Resident Operative Experience Research Articles

Advanced laparoscopic fellowship and general surgery residency can co-exist without detracting from surgical resident operative experience

Advanced laparoscopic fellowship and general surgery residency can co-exist without detracting from surgical resident operative experience

The Impact of a Fellowship on Resident Training in an Academic Pediatric Urology Practice

The impact of a fellowship on resident operative experience and education is unclear. We sought to address this issue by comparing resident operative case logs and the pediatric portion of the American Urological Association resident inservice examination at our institution before and after establishing a pediatric urology fellowship in 2002. Pediatric operative case logs of all urological residents from 1998 to 2006 at Vanderbilt University were reviewed. We recorded index and total number of cases as specified by the Accreditation Council for Graduate Medical Education. All residents had completed 6 months of pediatric urology training. Statistical analysis was performed using 2-sample equal variance Student t tests. We compared the 8 index categories and total index cases performed by residents, scores on the pediatric portion of the American Urological Association inservice examination and resident average percentiles for index cases referenced to national data, before and after the implementation of an Accreditation Council for Graduate Medical Education accredited pediatric urology fellowship. Before implementation of the pediatric urology fellowship residents performed significantly more hypospadias procedures, pyeloplasties, renal surgeries, ureteroneocystostomies and urinary/bowel diversions (p <0.05), while the total number of index cases performed was not significantly affected (p = 0.13). In contrast, after the fellowship was started residents performed more hydrocelectomies/hernia repairs (p = 0.01). Compared to national averages for index cases in 2004 to 2005, residents maintained greater than the 50th percentile in all categories except urinary diversion, which was between the 30th and 50th percentiles. Furthermore, residents were in the 70th to 90th percentile in 3 of 9 categories, and greater than the 90th percentile in 3, including total number of index cases. No statistically significant difference in the area of pediatric urology was observed on the resident inservice examination scores before and after the fellowship was established. Residents performed significantly fewer index cases in some areas following initiation of a pediatric urology fellowship at Vanderbilt University, although the total number of index cases performed by residents remained unchanged. Despite the presence of a fellow, residents have remained at or well above the national average in all index case categories except urinary diversion. Moreover, establishment of a fellowship did not negatively impact the educational experience as measured by American Urological Association resident inservice examination scores, specifically in the area of pediatric urology. Choosing the optimal time to institute a fellowship should be made with fellow and resident education as the utmost priority. Periodic review of the data should also be performed to maintain consistent, positive experiences for fellowship and residency training.

ACGME Duty-Hour Restrictions Decrease Resident Operative Volume: A 5-Year Comparison at an ACGME-Accredited University General Surgery Residency

We compared the operative experience of chief residents at the Michigan State University Integrated Residency Program in General Surgery before and after duty-hour restrictions mandated by the Accreditation Council for Graduate Medical Education. Conflicting evidence exists regarding the influence of duty-hour restrictions upon resident operative experience. Resident self-reported operative experience submitted to the Residency Review Committee (RRC) for Surgery was tabulated. To control for a possible overall decrease in surgical procedures, for example, a decrease in referrals to the institution, the departmental database of surgical billings that is maintained independently from resident operative experience data also was reviewed. An overall decrease of nearly 20% occurred in resident operative volume after promulgation of duty-hour restrictions. All residents met minimum RRC operative experience requirements. Over the same period, no decrease was found in the number surgical procedures performed by the department. Our data suggest that restriction of resident duty hours is associated with a significant decrease in operative experience.

Are We Training Our Residents to Perform Open Gall Bladder and Common Bile Duct Operations?

