Graduating Chief Residents Research Articles

A national analysis of vascular surgery resident operative experience in peripheral artery disease

BackgroundEndovascular and hybrid interventions have played an increasingly prominent role in the treatment of peripheral arterial disease (PAD) in the past decade. This shift has prompted concerns about the adequacy of open surgical training for current surgical residents. Moreover, the recent Best Surgical Therapy in Patients With Critical Limb Ischemia trial has further emphasized the importance of open surgical techniques in the treatment of peripheral arterial disease. The purpose of this study was to examine national temporal trends in peripheral operative volume among integrated vascular surgery residents. MethodsData was obtained from the Accreditation Council for Graduate Medical Education national data reports for integrated vascular surgery residents. Case volumes for surgeon chief or surgeon junior cases were collected from academic years 2012 to 2013 and 2021 to 2022. Trends in case-mix and volume were evaluated using linear regression analysis. ResultsThe mean total vascular operative volume increased from 851.2 to 914.3 cases among graduating chief residents, with an annual growth of 8.5 ± 1.7 cases/year (R2 = 0.77; P < .0001). Major vascular case volume also increased at a rate of 5.7 ± 1.2 cases/year (R2 = 0.74; P < .001). Among operative categories, peripheral cases were the most frequent (n = 232.2 [26.6%]) and demonstrated the greatest annual growth (+8.0 ± 0.8 cases/year, R2 = 0.93; P < .001). No changes were seen in volume of open peripheral cases, including suprainguinal bypass (+0.1 ± 0.2 cases/year; R2 = 0.08; P = .40) or femoropopliteal bypass procedures (−0.1 ± 0.2 cases/year; R2 = 0.17; P = .20). Infrapopliteal bypass (+0.4 ± 0.1 cases/year; R2 = 0.48; P = .006), iliac/femoral endarterectomy (+1.3 ± 0.2 cases/year; R2 = 0.82; P < .001), and leg thromboembolectomy (+0.4 ± 0.1 cases/year; R2 = 0.64; P < .001) all demonstrated annual growth. For endovascular peripheral cases, aortoiliac revascularization (+3.4 ± 0.3 cases/year; R2 = 0.94; P < .001), femoropopliteal revascularization (+5.4 ± 0.2 cases/year; R2 = 0.98; P < .001), and tibioperoneal revascularization (+2.0 ± 0.2 cases/year; R2 = 0.92; P < .001) all increased in volume. Lower extremity amputations, including above-knee amputation (+0.6 ± 0.2 cases/year; R2 = 0.65; P < .001) and below-knee amputation (+0.9 ± 0.2 cases/year; R2 = 0.72; P < .001) also demonstrated an increase in volume. ConclusionsCurrent graduating residents have higher open and endovascular case volumes for peripheral artery disease on a national level, despite the increasing popularity of endovascular techniques. Further studies are needed to identify how these trends may impact current vascular surgery milestones. These trends may also influence the rising interest in competency-based training programs.

Implementation of Entrustable Professional Activities in General Surgery: Results of a National Pilot Study.

The ongoing complexity of general surgery training has led to an increased focus on ensuring the competence of graduating residents. Entrustable professional activities (EPAs) are units of professional practice that provide an assessment framework to drive competency-based education. The American Board of Surgery convened a group from the American College of Surgeons, Accreditation Council for Graduate Medical Education (ACGME) Surgery Review Committee, and Association of Program Directors in Surgery to develop and implement EPAs in a pilot group of residency programs across the country. The objective of this pilot study was to determine the feasibility and utility of EPAs in general surgery resident training. 5 EPAs were chosen based on the most common procedures reported in ACGME case logs and by practicing general surgeons (right lower quadrant pain, biliary disease, inguinal hernia), along with common activities covering additional ACGME milestones (performing a consult, care of a trauma patient). Levels of entrustment assigned (1 to 5) were observation only, direct supervision, indirect supervision, unsupervised, and teaching others. Participating in site recruitment and faculty development occurred from 2017 to 2018. EPA implementation at individual residency programs began on July 1, 2018, and was completed on June 30, 2020. Each site was assigned 2 EPAs to implement and collected EPA microassessments on residents for those EPAs. The site clinical competency committees (CCC) used these microassessments to make summative entrustment decisions. Data submitted to the independent deidentified data repository every 6 months included the number of microassessments collected per resident per EPA and CCC summative entrustment decisions. Twenty-eight sites were selected to participate in the program and represented geographic and size variability, community, and university-based programs. Over the course of the 2-year pilot programs reported on 14 to 180 residents. Overall, 6,272 formative microassessments were collected (range, 0 to 1144 per site). Each resident had between 0 and 184 microassessments. The mean number of microassessments per resident was 5.6 (SD = 13.4) with a median of 1 [interquartile range (IQR) = 6]. There were 1,763 summative entrustment ratings assigned to 497 unique residents. The average number of observations for entrustment was 3.24 (SD 3.61) with a median of 2 (IQR 3). In general, PGY1 residents were entrusted at the level of direct supervision and PGY5 residents were entrusted at unsupervised practice or teaching others. For each EPA other than the consult EPA, the degree of entrustment reported by the CCC increased by resident level. These data provide evidence that widespread implementation of EPAs across general surgery programs is possible, but variable. They provide meaningful data that graduating chief residents are entrusted by their faculty to perform without supervision for several common general surgical procedures and highlight areas to target for the successful widespread implementation of EPAs.

