Surgery Residency Training Programs Research Articles

Comparison of Quantitative Educational Metrics between Integrated and Independent Plastic Surgery Residents

The purpose of this study was to compare residents in the integrated and independent tracks of plastic surgery residency training using several quantitative educational metrics. The Harvard Combined Plastic Surgery Residency Training Program offers an ideal model for this comparison, as it is the largest in the country and operates both tracks simultaneously. The authors compared several quantitative educational metrics of all 22 independent and 24 integrated residents matched into the Harvard Program since its inception. These quantitative educational metrics include medical school reputation, United States Medical Licensing Examination (USMILE, Philadelphia, Pa.) step 1 scores, publication productivities during different educational periods (preresidency and pre-plastic surgery training), in-service scores, exit rankings (overall and operative skills), and percentage of M.D./Ph.D. residents. Integrated residents graduated from more highly ranked medical schools than independent residents (mean tier, 1.5 versus 2.3; p = 0.0345), had higher United States Medical Licensing Examination step 1 scores (mean, 235 versus 220; p = 0.0234), and had higher preresidency publication scores (mean, 68 versus 14; p = 0.015). There are more M.D./Ph.D. residents in the integrated than in the independent track (33.3 percent versus 4.4 percent; p = 0.027). Independent residents had higher pre-plastic surgery training publication scores (mean, 77 versus 6; p = 0.0003). In-training quantitative educational metrics were similar between the two tracks (p > 0.05 in all cases). To address potential caveats of the study, all publication scores were compared with and without correction for the presence of M.D./Ph.D. residents, which yielded similar results. The authors also compared the match ranks of all their residents and found them to be statistically comparable between the two tracks. In the Harvard Program, the integrated residents had better preresidency quantitative educational metrics, whereas the independent residents had better pre-plastic surgery training quantitative educational metrics. In training quantitative educational metrics were remarkably similar between the two tracks. In conclusion, this study, a systematic comparison between the two tracks, offers not only a valid foundation for future study of long-term outcome results but also a starting point from which to improve on the educational experience of residents in either track.

Evolution of cardiothoracic surgery residency training programs in India

Evolution of cardiothoracic surgery residency training programs in India

Operative Experience in an Orthopaedic Surgery Residency Program: The Effect of Work-Hour Restrictions

The implementation of Section 405 of the New York State Public Health Code and the adoption of similar policies by the Accreditation Council for Graduate Medical Education in 2002 restricted resident work hours to eighty hours per week. The effect of these policies on operative volume in an orthopaedic surgery residency training program is a topic of concern. The purpose of this study was to evaluate the effect of the work-hour restrictions on the operative experiences of residents in a large university-based orthopaedic surgery residency training program in an urban setting. We analyzed the operative logs of 109 consecutive orthopaedic surgery residents (postgraduate years 2 through 5) from 2000 through 2006, representing a consecutive interval of years before and after the adoption of the work-hour restrictions. Following the implementation of the new work-hour policies, there was no significant difference in the operative volume for postgraduate year-2, 3, or 4 residents. However, the average operative volume for a postgraduate year-5 resident increased from 274.8 to 348.4 cases (p = 0.001). In addition, on analysis of all residents as two cohorts (before 2002 and after 2002), the operative volume for residents increased by an average of 46.6 cases per year (p = 0.02). On the basis of the findings of this study, concerns over the potential adverse effects of the resident work-hour polices on operative volume for orthopaedic surgery residents appear to be unfounded.

When Things Go Wrong: The Impact of Being a Statistical Outlier in Publicly Reported Coronary Artery Bypass Graft Surgery Mortality Data

The public reporting of hospital quality and safety data is a growing phenomenon. Yet there are few reports of the effects of publicly reported data on individual organizations, particularly when the data show worse than expected performance. In this article, our hospital's response to having a mortality rate from coronary artery bypass graft surgery that was significantly higher than other programs in the Commonwealth of Massachusetts is reported. The data caused suspension of elective cardiac surgery at the institution, and an independent review of the program was undertaken. The effects of the suspension and publication of mortality data on quality and patient safety, the residency training program in cardiothoracic surgery, and the financial performance of the hospital are described. Several lessons were learned that may be of value to other health care organizations that experience a public crisis in clinical quality.