In the new era of resident work hour restrictions and an emphasis on minimally invasive surgery, experience in performing open biliary surgery is diminishing. We sought to review our resident operative experience to determine if it appears adequate for a well-trained general surgeon. The case logs of the General Surgery, Oncology, and Trauma/Emergency General Surgery (EGS) services were reviewed for a 1-year period. All biliary procedures that included the potential for gallbladder or bile duct surgery were reviewed. We performed 745 laparoscopic cholecystectomies last year on our General Surgery, Oncology, and Trauma/EGS services. Conversion to open procedure was 4.5% (16/364) on our elective services and 6% (23/381) on our Trauma/EGS services. Effective clearance of common bile duct stones performed retrograde by endoscopy and transhepatically by interventional radiology limited our residents' experience performing common bile duct surgery for stones to 13 performed laparoscopically and 10 performed open. Other operations that included open cholecystectomies and common bile duct procedures were pancreatico-duodenectomy (87), biliary bypass (22), biliary resection/reconstruction (20), hepatic lobectomy (48), sphincteroplasty and ampullectomy (6). The small number of conversions from laparoscopic to open cholecystectomies and the few common bile duct explorations performed for stone disease would be inadequate to train our six categorical surgical residents to perform open cholecystectomies and common bile duct procedures without a training program that augments this by providing a strong hepato-biliary-pancreatic experience. Programs without a strong hepato-biliary-pancreatic program should review their residents' operative experience.

Effect of the 80-hour work week on resident operative experience in general surgery

Background The goal of this study was to determine the effect of the 80-hour work week on resident operative experience. Methods General surgery resident operative experience was evaluated during a 4-year period and divided into 2 groups: before (group A [July 1, 2001, to June 30, 2003]) and after (group B July 1, 2003, to June 30, 2005]) implementation of the Accreditation Council for Graduate Medical Education duty hour guidelines. Results There was a significant decrease in mean total and primary surgeon cases in group B for postgraduate year (PGY) levels 1, 2, and 4 ( P ≤ .001). There was a significant decrease in PGY 5 teaching assistant and PGY 1 first assistant experience in group B ( P ≤ .001). There was no difference in PGY 3 resident operative volume. Conclusions The mandated work-hour guidelines have negatively impacted the operative experience of general surgery residents, especially at the junior level. Despite implementing modifications designed to optimize resident operative experience, surgical training programs may require further adaptations.

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Introduction: In the new era of resident work hour restrictions and an emphasis on minimally invasive surgery, experience in performing open biliary surgery is diminishing. We sought to review our resident operative experience to determine if it appears adequate for a well-trained general surgeon. Methods: The case logs of the General Surgery, Oncology and Trauma/Emergency General Surgery (EGS) services were reviewed for a 1-year period. All biliary procedures that included the potential for gallbladder or bile duct surgery were reviewed. Results: We performed 745 laparoscopic cholecystectomies last year on our General Surgery, Oncology and Trauma/EGS Services. Conversion to open procedure was 4.5% (16/364) on our elective services and 6% (23/381) on our Trauma/EGS services. Effective clearance of common bile duct stones performed retrograde by endoscopy and transhepatically by interventional radiology limited our residents’ experience performing common bile duct surgery for stones to 13 performed laparoscopically and 10 performed open. Other operations which included open cholecystectomies and common bile duct procedures were pancreatico-duodenectomy-87, biliary bypass-22, biliary resection/reconstruction-20, hepatic lobectomy-48, sphincteroplasty and ampullectomy-6. Conclusions: The small number of conversions from laparoscopic to open cholecystectomies and the few common bile duct explorations performed for stone disease would be inadequate to train our six categorical surgical residents to perform open cholecystectomies and common bile duct procedures without a training program that augments this by providing a strong hepato-biliary-pancreatic experience. Programs without a strong hepato-biliary-pancreatic service should review their residents’ operative experience.