Implementation of a structured robotic colorectal curriculum for general surgery residents.

There is increasing demand for colorectal robotic training for general surgery residents. We implemented a robotic colorectal surgery curriculum expecting that it would increase resident exposure to the robotic platform and would increase the number of graduating general surgery residents obtaining a robotic equivalency certificate. The aim of this study is to describe the components of the curriculum and characterize the immediate impact of the implementation or residents. Our curriculum started in 2019 and consists of didactics, simulation, and clinical performance. Objectives are specified for both junior residents (post-graduate years [PGY]1-2) and senior residents (PGY3-5). The robotic colorectal surgical experience was characterized by comparing robotic to non-robotic operations, differences in robotic operations across post-graduate year, and percentage of graduates achieving an equivalency certificate. Robotic operations are tracked using case log annotation. From 2017 to 2021, 25 residents logged 681 major operations on the colorectal service (PGY1 mean = 7.6 ± 4.6, PGY4 mean = 29.7 ± 14.4, PGY5 mean = 29.8 ± 14.8). Robotic colorectal operations made up 24% of PGY1 (49% laparoscopic, 27% open), 35% of PGY4 (35% laparoscopic, 29% open), and 41% of PGY5 (44% laparoscopic, 15% open) major colorectal operations. Robotic bedside experience is primarily during PGY1 (PGY1 mean 2.0 ± 2.0 bedside operations vs 1.4 ± 1.6 and 0.2 ± 0.4 for PGY4 and 5, respectively). Most PGY4 and 5 robotic experience is on the console (PGY4 mean 9.1 ± 7.7 console operations, PGY5 mean 12.0 ± 4.8 console operations). Rates of robotic certification for graduating chief residents increased from 0% for E-2013 to 100% for E-2018. Our robotic colorectal curriculum for general surgery residents has facilitated earlier and increased robotic exposure for residents and increased robotic certification for our graduates.

Declining Resident Surgical Autonomy and Improving Surgical Outcomes: Correlation Does Not Equal Causality