The Gap in Laparoscopic Colorectal Experience Between Colon and Rectal and General Surgery Residency Training Programs

In this article, we review the laparoscopic experience of general surgery and colorectal residency training programs in the United States during the past 5 and 12 years, respectively. The purpose of this study was to determine whether an adequate experience was being provided, and at what level of training, to safely and effectively perform advanced laparoscopy. General Surgery Operative Reports from the training years 2000 to 2004 were obtained from the Accreditation Council for Graduate Medical Education. Similarly, colorectal operative performance logs from the training years 1994 to 2005 were obtained from the American Board of Colon and Rectal Surgery. From 2000 to 2004, basic and advanced laparoscopic cases (as designated by the Accreditation Council for Graduate Medical Education) have increased from 10.1 to 12.2 percent and 2.1 to 3.7 percent, respectively. Within this period, the number of laparoscopic colon cases/resident/career has increased from 1.8 to 4.6. The percentage of cases performed laparoscopically increased from 3.9 to 22.5 percent from 1993-1994 to 2004-2005 training years. From 1993 to 2001, the average number of laparoscopic cases/resident increased from 6.3 to 16.1. In 2004, the average number of cases/resident increased to 45.3. Of this number, 30 were colon, 9.4 were rectal, and the remaining 5.9 were miscellaneous colorectal procedures. Learning curves for laparoscopic colectomy are reported in the range of 20 to 60 cases. Based on the most recent data reviewed, colon and rectal resident experience is tending toward this threshold. Recent general surgery graduates may be lacking the appropriate volume to reach proficiency in laparoscopic colorectal surgery.

The Impending Disappearance of the General Surgeon

IN THE UNITED STATES, APPROXIMATELY 1000 GENERAL SURgeons complete their residency training each year. These surgeons have completed 4 years of medical school and 5 clinical years of residency, and during residency many also have spent 1 or 2 years in a research laboratory. Thus, these physicians enter the workforce between the ages of 33 and 35 and usually have $150 000 to $250 000 in educational debt. The training of surgeons has been stable since the early 1970s, and the number of general surgery residency training programs will not likely increase. Even if new medical schools were established the number of surgeons trained would not likely increase much, because many medical students have lost interest in pursuing a career in surgery. In small urban or rural hospitals, which care for approximately 54 million patients, general surgeons care for emergencies and trauma and perform a variety of operations. They are essential to the provision of adequate health care and often are the most well-rounded surgical clinicians in the area. Therefore, training only 1000 general surgeons per year will not meet demands. Specialization also affects the general surgical workforce. Presently, approximately 70% of graduating surgical residents pursue specialized surgery training, and this percentage may be increasing. Thus, only about 300 to 400 of the 1000 general surgeons completing residency each year will choose general surgery practice. There are several reasons for surgeons to specialize. To be thoroughly competent in the face of a knowledge base that is increasing in all areas, many surgeons choose to limit the number and types of surgical procedures they perform. Additionally, it may be easier to develop expertise in some subspecialties, and more refined expertise often leads to economic rewards. In some large urban environments, subspecialists bill at higher fees than general surgeons performing the same procedures. A career as a specialist caters to the lifestyle preference of medical school graduates, who have little desire to work 80 to 100 hours per week with little time for families. They are less focused on being entrepreneurial and accept being employed by large group practices if it means they need not worry about the economics of practice and if they can have less demanding on-call schedules, which enable them to spend more time with their families. Furthermore, current surgical residents are being trained in the environment of an 80-hour work week. These individuals have come to understand that even if they have a sick patient who has not been totally stabilized, they must hand over the care of the patient to someone else. Residents are forced to be content with this system, in which they are instructed about number of work hours. While limited work hours and a lifestyle conducive to family priorities are desirable, the nature of surgical problems remains unchanged or may be more intense because of an aging patient population. For example, the situation of a patient with a perforated colon who will die in 12 to 24 hours if peritonitis is not controlled does not change so a surgeon can go home at a decent hour.