Impact of the 80-hour work week on resident emergency operative experience

Impact of the 80-hour work week on resident emergency operative experience

The impact of work hour restrictions on surgical resident education

Objective Resident work-hour restrictions were instituted in July 2003 based on ACGME mandates. The American Board of Surgery In-Training Examination (ABSITE), American Board of Surgery Qualifying Examination (ABSQE), and operative volume traditionally have been measures of surgical resident education and competency. The objective of this study was to determine the effect of reduced work hours on resident standardized test scores and operative volume at our institution. Design We reviewed ABSITE scores, ABSQE scores, and operative logs from 1997 to 2005 of all general surgery residents. Linear mixed-effects models were fitted for each component ABSITE score (total, basic science, and clinical management), and they were compared using a chi-squared likelihood ratio. Operative logs of graduating residents were compared before and after the work restrictions and were evaluated for association with ABSITE score. p-values less than 0.05 were considered significant. Results The program was compliant with ACGME mandates within 6 months of institution. ABSITE scores improved significantly after the restriction of work hours in both basic science (p = 0.003) and total score (p = 0.008). Clinical management scores were not affected. The number of major cases recorded by graduating residents did not change. A positive correlation was found between number of cases performed during residency and clinical management ABSITE scores (p = 0.045). ABSQE scores were not impacted by operative volume during residency. Conclusions ABSITE scores improved significantly after the restriction of resident work hours. Resident operative experience was not affected. An unexpected consequence of work-hour restrictions may be an improvement in surgical resident education.

The Effect of Work Hour Restrictions on the Education of Orthopaedic Surgery Residents

In 2005 the Academic Leadership Group of the American Orthopaedic Association surveyed orthopaedic program directors, chairs, and members of the Resident Leadership Forum to gather information about the effect of the Accreditation Council for Graduate Medical Education work-hour restrictions on resident education. We compared these results with a similar survey performed 2 years ago. Ninety-four program directors and chairs and 59 senior residents responded to this survey. Overall, the respondents thought the duty hour restrictions had a negative impact on orthopaedic residency education but less so than in the previous survey. This conclusion was based on perceived negative effects on professionalism, resident operative experience, continuity of care, and increased workload for the faculty. Senior residents who worked before and after the work-hour limitations were instituted were more concerned about the negative effects than junior residents. Residents did seem more rested and content but not better prepared or necessarily more attentive. Respondents were not of the opinion resident performance had improved as measured by perceptions of performance on standardized tests. Orthopaedic departments had adapted to the work-hour limitations by scheduling night float rotations, converting in-house call to home call, and by hiring additional personnel in the form of physician extenders.

The impact of duty hour regulations on resident operative experience education

The impact of duty hour regulations on resident operative experience education

Development of a Dedicated Hepatopancreaticobiliary Program in a University Hospital System

In 2001, a dedicated hepatopancreatobiliary (HPB) cancer program was established at a large, university hospital. Changes included recruitment of specialized HPB faculty, standardization of patient protocols, development of coordinated multidisciplinary research and clinical efforts, collection of prospective surgical outcomes data, and construction of a dedicated cancer hospital. The aim of this study was to evaluate the impact of this program on a university health system including effects on patient volume, surgical volume, outcomes, costs, resident education, and research productivity. Hospital and departmental databases were reviewed for all records pertaining to HPB surgical cases, diagnosis, and financial information over a 6-year period, including 2 years before (1999-2000) and 4 years after (2001-2004) HPB program development. A more than two-fold increase in the number of distinct patients who had HPB diagnosis was seen across all pertinent departments. A five-fold increase in surgical volume was observed. A multidisciplinary approach to care was implemented, leading to a four-fold increase in sharing of patients across departments. Improvements in operative mortality, hospital contribution margin, resident operative experience, and research productivity were observed. The implementation of a dedicated HPB cancer program with coordinated and standardized research, educational, and clinical efforts had measurable institutional benefit.

The economic impact of incorporating flexible endoscopy into a community general surgery practice