The volume of cases that residents perform independentlyhave decreased leaving graduating chief residents less prepared for independent practice. Outcomes are not worse when residents are given autonomy with appropriate supervision, however it is unknown if outcomes are worsening with decreasing operative autonomy experience. We hypothesize that resident autonomous cases parallel the improving outcomes in surgical care over time, however, are less complex and on lower acuity patients. Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Operative cases performed on teaching services within the VASQIP database from July 1, 2004 to September 30, 2019, were included. All adult patients who underwent a surgical procedure from July 1, 2004, to September 30, 2019, at a VA hospital on a service that included residents were initially included. After inclusions and exclusions, there were 1,346,461 cases. Cases were divided into 3 sequential 5 year eras (ERA 1: 2004-2008 n = 415,614, ERA 2: 2009-2013 n = 478,528, and ERA 3: 2014-2019 n = 452,319). The main exposure of interest was level of resident supervision, coded at the time of procedure as: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). We compared 30 day all-cause mortality, composite morbidity, work relative value unit (wRVU), hospital length of stay, and operative time between each ERA for RP cases, as well as within each ERA for RP cases compared to AR and AP cases. There was a progressive decline in the rate of RP cases in each successive ERA (ERA 1: 58,249 (14.0%) vs ERA 2: 47,891 (10.0%) vs ERA 3: 35,352 (7.8%), p < 0.001). For RP cases, patients were progressively getting older (60 yrs [53-71] vs 63 yrs [54-69] vs 66 yrs [57-72], p < 0.001) and sicker (ASA 3 58.7% vs 62.5% vs 66.2% and ASA 4/5 8.4% vs 9.6% vs10.0%, p < 0.001). Odds of mortality decreased in each ERA compared to the previous (aOR 0.71 [0.62-0.80] ERA 2 vs ERA 1 and 0.82 [0.70-0.97] ERA 3 vs ERA 2) as did morbidity (0.77 [0.73-0.82] ERA 2 vs ERA 1 and 0.72 [0.68-0.77] ERA 3 vs ERA 2). Operative and length of stay also decreased while wRVU stayed unchanged. When comparing RP cases to AP and AR within each ERA, RP cases tended to be on younger and healthier patients with a lower wRVU, particularly compared to AR cases. Mortality and morbidity were no different or better in RP compared to AR and AP. Despite resident autonomy decreasing, outcomes in cases where they are afforded autonomy are improving over time. This despite RP cases being on sicker and older patients and performing roughly the same complexity of cases. They also continue to perform no worse than cases with higher levels of supervision. Efforts to increase surgical resident operative autonomy are still needed to improve readiness for independent practice.

MP20-16 COVID-19 IMPACT ON UROLOGY RESIDENT ROTATION CASE VOLUME

You have accessJournal of UrologyEducation Research III (MP20)1 Sep 2021MP20-16 COVID-19 IMPACT ON UROLOGY RESIDENT ROTATION CASE VOLUME Dora Jericevic, Jamie Kanofsky, Benjamin Brucker, Herbert Lepor, and William Huang Dora JericevicDora Jericevic More articles by this author , Jamie KanofskyJamie Kanofsky More articles by this author , Benjamin BruckerBenjamin Brucker More articles by this author , Herbert LeporHerbert Lepor More articles by this author , and William HuangWilliam Huang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002005.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Like most surgical specialties, the volume of urology was affected by the COVID19 pandemic with the temporary suspension of all elective surgeries in March 2020. Our study’s objectives were to describe surgical volume across urologic subspecialties and its impact on graduating chief residents, and to assess for any changes in our patient population during the pandemic. METHODS: A retrospective analysis was conducted using our institution’s quality dashboards. The analysis includes all surgery cases at a single site tertiary referral center in NYC across urologic subspecialities. The periods between January 1 and Dec 31 in 2020 and 2019 were chosen. We chose the same period in 2019 as the control to account for seasonal factors affecting surgical volume. RESULTS: There was a significant decline across all subspecialties in 2020 compared to 2019 (-19%; 2,922 vs 2,359). There was no statistically significant difference in the proportion of robotic surgery, elective surgery, and cases by subspecialty. The 2019 and 2020 patient cohorts were comparable (table 1). Controlling for surgeon preference in booking cases, endourology and oncology cases were the least likely to exhibit declines in volume (OR 1.2, 1.1-1.3; p<0.01). After elective surgeries were allowed to resume in May 2020, surgical volume recovered within 4-6 weeks. Overall, no rebound in surgical volume to correct for the suspension period was observed (figure 1). The 2020 graduating chief class logged 17% fewer cases in residency years U4 and U5 compared to the 2019 class (624 vs 753 cases), but minimum ACGME case counts at the time of graduation were met without issue. CONCLUSIONS: The COVID19 pandemic had a marked impact on urology resident rotation surgical volume with no rebound effect observed. A broader analysis across training sites is needed to estimate the full impact on the residency program. The effect of the lockdown measures on outcomes for untreated or underdiagnosed patients has yet to be established. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e343-e343 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dora Jericevic More articles by this author Jamie Kanofsky More articles by this author Benjamin Brucker More articles by this author Herbert Lepor More articles by this author William Huang More articles by this author Expand All Advertisement PDF downloadLoading ...

Practical Techniques to Adapt Surgical Resident Education to the COVID-19 Era.

Practical Techniques to Adapt Surgical Resident Education to the COVID-19 Era.