Major pancreatic resections for suspected cancer in a community‐based teaching hospital: Lessons learned

The literature reports 4-10% mortality rate, 30-60% morbidity rate, and 9-29% anastomotic leak rate after pancreaticoduodenectomy (PD) performed for periampullary tumors. These data demonstrate a linear relationship between surgical volume and outcome. The objective of this study was to evaluate the experience of a high-volume hospital with low-volume pancreatoduodenectomy for suspected cancer. The study was designed as a retrospective review of medical records of all patients who underwent pancreatoduodenal resection or total pancreatectomy for a suspected periampullary carcinoma between January 1994 and December 2003. The setting of the study was a community-based teaching hospital with a general surgery residency training program. A total of 63 patients underwent pancreatoduodenal resection or total pancreatectomy. All procedures were performed by a total of 15 different surgeons; however, 27 operations were performed by one surgeon. Pre-operative diagnosis in most cases was either a known malignancy-27 cases (43%) or a tumor of the head of the pancreas, suspicious for malignancy-36 cases (57%). One patient underwent a total pancreatectomy. In 62 patients a pancreatoduodenal resection (Whipple procedure) was performed. Post-operative 30-day mortality was 4.7% (three patients). Overall in-hospital mortality was 9.5% (six patients). Ten (16.1%) had a leak of the pancreato-jejunal anastomosis, six of which resolved with non-operative management. Of the remaining four patients, three died from peritonitis or consequences of erosive hemorrhage. Post-operative leak of the pancreatic anastomosis represents a technical challenge. Although most of the leaks can be treated non-operatively, those that lead to peritonitis or erosive hemorrhage warrant operative intervention. Major pancreatic resections can be performed safely with low rates of morbidity and operative mortality with careful selection of patients at a low-volume community-based teaching hospital.

Physician Incentives for Academic Productivity<sbt aid="1122205">An Analysis of Orthopaedic Department Compensation Strategies</sbt>

Changes in the health-care industry have led to increasing demand for physician-driven clinical volume. This environment has altered the traditional balance among teaching, research, and service responsibilities for faculty in residency training programs. As economic pressures mount and budgets shrink, academic departments are exploring ways of paying faculty that would help to maintain the global mission of the organization. The purpose of this study was to examine the compensation strategy for faculty in academic orthopaedic surgery departments in the United States with a focus on compensation methods for academic productivity. Thirty-one academic orthopaedic surgery residency training programs were recruited for the study. Two methods of data collection were used: (1) a survey was mailed electronically to the program chairpersons or the finance directors, and (2) eight program leaders were interviewed to obtain more in-depth information regarding compensation for academic productivity in their organizations. All thirty-one programs responded to the survey. To compensate faculty for clinical productivity, twenty-two programs used a salary and bonus system, two used salary alone, and the remainder used combined methods. Nineteen departments had a compensation system that included academic productivity, and twelve did not. Of those that compensated for academic work, seven used the chair's decision, six used a point system, one used academic rank alone, and the remainder used a combination of methods. The point systems varied in breadth, focus, and amount of detail. Most, but not all, departments accounted for academic productivity in their compensation system. Most programs used the chair's discretion to determine academic bonuses, but several departments had developed point systems. There are common themes with regard to this issue, including the importance of the academic mission, the need for clinical revenues, the value of flexibility and transparency, and the importance of culture and leadership.