Flexible endoscopy is a vital component of gastrointestinal surgery. It has and will replace many of the surgical procedures now commonly performed. Flexible endoscopy, unfortunately, is not an integral part of surgical residency training based on resident operative experience as reported by the Residency Review Committee. Moreover, general surgeons have deferred the practice of flexible endoscopy to the gastroenterologists because of concerns over turf battles and referral patterns. The purpose of this study was to assess the overall case load and the economic impact of flexible endoscopy on the practice of general surgery in a community hospital setting. This retrospective review was performed over a 6-month period. The total cases and the total billings of inpatient and outpatient procedures for a group practice of five general surgeons in a community hospital were evaluated. The billings were the actual charges based on current procedural terminology (CPT) codes for these procedures using the Medicare fee schedule. Of the 2,159 procedures performed, 1,154 involved flexible endoscopy cases accounting for 54% of all cases (1,154 of 2,159) performed from February 1, 2003 to July 31, 2003. Flexible endocopy accounted for 43% of the total charges. A. total of 46 surgical procedures and 216 future endoscopies were generated from the flexible endoscopic procedures. Future endoscopic cases were for surveillance of colonic neoplasia and Barrett's esophagus. Flexible endoscopy contributed to a major portion of the caseload and revenue generated by the general surgery group studied. The overall impact of flexible endoscopy is even greater than reported because of the future endoscopic surveillance cases or surgical interventions generated on the basis of endoscopic findings.

Resident Operative Experience During the Transition to Work-Hour Reform

The operative volume of chief residents would decrease with work-hour reform by the Accreditation Council for Graduate Medical Education (ACGME). Mixed-design study performed during July and December 2003. Collected data were from programs experimenting with work-hour reform and programs that had not yet implemented reform. New York programs were also included. University-, community/university-, and community-based surgical residency programs. Telephone conversations occurred with 10 randomly selected program directors. Operative logs from chief residents graduating in 2002 and 2003 and a survey requesting information on programmatic changes. Of the 80 programs that responded, statistical analyses revealed the following findings: (1) there were no significant differences in the operative volume of chief residents based on work-hour model, program setting, or graduating class; (2) there was no significant difference in chiefs' operative volume between programs that experimented with work-hour reform and programs that did not experiment with work-hour reform during 2002-2003; (3) there was no relationship found between work hours and volume of operative cases; and (4) there was an inverse relationship found between work hours and operative volume for residents in New York programs. Several correlates must be considered for effective assessment and evaluation of the impact of work-hour reform on surgical training and education.

The laparoscopic experience of surgical graduates in the United States.

Although laparoscopic surgery has become widespread during the past decade, no systematic study of the training needs exists. To obtain guidance for planning, we analyzed the national resident operative experience during the past 8 years. The laparoscopic experiences of all surgical residents graduating between 1994 and 2001 were subjected to regression analysis. The laparoscopic volume of each trainee and change in ratio of laparoscopic/open operation over time were used to estimate the growth of individual laparoscopic operations in training programs. Laparoscopic surgery constituted only 5.7% of a trainee's total surgical experience in 1994, but comprised 13% by 2001. A resident completing training in 1994 performed 53 laparoscopic operations, of which 79% (42) were cholecystectomies. By 2001, a graduate performed 126 laparoscopic operations, of which 68% (86) were cholecystectomies. During the interim, most laparoscopic operations exhibited growth. Trainee experience in some newer operations has also increased steadily but at a much slower rate. This descriptive statistical survey of training experience yields a comprehensive picture of the laparoscopic capability of the young surgeon. The growth potential of some newer operations has also been measured. Using these data, guidelines can be drawn as to which operation programs should focus resources on training residents. Since competence depends on exposure, residency training alone may not provide sufficient depth to allow recent graduates to perform the newer operations independently.

1990ȁ2001 U.S. general surgery resident gastric surgery operative experience: A paradigm shift

1990ȁ2001 U.S. general surgery resident gastric surgery operative experience: A paradigm shift