Undergraduate, Nonmedical Students can Pass the FLS Manual Skills Exam With Minimal Practice

The primary objective of this study is to investigate whether undergraduate, nonmedical students could pass the FLS Manual Skills Exam with minimal practice. The secondary objective is to examine ACGME case log data from graduating chief residents over the past 18 years to examine how laparoscopic experience has evolved over that time period. Undergraduate, nonmedical students received training and unlimited practice time before being tested on each task of the FLS Manual Skills Exam. Each task was timed and scored using the MISTELS system. ACGME case log data from graduating chief residents over the past 18 years was obtained. The setting is SimPortal, the simulation center associated with the University of Minnesota Medical School. The participants are 25 undergraduate, nonmedical students from the University of Minnesota. Participants were recruited on campus. Twenty-three out of 25 (92%) undergraduate, nonmedical students successfully completed one attempt for each task of the FLS Manual Skills Exam and 21 out of 25 (84%) completed both attempts. The average total practice time was 39 minutes. Over the past 18 years, the average number of laparoscopic cases completed by a graduating chief increased from 142 to 275 cases (93% increase). Additionally, the average number of cases of the top 5 most common laparoscopic operations increased from 25% to over 400%. Undergraduate, nonmedical students can pass the FLS Manual Skills Exam with minimal practice. Additionally, general surgery residents and medical students continue to gain more laparoscopic experience throughout medical training as laparoscopic surgery is utilized for more operations. The FLS Manual Skills Exam should be re-examined to determine its utility as a high-stakes exam.

Resident Education in Complex Obstetric Procedures: Are We Adequately Preparing Tomorrow's Obstetricians?

PURPOSE: Describe resident experience with surgical obstetrics and comfort in performing those procedures after graduation. BACKGROUND: ACGME milestones and CREOG objectives for OB/GYN residents include obstetrical technical skills. Data is limited on how often graduating residents meet these. METHODS: Anonymous 27-question e-survey sent to all US OB/GYN residents in 3/2018 via CREOG coordinator-listserv. Complex obstetric procedures included: forceps (FAVD), vacuum (VAVD), cerclage, breech second twin (B2T), breech delivery (BVD), perineal repairs, and cesarean hysterectomy. Technical skills questions included experience as primary surgeon (PS), comfort performing procedures independently (CPI), and for 4th year residents only-comfort performing procedures post-residency (CPPR). Descriptive statistics used to analyze responses. RESULTS: 417 residents completed the survey. Respondents were 88% female, 75% from academic programs, and nearly 50% were post-graduate year (PGY) 3&amp;4. Among residents of all levels, many had been primary surgeon in operative vaginal deliveries (51%-FAVD,72%-VAVD) and cerclage (62%), fewer for BVD (21%) and B2T (34%), cesarean hysterectomy (21%), and 4th degree repairs (37%). For PGY 3&amp;4, 85% were CPI VAVD, while only 34% were CPI FAVD. 14% and 37% were CPI BVD and 4th degree repairs respectively. Of the 95 PGY4 respondents, all felt CPPR either VAVD or FAVD. Nearly all felt CPPR a 3rd degree repair (97%), but almost 20% did not feel CPPR a 4th degree repair. 33% did not feel CPPR a cesarean hysterectomy, 28% and 74% did not feel CPPR with B2T and BVD respectively. DISCUSSION: Though ACGME and CREOG recommend that graduating residents are able to perform complex obstetric procedures, data suggest that for many graduating chief residents, this is not the case.

Complex hepato-pancreato-biliary caseload during general surgery residency training: are we adequately training the next generation?

BackgroundInformation on procedure volume of graduating chief residents (GCRs) for hepato-pancreato-biliary(HPB) surgical procedures may inform assessments of resident training. This study sought to characterize trends in operative volumes over a 19-year period to define the degree to which general surgery residents gain exposure to HPB procedures during training. MethodsThe ACGME was queried for all HPB operations performed by GCR between 2000-2018. Total procedures as well as means and fold change was calculated and reported for each year. ResultsBetween 2000–2018, the number of general surgery residency programs varied between 240 and 254. A total of 411,383 HPB procedures (36.2% liver, 42.8% pancreas, 21% complex biliary) were performed by 22,229 GCR. Each year of the study, GCR had similar mean number total procedures:liver 7.4, pancreas 8.7, and complex biliary 4.4. For liver procedures there was no difference in the fold change over time, however for pancreas there was an increase in the fold change from 2.25 to 3.25. ConclusionMost GCRs are graduating with a low number of HPB procedures and trends suggesting a decrease in the mean number of procedures per GCR and an increasing variability among residents.

