Graduating Chief Residents Research Articles

The changing face of trauma management and its impact on surgical resident training.

The management of trauma patients has become increasingly nonoperative, especially for solid abdominal organ injuries. However, the Residency Review Committee (RRC) still requires an operative trauma experience deemed essential for graduating general surgical residents. The purpose of this study was to review the trauma volume and mix of patients at two trauma centers and determine the major operative trauma cases available to residents involved in the care of these patients. A retrospective chart review was conducted at the two trauma centers used by the Michigan State University surgery residency. Both of the trauma centers are American College of Surgeons verified. Surgical residents are involved with the care of every trauma patient at each of the hospitals. Cumulative data were collected and analyzed from January 1, 1997, through December 31, 1999. Age, gender, mechanism of injury (blunt vs. penetrating), Injury Severity Score, length of stay, operative interventions, and patients managed nonoperatively were reviewed. There were 434 patients selected for this study from 2,340 patients admitted to the trauma services. Male patients accounted for 66% of patients and female patients accounted for 34% of patients. Blunt trauma was the mechanism in 89% of patients, with penetrating trauma accounting for the other 11% of patients. Of the total number of patients, motor vehicle crashes accounted for the majority of cases, 325 of 434 (75%). Overall, 85% (370 of 434) of patients were managed without an index trauma surgical procedure according to RRC guidelines. Only 14.7% (64 of 434) of patients underwent operative intervention that qualified as index trauma surgical cases identified by the RRC. The spleen and small bowel were the two most commonly injured organs found at laparotomy. Nonoperative intervention of many patients with solid abdominal organ injuries did not meet the operation requirements expected by the RRC. Our residency program had 10 graduating chief residents over the 3-year time period. With only 64 operative trauma cases, this yields an average of 6.4 trauma cases per resident. This falls significantly short of the 16-case minimum requirement in trauma surgery established by the RRC. The operative trauma requirements established by the RRC for graduating residents may be unattainable in many residency programs because of the high incidence of blunt trauma and the changing patterns of trauma management.

Effects of limited work hours on surgical training.

Legal mandates to reduce resident work hours have prompted changes in the structure of surgical training programs. Such changes have included modification of on-call schedules and the adoption of "night float" resident coverage. Little is known about the effects of these changes on surgical resident education and perceptions of quality of patient care. The surgical housestaff and faculty at a single institution completed a 21-point Likert survey. Subjects were asked to compare parameters of resident education, patient care, and resident quality of life before and after institution of a strict 80-hour work week resident training schedule. The number of hours worked per week before and after these changes were reported. American Board of Surgery In-Training Examination (ABSITE) scores were compared for the 2 years before and after implementation of this schedule. Total number of surgical cases performed by graduating chief residents were recorded and compared for the 3 years before and after the schedule changes. Resident work hours reduced significantly after schedule changes were implemented. A majority of surgical residents reported an improvement in quality of life, but residents and faculty perceived changes to have a negative impact on continuity of patient care. Mean ABSITE composite percentile scores significantly improved after the reduction of working hours. ABSITE scores for junior residents improved significantly; no significant differences were noted in scores for senior residents. Reduction in resident work hours has salutary effects on perception of quality of life and basic education for surgical residents. These benefits may come at the expense of patient care, particularly continuity of care. This study did not directly assess patient outcomes but the perceptions of caregivers suggest that patient care may be compromised. Further research is needed to assess the longterm effects of changes on both residents and patients.

The effects of TRICARE implementation on general surgery residency training at Travis Air Force Base

Purpose TRICARE is the military version of health care insurance. The conversion from CHAMPUS (the former version) to TRICARE was completed at David Grant Medical Center (DGMC) in October 1995. Because of a perceived decrease in the overall surgical caseload at DGMC in recent years, a review of the operative case logs of all graduating chief residents in general surgery was undertaken. The goal was to determine if institution of TRICARE was adversely affecting the surgical experience of our residents. Methods A retrospective review of the residency review committee (RRC) case logs of all graduating chief residents in general surgery at David Grant Medical Center was performed from 1990 to 1999. The review was divided into 2 groups: group 1 included all individuals who graduated in those years before initiation of TRICARE (1990 to 1995); group 2 included those who graduated after the initiation of TRICARE (1996 to 1999). Each of the 16 separate RRC reporting categories and 3 summary categories were compared to detect differences in overall caseloads between group 1 and group 2. Results Compared with group 1, group 2 had significantly fewer aortic, pediatric surgery, endoscopy, and total cases done in the chief year. Conclusions Since the initiation of the TRICARE health plan at David Grant Medical Center, overall caseloads have not declined. However, there has been a concerning decline in chief resident-year cases. This decline may not become fully apparent for several more years as the current junior residents report their caseloads upon their graduation. (Curr Surg 57:359–362)

