidectomy, prolapse repair, other anorectal procedures all increased (p ≤ 0.01). Mean numbers of sphincterotomy/sphincteroplasty and other procedures for fecal incontinence significantly decreased (p ≤ 0.01). ConclusionsGeneral surgery residents have gained more experience in some anorectal procedures over time. The required number of procedures to establish competence is not well defined and should be formally evaluated.

See None, Do Some, Teach None: An Analysis of the Contemporary Operative Experience as Nonprimary Surgeon

The operative experience of today's general surgery resident has changed, but little is known about the modern experience as nonprimary surgeon. We set out to explore changes in the operative experience of general surgery residents as first assistant (FA) and teaching assistant (TA). This is a review of ACGME national operative log reports from 1990 to 2018. TA and FA cases were analyzed. Statistical analysis was performed using polynomial regression analysis and Kruskal-Wallis test. Statistical significance was set at p < 0.05. 30,260 individuals completed general surgery residency during the study period with medians of 951 (interquartile range: 929-974) total major, 63 (31-184) FA, and 32 (25-48) TA cases. As a proportion of total cases completed, FA cases decreased from 21.8% of the total operative experience in 1990 to 2.5% in 2018, and TA cases declined from 7.4% of the total operative experience in 1990 to 3.5% in 2018. Regression modeling demonstrated that both operative roles decreased over time, but at a progressively decreasing rate, with FA cases reaching a "floor" around 2010 and TA cases reaching a "breakpoint" in 2008 at which time operative volume rebounded and began to increase. Among the core general surgery domains of abdomen and alimentary tract, compositional analysis revealed a decrease across each of the 11 operative subcategories (all p < 0.05) for FA, and for TA, a decrease in 6 of the 11 operative subcategories (stomach, small intestine, large intestine, anorectal, hernia, and biliary, all p < 0.05). Over the past 3 decades, the resident operative experience as nonprimary surgeon has decreased dramatically, with today's residents graduating with fewer FA and TA cases. As surgical training has traditionally relied heavily on an apprenticeship model for learning technical skills, it is essential that surgical educators recognize and rectify these trends.

Complex hepato-pancreato-billiary (HPB) caseload during general surgery residency training: Are we adequately training the next generation?

Background: Hepato-pancreato-biliary (HPB) procedures are considered among the most technically complex procedures to teach, requiring repetition and procedural volume to obtain proficiency. Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations, increasing emphasis on quality and efficiency, and regionalization of care may impact the HPB experience of general surgery residents. We sought to define overall numbers, as well as recent trends, in HPB surgical volume among general surgery residents. Methods: The ACGME case log database was used to obtain data on graduating resident procedural volumes between 1999 and 2016. Data on liver cases (lobectomy, segmentectomy and wedge resection), pancreas (pancreatoduodenectomy, distal pancreatectomy), and biliary (common bile duct exploration, choledochoenteric anastomosis) procedures were obtained. Trends in average HPB operative volume, as well as changes in operative volume stratified by resident role (surgeon chief, surgeon junior) were examined over time. Results: During the time period analyzed, the number of general surgery residency programs varied between 240 and 253; the average number of graduating chief residents (GCR) at each program increased over time (1999: 3.9 vs. 2016: 4.8). A total of 388,502 HPB cases (36% liver, 42.6% pancreas, 21.4% biliary) were performed by 19,031 graduating chief residents (GCR) over the 18 years examined (mean number of total HPB cases 20.4 per GCR). The average number of HPB cases among GCR was: liver, 7.4 (range: 6.7 to 8.2), pancreas 6.3 (range: 4.5 to 8.1), and biliary 4.5 (range: 2.8 to 6.8). Most HPB cases were performed during the chief years (58%), while a smaller proportion (42%) were done during the junior years. While the mean number of HPB cases logged as a junior resident remained stable over time over time (1999: 7.9 vs. 2016: 8.0), the vast majority of HPB cases were logged as senior resident cases. The total number of cases increased from 18,778 (mean 18.9) in 1999 to 23,978 (mean 19.8) in 2016. The minimum average number of liver and pancreas cases per resident was 3.1 and 4.5, respectively, in 1999; the mean number of liver and pancreas cases among GCR peaked at 8.2 and 8.1, respectively, in 2008 and has subsequently plateaued (Figure). In contrast, the mean number of complex biliary cases among GCR was highest at 6.6 in 1999 with a steady decrease to 2.8 in 2016. Of note, the standard deviation for all three procedures increased over the study period examined suggesting wide variability in the number of HPB operations performed among GCR at different general surgery programs. Conclusion: While the average number of HPB cases logged by GCR has doubled since 1999, more than one-half of GCR still perform fewer than 20 HPB cases at the time of graduation. In addition, most GCR have done fewer than 10 liver, pancreas, or complex biliary operations. The increasing standard deviation for HPB cases among GCR suggests a widening variability in HPB operative experience among residents. These data suggest that most residents are unlikely to have had the experience or training necessary to perform complex HPB at the time of graduation.