Short term outcomes and unintended benefits of establishing a HPB program at a university-affiliated community hospital

BackgroundIn hepato-pancreato-biliary (HPB) surgery higher volumes are associated with improved outcomes; however, there are limitations to regionalization. Here we report our experience establishing multidisciplinary HPB program at a university-affiliated community hospital. MethodsThis is a retrospective review of patients who underwent HPB surgery between 2015 and 2017. Chief residents’ HPB case logs were collected. Results61 pancreatic resections and 62 hepatic resections were performed. The morbidity, 30-day mortality and median length of stay following pancreatic resections were 27%, 1.5%, and 8 days, respectively. The morbidity, 90-day mortality, and median length of stay following hepatic resections were 24%, 3%, and 7 days, respectively. The median pancreatic and liver case volumes for graduating chief residents increased from 7 to 8 to 16 and 16, respectively (p < 0.05), after the establishment of a HPB program. Participation in multidisciplinary care (p = 0.08) and clinical trial enrollment increased. ConclusionOur study demonstrates short-term outcomes comparable to high volume centers. Development of a HPB program had a positive impact on resident operative experience, increased multidisciplinary care and increased clinical trial enrollment.

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.

Impact of integrated programs on general surgery operative volume

BackgroundIntegrated residencies are now commonplace, co-existing with categorical general surgery residencies. The purpose of this study was to define the impact of integrated programs on categorical general surgery operative volume. MethodsCase logs from categorical general, integrated plastics, vascular, and thoracic surgery residents from a single institution from 2008 to 2016 were collected and analyzed. ResultsIntegrated residents have increased the number of cases they perform that would have previously been general surgery resident cases from 11 in 2009–2010 to 1392 in 2015–2016. Despite this, there was no detrimental effect on total major cases of graduating chief residents. ConclusionsMultiple integrated programs can co-exist with a general surgery program through careful collaboration and thoughtful consideration to longitudinal needs of individual trainees. As additional programs continue to be created, both integrated and categorical program directors must continue to collaborate to insure the integrity of training for all residents.

Implementing a resident acute care surgery service: Improving resident education and patient care

To simulate the duties and responsibilities of an attending surgeon and allow senior residents more intraoperative and perioperative autonomy, our program created a new resident acute care surgery consult service. We structured resident acute care surgery as a new admitting and inpatient consult service managed by chief and senior residents with attending supervision. When appropriate, the chief resident served as a teaching assistant in the operation. Outcomes were recorded prospectively and reviewed at weekly quality improvement conferences. The following information was collected: (1) teaching assistant case logs for senior residents preimplentation (n=10) and postimplementation (n=5) of the resident acute care surgery service; (2) data on the proportion of each case performed independently by residents; (3) resident evaluations of the resident acute care surgery versus other general operative services; (4) consult time for the first 12months of the service (June 2014 to June 2015). During the first year after implementation, the number of total teaching assistant cases logged among graduating chief residents increased from a mean of 13.4±13.0 (range 4-44) for preresident acute care surgery residents to 30.8±8.8 (range 27-36) for postresident acute care surgery residents (P<.01). Of 323 operative cases, the residents performed an average of 82% of the case independently. There was a significant increase in the satisfaction with the variety of cases (mean 5.08 vs 4.52, P<.01 on a 6-point Likert scale) and complexity of cases (mean 5.35 vs 4.94, P<.01) on service evaluations of resident acute care surgery (n=27) in comparison with other general operative services (n=127). In addition, creation of a 1-team consult service resulted in a more streamlined consult process with averageconsult time of 22minutes for operative consults and 25minutes for nonoperative consults (range 5-90minutes). The implementation of a resident acute care surgery service has increased resident autonomy, teaching assistant cases, and satisfaction with operative case variety, as well as the efficiency of operative consultation at our institution.

Characterizing the Operative Experience of Cardiac Surgical Trainees: What Are Residents Really Doing in the Operating Room?