The financial impact of teaching surgical residents in the operating room

Background: There have been no published data regarding the cost of training surgical residents in the operating room. Methods: At the University of Tennessee Medical Center-Knoxville, in addition to resident-performed teaching cases, some cases are performed without the assistance of residents by the same faculty. Results: Sixty-two case categories involving 14,452 cases were compared for operative times alone. In 46 case categories (10,787 procedures), resident operative times were longer than faculty alone. In 16 case categories, resident operating times were shorter than faculty times. The net incremental operative time cost was 2,050 hours between July 1993 and March 1997. Assuming 4 years of operative training for 11 graduating chief residents, the cost per graduating resident was $47,970. Conclusion: Extrapolated to a national annual cost for the 1,014 general surgery residents who completed training in the 1997 academic year, the annual cost of training residents in the operating room is $53 million. This high monetary cost suggests the need for digital skills, selection criteria, the development of training curriculum and resource facilities, the pre-operating room need for suturing and stapling techniques, and perhaps the acquisition of virtual surgery training modules.

Chief resident experience with laparoscopic cholecystectomy.

Resident competence in both open and laparoscopic cholecystectomy (LC) has been a concern among general surgeons. Laparoscopic surgery was late in coming at many surgical residency programs in the United States, and many residents have graduated with limited experience in LC. We are chief residents who were fortunate enough to start our training when LC was first introduced at our institution in 1990. This report summarizes our experience with LC in our chief year, during which we performed LC on 147 patients. The average operating time was 37 minutes (range, 12-82 minutes). Six patients (4%) required conversion to an open procedure. There were three complications (2 postoperative cystic duct leaks and 1 intraoperative common bile duct injury) for an overall complication rate of 2%. There was no mortality. It is our conclusion that graduating chief residents with 5 years' exposure to LC may perform the procedure with a complication rate comparable to that reported in the current literature. Insuring that graduating chief residents have adequate training in open cholecystectomy may become a more pressing issue in the near future.

Spectrum of general surgery in rural America.

To define the types of surgery performed by rural surgeons, to compare their experience to that of graduating US surgical residents and to document rural surgical mortality. Prospective registry of consecutive cases recorded by 7 rural general surgeons working in one department of surgery from December 31, 1994, through March 30, 1996. Comparison with the 1995 Report C (Resident Operative Logs) of the Residency Review Committee. National survey of surgical residency programs regarding formal gynecology experience. Nine rural community hospitals in the Midwest. Patients undergoing surgery in 9 cities with populations of fewer than 10000. Type of surgery and postoperative (30-day) mortality. Two thousand four hundred twenty procedures were performed by 7 surgeons practicing in 9 cities with populations of 1500 to 8000. There were 6 (0.25%) postoperative deaths. Case types are as follows: endoscopy, 686 (28.3%); gynecology, 498 (20.6%); hernia, 241 (10%); colorectal, 194 (8%); biliary, 183 (7.6%); cesarean sections, 130 (5.4%); breast, 129 (5.3%); orthopedic, 115 (4.8%); carpal tunnel, 63 (2.6%); otolaryngology, 35 (1.4%); and endocrine, 1 (0.4%); for a total of 2420 (100%). Report C indicated 1995 graduating chief residents averaged 8 obstetric and and gynecologic and 5.3 orthopedic cases during their residency. Of 204 surgical residency programs surveyed, 106 (52%) offered no obstetrics and gynecology rotation. A large volume of surgery was performed with low mortality by 7 rural general surgeons. The operative experience of 1995 residency graduates differed from our rural surgeons. We recommend a rural surgical track in selected training programs to prepare graduates better for rural practice. Senior level rotations in endoscopic, gynecologic, obstetric, and orthopedic surgery and mentorship with rural surgeons would be optimal.

Postgraduate trauma education; the surgeon; the cost.

Injuries account for 3.6 million hospital admissions and approximately 100 billion dollars in health care costs annually. Surgical educators have expressed concern about the adequacy of postgraduate trauma education in light of this trauma epidemic. The purpose of this report was to evaluate our residents' trauma exposure and to examine the associated cost of training a physician to treat critically injured patients. From July 1982 through June 1987, 38,714 patients were evaluated for injuries in the emergency department. Five thousand sixty-one patients required admission to the hospital, and of these, 2,045 were admitted to the intensive care unit. In addition, 3,851 major trauma operations were performed during this 5-year period. The majority of these procedures were neurosurgical and orthopedic; however, we have seen an increasing percentage of abdominal operations in the last 2 years. The last five graduating chief residents averaged 181 major trauma operations during their training. The hospital currently writes off an average of $250,000 per month in trauma patient non-collections. This averages to 1.5 million dollars per resident for 5 years of trauma education in our institution. It is imperative that we continue to train trauma surgeons to manage critically ill patients; however, society must address the enormous cost of doing so.