A comparison of laparoscopic and open pyloromyotomy at a teaching hospital

Background/Purpose: An increasing number of pediatric surgeons are using the laparoscopic approach to treat pyloric stenosis. The advantage of laparoscopic pyloromyotomy is uncertain and has not been evaluated in the setting of a pediatric surgery fellowship program. Methods: The authors retrospectively reviewed the medical records of all patients who underwent pyloromyotomy for congenital hypertrophic pyloric stenosis at their institution from January 1, 1997 through December 31, 2000 (n = 117). Information obtained included age, sex, weight, admission laboratory values, attending surgeon, resident surgeon and their level of training, operating time, intraoperative and postoperative complications, time to full feedings, incidence of postoperative emesis, duration of postoperative emesis, length of stay, and total hospital charges. These variables then were compared between the open (OPEN) and laparoscopic (LAP) groups. Results: From January 1, 1997 through December 31, 2000, 65 LAP and 52 OPEN pyloromyotomies were performed. Characteristics of patients in the OPEN and LAP groups were similar. The mean operating time was 33 ± 2 minutes for OPEN versus 38 ± 2 minutes for LAP (P =.07). The incidence of postoperative emesis (LAP, 68%, OPEN, 65%), duration of postoperative emesis (LAP, 7.3 ± 1.2 hours; OPEN, 8.1 ± 1.8 hours), and time to full feedings (LAP, 19.5 ± 1.6 hours; OPEN, 19.5 ± 1.3 hours) did not differ significantly between groups (P >.05). Mean postoperative length of stay in both groups was similar (LAP, 31 ± 5; OPEN, 28 ± 2 hours; P =.64). Mucosal perforation occurred in 5 patients (8%) in the Lap and 2 patients (4%) in the OPEN group (P =.39). Postoperative complications occurred in 12 LAP (18%) and 6 OPEN patients (12%, P =.31). Five LAP cases were converted to OPEN. In the LAP group there was one unrecognized mucosal perforation and one incomplete pyloromyotomy both of which required reoperation. As the laparoscopic approach was adopted, general surgery resident participation as operating surgeon in these cases decreased from 81% in 1997 to 19% in 2000. Hospital charges were higher in the LAP group, but not significantly (LAP, $6,676 ± 1,005; OPEN, $5,292 ± 306; P = 27). Conclusions: Laparoscopic pyloromyotomy has progressively become the dominant surgical approach to pyloromyotomy at our institution. The LAP and OPEN approaches have similar outcomes. However, the Lap approach may be associated with increased complication rates, a reduction in general surgery resident operative experience, and higher hospital charges. J Pediatr Surg 37:1068-1071. Copyright 2002, Elsevier Science (USA). All rights reserved.

Has Nonoperative Management of Solid Visceral Injuries Adversely Affected Resident Operative Experience?

The purpose of this study was to assess the impact of increased use of nonoperative management of blunt injuries to the spleen or liver on surgical residents' operative experience with solid visceral injuries. We conducted a 10-year retrospective study of blunt spleen and liver injuries at a state-designated Level I trauma center and a survey of chief residents' operative experience with splenic and hepatic injuries from blunt trauma during the same time period. From 1990 through 1999, 431 patients were admitted with splenic injuries and 634 patients were admitted with liver injuries; 350 splenic injuries (81%) were due to blunt trauma; 317 liver injuries (50%) were caused by blunt mechanisms. In 1990 100 per cent of patients with splenic injuries and 93 per cent of those with liver injuries underwent surgery for those injuries. These rates were 19 and 28 per cent respectively in 1999. The number of patients with blunt solid visceral injuries increased more than fourfold from 1990 through 1999. The number of operations for splenic and hepatic injuries performed by chief residents did not decline significantly during this time period (5.5 cases per chief resident in 1990; 4.6 cases per chief resident in 1999). The increased numbers of patients with solid visceral injuries were due to two factors: increased proportion of blunt trauma admissions especially from motor vehicle collisions and improved recognition of spleen and liver injuries by expanded use of CT scans. We conclude that nonoperative management of blunt solid visceral injuries does not necessarily lead to a diminution of operations nor jeopardize resident education. However, trauma volumes must be high enough to support adequate operative experience.

Impact of recent trends of noninvasive trauma evaluation and nonoperative management in surgical resident education.