The present study aimed to describe and compare the operative experience of cardiothoracic surgical residents for basic and advanced cardiac surgical procedures. Data were obtained from the 2015 Thoracic Surgery Directors Association Survey administered to all thoracic surgical residents taking the yearly In-Service Training Examination (n= 356). Residents were asked whether they routinely served as the operative surgeon on various cardiac operations and operative tasks. Results were stratified by postgraduate year (PGY), residency type, and primary career interest. The survey response rate was 100%. Considering all training pathways, only 2 of 13 cardiac operations surveyed were routinely performed by graduating chief residents as the operative surgeon: coronary artery bypass grafting (CABG; 92%) and aortic valve replacement (AVR; 88%). Off-pump CABG, minimally invasive mitral valve operation, and transcatheter aortic interventions were infrequently (<30% of the time) performed by graduating residents as the operative surgeon. These results were similar when residents with a career interest in general thoracic surgery were excluded from the analysis. For the operative progression of integrated 6-year (I-6) residents, most began to routinely cannulate for cardiopulmonary bypass, perform proximal coronary anastomoses, and harvest the mammary artery during PGY3. The majority (>50%) of I-6 residents performed CABG as the operative surgeon by PGY4. There is pronounced heterogeneity in the cardiac operative experience of cardiothoracic surgical residents in the United States, with only CABG and AVR routinely performed by graduating residents as the operative surgeon. This heterogeneity may lead to insufficient training in certain procedures for many graduates.

Residency and Beyond: Subspecialization Trends Among Graduating Physiatry Residents and the Musculoskeletal Curriculum.

Previous studies and informal surveys have demonstrated a trend among graduating physiatry residents who desired to practice in an outpatient musculoskeletal (MSK)- or spine-type setting. However, there has been no updated information on the current trend among graduating residents as well as sparse information on gauging if current trainees feel prepared on graduation to treat patients with such disorders. This article describes a prospective survey of graduating chief residents during the 2013-2014 academic year in which 72% of chief residents planned to pursue a fellowship. A total of 54% of those chief residents planned to pursue a pain, sports, or spine fellowship. Seventy-five percent of the responding chief residents reported that most of the residents in their program felt that the current amount of required rotations in MSK, sports, spine, or pain medicine was adequate and 85% felt comfortable practicing in a noninterventional spine or MSK position after graduation without a fellowship. The results of this survey provide an updated perspective on the current trends among graduating residents as well as how residents perceive their MSK curriculum. These results may prove useful when evaluating MSK curriculums and shaping resident education to maximize career goals.

See one, do one, and teach none: resident experience as a teaching assistant

BackgroundTraining of surgical residents depends on graduated autonomy in and out of the operating room. We sought to define trends in operative volume and number of teaching cases in graduating surgical residents over time. MethodsWe queried the Accreditation Council for Graduate Medical Education general surgery case log (1999–2012) for all case categories in which graduating chief residents performed a median of 20 or more cases during their training. Median (10th and 90th percentiles) number of cases performed as surgeon chief, surgeon junior and teaching assistant (TA) were analyzed using R2 for all trends. ResultsThe median number of cases performed by graduating chief residents remained stable over time (965–971; R2 = 0.01). Surgeon junior cases increased slightly (718–725; R2 = 0.07), whereas surgeon chief cases decreased slightly (246–235; R2 = 0.08). The most frequently performed cases were in the categories of the large intestine (125 [85,167], biliary (109 [74,167]), and abdominal hernia (99 [67.5,139]). The median number of TA cases decreased by 79% (126–27; R2 = 0.34), with the most significant decrease occurring early in the study period (median: 126–22; R2 = 0.91). The number of median teaching cases decreased in every category analyzed, with the most pronounced occurring in the categories of thoracic (9–0 [100%]; R2 = 0.37) and breast (6–0 [100%]; R2 = 0.55). The only categories with a median number of teaching cases >1 in 2012 were the large intestine (5), biliary (4), and abdominal hernia repairs (3). ConclusionsDespite a relative stability of case volume over time, GSRs are graduating with relatively few cases recorded as TA. Improved opportunities for trainees to take on the role of TA while in residency may lead to improved confidence as surgeons on graduation.

Don LaRossa, M.D., 1941 to 2014.

Don LaRossa, M.D., 1941 to 2014.

Does Intentional Support of Degree Programs in General Surgery Residency Affect Research Productivity or Pursuit of Academic Surgery?