Early Perioperative Outcomes and Pancreaticoduodenectomy in a General Surgery Residency Training Program

Current trends in national health care are triggering a reassessment of training in general surgery. Currently, 75% of general surgery residents seek postgraduate fellowship training, and significant debate has occurred regarding the best manner for surgeons to acquire competency in performing complex operations. Pancreaticoduodenectomy (PD) is a complex procedure performed infrequently by most surgical graduates. From 1990 through 1997, the average number of PD operations performed per general surgery graduate ranged from 1.5 to 2.5. We examine the surgical outcomes following PD performed by surgical resident staff in a university-based general surgery training program. Between January 2001 and October 2004, 164 patients underwent PD for periampullary disease. Data were prospectively entered into a computerized database, including resident participation. We analyzed 30-day mortality and morbidity rates. Perioperative outcomes were 30-day mortality (2.2%), pancreatic fistula (6.1%), reoperation (2.2%), average length of hospital stay (13.5 days), mean operating time (489 minutes), and median estimated blood loss (1274 ml per case). PD can be performed with an acceptable morbidity and mortality within the teaching structure of a general surgery training program. These outcomes are likely related to the performance of PD at a high-volume, tertiary center by a single surgeon and compare favorably to best-practice benchmark outcomes.

Bariatric surgery training in the United States

Background To provide evidence of the status of bariatric surgical education in the accredited surgery training programs in the United States. Methods A questionnaire was sent by mail to the 251 accredited surgery residency training programs, including the 48 minimally invasive surgery fellowship programs, in the United States. Results There was a 100% response to the questionnaire. Of the 251 surgery residency training programs and 48 minimally invasive surgery fellowship programs, 185 (73.7%) and 43 (89.6%) performed bariatric surgery, respectively. The open Roux-en- Y gastric bypass was the dominant procedure (85.1%), followed by laparoscopic Roux-en- Y gastric bypass (60.9%), in the residency programs; the laparoscopic Roux-en- Y gastric bypass was the dominant procedure (70.1%) in the minimally invasive fellowship programs. Conclusions Bariatric surgery has been mainstreamed into accredited training programs in the United States.

Impact of a surgical oncologist on general surgery residency training program

Background To assess the impact of adding a surgical oncologist to our faculty we examined the operative experience in our program before and after the addition. Methods Operative case numbers reported to the American Board of Surgery over a 10-year period were analyzed. This time period encompassed 5 years before and after the addition of a surgical oncologist to our faculty. All defined category case numbers were examined using t test analysis. Significance was defined as a P value of less than 0.05. Results The overall caseload increased in the time period after the faculty addition. There was a statistically significant increase in skin/soft tissue, breast, esophagus, small intestine, large intestine, live, spleen, and endocrine cases. No statistical significance was seen in head/neck, stomach, pancreas, and biliary cases. Conclusions The addition of a surgical oncologist to our faculty coincides with a statistically significant increase in areas of skin/soft tissue, breast, esophagus, small intestine, large intestine, liver, spleen, and endocrine. Other areas not statistically significant may reflect referral patterns or this particular oncologist's preferences of practice.

Foot and ankle experience in orthopaedic residency.

Dedicated orthopaedic residency training in the musculoskeletal discipline of foot and ankle is an important contribution to the development of a well-rounded orthopaedic surgeon. Current residency training guidelines are vague and do not require specific experience or proficiency in this discipline. A one-page questionnaire on commitment to foot and ankle education in American Orthopaedic Surgery residency training programs was completed by all 148 program directors. Eighty of the programs (54.1%) had a single faculty member dedicated to foot and ankle orthopaedics, while 21 (14.2%) did not have a faculty member with a specific interest or commitment to problems related to the foot and ankle. Fifteen programs (10.1%) did not have a committed faculty member, nor did their residents have a clinical rotation dedicated to foot and ankle. Ninety-six programs (64.9%) had at least one clinical rotation dedicated to foot and ankle. Fifty-two (35.1%) did not. Thirty-three (34.7%) of those programs with a dedicated foot and ankle experience assigned residents during at least two periods of their training. Of those programs with a single foot-specific rotation, the most common year for training was in the PGY3 year (27 of 63, 42.9%). Of the 60 months' duration of most orthopaedic residency programs, 39 of 96 (40.6%) programs with a dedicated clinical foot and ankle rotation allocated an average of 12 weeks to foot and ankle. Twenty-six (27.1%) allocated less than 3 total months, and 31 (32.3%) allocated 16 to 24 weeks of dedicated foot and ankle experience. Current residency training in the United States does not universally require a commitment to foot and ankle education. A large number of residency programs do not have a faculty member committed to foot and ankle education, and almost one-third have no time specifically allocated to foot and ankle education.