The use of ultrasonography and nonoperative management of solid organ injury has become standard practice in many trauma centers. Little is known about the effects of these changes on resident educational experience. We retrospectively reviewed resident evaluation of abdominal trauma and trauma operative experience as reported to the residency review committee between 1994 and 1999. A total of 4,052 patients underwent one or more of three diagnostic modalities. The nontherapeutic laparotomy rate as a result of positive diagnostic peritoneal lavages decreased from 35% to 14%. Although resident operative trauma experience was stable because of increases in operative burns and nonabdominal trauma, the number of abdominal procedures declined. Noninvasive diagnostic tests have allowed more rapid trauma evaluation and fewer nontherapeutic laparotomies. As nonoperative experience grows, the opportunity for operative experience decreases. These trends may adversely affect the education of residents and suggest that novel approaches are needed to ensure adequate operative experience in trauma.

Quality Control of Resident Operative Experience: Compliance with RRC Criteria

Purpose. Process Capability Analysis (PCA) is a quality control tool that can be applied to how resident cases are allocated. PCA measures how close an output is to its target (Cp) and its location (K) in relation to Cp. For resident cases, the statistics of Cp and K measure variability in case numbers, which is useful in planning how a program meets RRC criteria in operative experience on specialty services.Methods. A review of 6 years of vascular surgery cases (1994–1999) using PG 5 RRC case logs and the departmental quality database as sources was done. PCA was applied to resident case numbers. RRC 1997–1998 National Program Data were used to define quality control limits. The 30th, 50th, and 70th percentiles in vascular procedures served as lower, nominal, and upper control limits, respectively.Results. Cases were grouped into aortic (AO), cerebrovascular (CER), peripheral (PER), and visceral (VSC), to meet RRC definition for major reconstructions. PCA analysis of PG5 RRC submitted data, total cases reported by the graduating residents (n = 20) in their submitted RRC Case logs, and department QA log numbers over 6 years of the period revealed the following mean numbers for AO = 13.7 ± 4.2 (Cp = 0.279, K = +70.5%), CER = 15.6 ± 6.4 (Cp = 0.365, K = +78.6%), PER = 23.1 ± 10.5 (Cp = 0.237, K = +80.1%), VSC = 2.5 ± 1.5 (Cp = 0.189, K = +175.0%), and total = 55.1 ± 20.2 (Cp = 0.305, K = +70.5%).Conclusions. Processes that are in statistical control should have a Cp > 1.0, and a small K: i.e., centered tightly and near the desired nominal limit. By PCA analysis, the vascular surgery service product of PG5 case numbers is not in statistical control, but instead exceeds the defined control limits (RRC 50th percentile levels). The low Cp values demonstrate that specific case numbers may vary from resident to resident. The high positive K percentages imply that more residents have case numbers that meet or exceed RRC 50th percentiles. Sources of potential error and variability may be partially explained by the data of total case volume and resident underreporting. More accurate RRC reporting by residents could account for up to 20% more cases, potentially offsetting individual case allocation differences within a particular resident year.

The challenge of objective assessment of surgical skill

Technical performance in surgery has come under increased scrutiny in recent years, not least due to several highly publicized cases where it has been suggested that poor outcomes were the result of inadequate technical skill [ 1 Hamdorf J.M. Hall J.C. Acquiring surgical skills. Br J Surg. 2000; 87: 28-37 Crossref PubMed Scopus (177) Google Scholar , 2 Parsa C.J. Organ C.H. Barkan H. Changing patterns of resident operative experience from 1990 to 1997. Arch Surg. 2000; 135: 570-575 Crossref PubMed Scopus (41) Google Scholar , 3 Smith R. All changed, changed utterly. British medicine will be transformed by the Bristol case. BMJ. 1998; 316 ([editorial] [see comments]): 1917-1918 Crossref PubMed Scopus (256) Google Scholar ]. In the Bristol case, which involved a pediatric cardiac surgery unit, the concerns voiced by a member of medical staff have now resulted in disciplinary action against two surgeons by the General Medical Council, and a judicial inquiry, which is yet to hand down its report (www.bristol-inquiry.org.uk). The resulting debate, both public and within the profession, has focused on the need for objective and independent assessment of surgical skill, and a significant research interest has developed in this area.