Narrowing of the surgical resident operative experience: A 27-year analysis of national ACGME case logs

BackgroundAlthough overall operative volume has remained stable since the implementation of duty hours, more detailed analyses suggest shifts in the resident operative experience. Understanding these differences allows educators to better appreciate the impact of the current training environment on resident preparation for practice. MethodsNational Accreditation Council for Graduate Medical Education case logs from 1990 to 2016 were reviewed. Statistical analysis was performed using analysis of variance and linear regression analysis. ResultsOver the study period there was no change in total major cases. Subcategory analysis revealed an increase in skin and soft tissue, alimentary tract, abdomen, and endocrine with a concurrent decrease in breast, pediatrics, and trauma. During this time, residents completed fewer cases during their chief year, operated more during non-chief years, taught fewer operations, and assisted in minimal cases. Finally, a decrease in the variability of overall operative volume for total major cases was found as a result of 90th and 10th percentiles converging toward the median. ConclusionAlthough total major cases logged by residents have remained stable, the operative experience of general surgery residents has narrowed significantly. Residents are operating earlier and performing fewer teaching and first assistant cases. Surgical educators must look beyond total case numbers and be aware of these changes to ensure all residents achieve technical competency on graduation.

Not all operative experiences are created equal: a 19-year analysis of a single center's case logs

BackgroundAlthough national operative volumes have remained stable, surgical educators should appreciate the changing experience of today's surgical residents. We set out to evaluate operative volume trends at our institution and study the impact of resident learning styles on operative experience. Materials and methodsThe Accreditation Council for Graduate Medical Education operative log data from 1999 to 2017 for a single general surgery residency program were examined. All residents completed the Kolb Learning Style Inventory. Statistical analyses were performed using linear regression analysis, Student's t-test, and Fischer's exact test. ResultsOver the study period, 106 general surgery residents graduated from our program. There were 87% action learners and 13% observation learners. Although there was no change in total major, total chief, or total non-chief cases, a decrease in teaching assistant cases was observed. Subcategory analysis revealed that there was an increase in operative volume on graduation in the following categories: skin, soft tissue, and breast; alimentary tract; abdomen; pancreas; operative trauma; pediatric; basic laparoscopy; complex laparoscopy; and endoscopy with a concurrent decrease in liver, vascular, and endocrine. Learning style analysis found that action learners completed significantly more cases than observation learners in most domains in which operative volume increased. ConclusionsWhile the operative volume at our center remained stable over the study period, the experience of general surgery residents has become narrowed toward a less subspecialized, general surgery experience. These shifts may disproportionally impact trainees as observation learners operate less than action learners. Residency programs should therefore incorporate methods such as learning style assessment to identify residents at risk of a suboptimal experience.

Disparities in hepatopancreatobiliary operative experience among general surgery residents: a 27-year analysis of ACGME case logs

Background: The ACGME requires hepatopancreatobiliary (HPB) surgery as a part of general surgery training. In this study, we evaluate the trends in HPB operative experience of general surgery residents. Methods: ACGME national operative log reports from 1990 to 2016 were examined. Trends were analyzed relative to the 2003 duty hour restrictions (DHR): pre-DHR (1990–1999), DHR transition (2000–2008) and post-DHR (2009–2016). Statistical analysis was performed using ANOVA and linear regression analysis. A p-value <0.05 was statistically significant. Results: Operative logs of 27,851 general surgery graduates were examined. Median biliary, liver and pancreatic operative volumes increased by 29.9%, 32.8% and 27.3%, respectively. Operative volume variability, defined as the difference between the most and least prolific residents (90th–10th percentile), increased by 15.5%, 21.2% and 73.0% for these categories (Figure). Trends were then analyzed for specific HPB operations. Increases in operative volume from pre- to post-DHR were seen for laparoscopic cholecystectomy (71.7%), hepatic lobectomy (140.9%), liver transplant (161.9%), distal pancreatectomy (130.8%) and pancreaticoduodenectomy (152.4%, p < 0.05 for each), while decreases were seen for open cholecystectomy (−61.9%), open common bile duct exploration (−76.7%), hepaticojejunostomy (−52.6%) and hepatic wedge resection (−31.4%, p < 0.05 for each). For each specific HPB operation that increased, linear regression analysis revealed an increase in operative volume variability (p < 0.05 for each). Conclusion: While the total HPB operative experience of surgical residents has increased over the past 27-years, an increase in operative volume variability has also occurred, suggesting a dissimilar HPB experience amongst trainees. Educators should be aware of this disparity to ensure equitable training amongst all graduates.