Improved continuity of care in a community teaching hospital model.

We created an ambulatory resident clinic in a community teaching hospital to improve the continuity of care in a surgery residency program. A retrospective chart review analysis. A community hospital, general surgery residency training program, and its ambulatory practice. Providence Hospital, Southfield, Mich, has established a new model, the Surgical Associates of Michigan, which is an association comprising private practice physicians serving as full-time faculty in the Department of Surgery. In addition to clarification of teaching requirements and reimbursement for educational activities, the most dramatic feature is the relocation of private practice offices and the staff surgical office to one central location within the hospital. The proximity of the staff and private surgical offices facilitates closer interaction of attending physicians, residents, and patients. Compliance rates of continuity of patient care provided by the same resident, as presented by the Surgery Residency Review Committee, including confirmation of diagnosis, provision of preoperative care, discussion with attending physician, selection and provision of intervention, direction of postoperative care, and postdischarge follow-up. Since the inception of this arrangement at our institution, surgical residents have seen 229 staff patients and 465 private patients in the offices under supervision. Compliance rate of continuity of care was defined as patient follow-up with the same senior surgical resident who performed an operation or evaluated the patient on initial presentation to the emergency department or offices. We achieved a compliance rate of 92.8% (169/182) in the staff surgical clinics. A compliance rate of 63.5% (205/323) for private general surgical patients and 70.4% (100/142) for vascular surgical patients was obtained. With the establishment of the teaching faculty group and the relocation of offices, we were able to achieve a dramatic improvement in continuity of care. In addition to fulfilling the Surgery Residency Review Committee requirements, we believe our model facilitates broader education of surgical residents and improves risk management. We recommend further similar studies, greater involvement of primary care specialties in recruiting staff surgical referrals, and implementation of a specialized computer program to continue to improve continuity of care in surgery residency programs.

Impact of a colon and rectal surgeon on a general surgery residency training program.

Most general surgery residents obtain scant exposure to anorectal disease during training. The aim of this study was to determine whether adding a colon and rectal surgeon to the faculty of a general surgery training program improves the amount or quality of the anorectal surgical experience. The surgical experience of all graduating residents from our university teaching program was reviewed during a ten-year period. Complete case data were obtained from the Residency Review Committee for surgery. The total small-intestine, colon and anorectal caseload was analyzed during the five-year period preceding the arrival of the colon and rectal surgeon and compared with the subsequent five-year period after the surgeon's arrival. There was a substantial increase in small-intestine (470 vs. 306) and anorectal cases (462 vs. 338). There was a particularly dramatic increase in anorectal cases performed during the chief resident year (159 vs. 36), which held true for all categories of anorectal cases. The addition of a full-time colon and rectal surgeon to a university general surgery residency program was associated with an increase in small-intestine and especially anorectal cases. However, most striking was the greater than fourfold increase in the number of anorectal cases performed during the chief resident year. This seems to reflect an increase in complexity of anorectal cases and an increased interest in anorectal surgery among general surgery residents.