Many residents supplement general surgery training with years of dedicated research, and an increasing number at our institution pursue additional degrees. We sought to determine whether it was worth the financial cost for residency programs to support degrees. We reviewed graduating chief residents (n = 69) in general surgery at Vanderbilt University from 2001 to 2010 and collected the data including research time and additional degrees obtained. We then compared this information with the following parameters: (1) total papers, (2) first-author papers, (3) Journal Citation Reports impact factors of journals in which papers were published, and (4) first job after residency or fellowship training. The general surgery resident training program at Vanderbilt University is an academic program, approved to finish training 7 chief residents yearly during the time period studied. Chief residents in general surgery at Vanderbilt who finished their training 2001 through 2010. We found that completion of a degree during residency was significantly associated with more total and first-author publications as compared with those by residents with only dedicated research time (p = 0.001 and p = 0.017). Residents completing a degree also produced publications of a higher caliber and level of authorship as determined by an adjusted resident impact factor score as compared with those by residents with laboratory research time only (p = 0.005). Degree completion also was significantly correlated with a first job in academia if compared to those with dedicated research time only (p = 0.046). Our data support the utility of degree completion when economically feasible and use of dedicated research time as an effective way to significantly increase research productivity and retain graduates in academic surgery. Aggregating data from other academic surgery programs would allow us to further determine association of funding of additional degrees as a means to encourage academic productivity and retention.

Assessing the experience in complex hepatopancreatobiliary surgery among graduating chief residents: Is the operative experience enough?

Resident operative autonomy and case volume is associated with posttraining confidence and practice plans. Accreditation Council for Graduate Medical Education requirements for graduating general surgery residents are four liver and three pancreas cases. We sought to evaluate trends in resident experience and autonomy for complex hepatopancreatobiliary (HPB) surgery over time. We queried the Accreditation Council for Graduate Medical Education General Surgery Case Log (2003-2012) for all cases performed by graduating chief residents (GCR) relating to liver, pancreas, and the biliary tract (HPB); simple cholecystectomy was excluded. Mean (±SD), median [10th-90th percentiles] and maximum case volumes were compared from 2003 to 2012 using R(2) for all trends. A total of 252,977 complex HPB cases (36% liver, 43% pancreas, 21% biliary) were performed by 10,288 GCR during the 10-year period examined (Mean = 24.6 per GCR). Of these, 57% were performed during the chief year, whereas 43% were performed as postgraduate year 1-4. Only 52% of liver cases were anatomic resections, whereas 71% of pancreas cases were major resections. Total number of cases increased from 22,516 (mean = 23.0) in 2003 to 27,191 (mean = 24.9) in 2012. During this same time period, the percentage of HPB cases that were performed during the chief year decreased by 7% (liver: 13%, pancreas 8%, biliary 4%). There was an increasing trend in the mean number of operations (mean ± SD) logged by GCR on the pancreas (9.1 ± 5.9 to 11.3 ± 4.3; R(2) = .85) and liver (8.0 ± 5.9 to 9.4 ± 3.4; R(2) = .91), whereas those for the biliary tract decreased (5.9 ± 2.5 to 3.8 ± 2.1; R(2) = .96). Although the median number of cases [10th:90th percentile] increased slightly for both pancreas (7.0 [4.0:15] to 8.0 [4:20]) and liver (7.0 [4:13] to 8.0 [5:14]), the maximum number of cases preformed by any given GCR remained stable for pancreas (51 to 53; R(2) = .18), but increased for liver (38 to 45; R(2) = .32). The median number of HPB cases that GCR performed as teaching assistants (TAs) remained at zero during this time period. The 90th percentile of cases performed as TA was less than two for both pancreas and liver. Roughly one-half of GCR have performed fewer than 10 cases in each of the liver, pancreas, or biliary categories at time of completion of residency. Although the mean number of complex liver and pancreatic operations performed by GCR increased slightly, the median number remained low, and the number of TA cases was virtually zero. Most GCR are unlikely to be prepared to perform complex HPB operations.

Assessing the Experience in Complex Hepatopancreatobiliary Surgery Among Graduating Chief Residents: Is the Operative Caseload Enough?

Assessing the Experience in Complex Hepatopancreatobiliary Surgery Among Graduating Chief Residents: Is the Operative Caseload Enough?