Percutaneous endoscopic gastrostomy tube placement in a surgical training program

This study examines the patterns of use of percutaneous endoscopic gastrostomy (PEG) and primary open gastrostomy (Gtube) performed in a residency training program in surgery. A retrospective cohort study that assesses the indications and outcomes of 317 PEGs and 75 isolated Gtubes used for gastric access between 1987 and 1997. The demographics and risk factors of the patients receiving Gtube and PEG were comparable. The mean number of PEGs performed per resident is currently 13 per year (mean 5 over 10 years) with a 97% PEG success rate; an 88% success rate is demonstrated for placement of jejunal extensions. PEGs are generally preferable to Gtubes as primary procedures. Surgical residents should become competent in PEG placement by performing adequate numbers of procedures with fully trained staff.

The United States Neurological Surgery Residency Matching Program.

After 3 years of deliberations, The Society of Neurological Surgeons approved a national Neurological Surgery Matching Program in 1983 for residency positions beginning July 1, 1985. All directors of United States neurological surgery residency training programs agreed to participate and abide by the rules of the match. A review of 10 years' experience with 11 matches from 1983 to 1994 indicates full acceptance by both applicants and program directors and a highly successful process and outcome, satisfactory for everyone except for qualified applicants who failed to obtain a residency position. Since 1985, 1455 neurosurgical (Postgraduate Year 2) residency positions have been offered for match, and 2708 applicants have submitted a ranking list, filling 1434 positions with the initial computer run each year and leaving 1274 unmatched applicants. Thus, the ratio of applicants to available positions is almost 2:1. Various interesting details about multiple-year applications, International Medical Graduates, and nonstart, transfer, and dropout rates are presented, including the eventual practice activities of residents not completing neurosurgical training. A comparison of all United States medical schools, considering data on applications and matches for neurosurgical residency versus number of senior medical students, reveals wide differences. These differences are probably related to the availability of neurosurgical clerkships, faculty participation in the undergraduate curriculum, and the presence of a neurosurgical residency program.

Laser safety programs in general surgery.

General surgery represents a speciality where, while any procedure can be performed with lasers, there are no procedures for which the laser is the sine quo non. The general surgeon may perform a variety of procedures with a multitude of laser wavelengths and technologies. Laser safety in general surgery requires a multidisciplinary approach. Effective laser safety requires the oversight of the hospital's "laser usage committee" and "laser safety officer" while providing a workable framework for daily laser use in a variety of clinical scenarios simultaneously. This framework must be user-friendly rather than oppressive. This presentation will describe laser safety at the Rochester General Hospital, a tertiary care, community-based teaching hospital. The safety program incorporates the following components: input to physician credentialing and training, education and in-servicing of nursing and technical personnel, equipment purchase and maintenance, quality assurance, and safety monitoring. The University of Rochester general surgery residency training program mandates laser training during the PGY-2 year. This program stresses the safe use of lasers and provides the basis for graded hands-on experience during the surgical residency. The greatest challenge for laser safety in general surgery centers on the burgeoning field of minimally invasive surgery. Safety assurance must be balanced so as to maintain a safe operating-room environment while ensuring patient safety and the ability to permit the surgery to proceed efficiently. Safety measures for laparoscopic procedures must be sensitive to the needs of the surgical team while not providing confusing signals for the "gallery" observers. This task is critical for the safe operation of lasers in general surgery. Effective laser safety in general surgery requires constant vigilance tempered with sensitivity to the needs of the surgeon and the patient as laser technology and its applications continue to evolve.

Major Hepatic Resection in a Residency Training Program*

Records of 30 major hepatic resections performed at David Grant USAF Medical Center and Wilford Hall USAF Medical Center were analyzed to assess the feasibility, safety, and resources required for such procedures in a general surgery residency training program. The mean intraoperative blood loss during surgery was 2022 mL and the mean intraoperative transfusion volume was 4.2 units of packed red blood cells. Patients spent an average of 2.7 days in the intensive care unit, with a mean overall postoperative stay of 15 days. One death occurred within 30 days of operation due to a postoperative myocardial infarction, and another death during the hospital stay was due to hepatic insufficiency and Candida endocarditis. Overall, five major postoperative complications occurred (17%), one requiring reoperation. All but one procedure was done by a closely supervised surgical resident. This experience compares favorably with others in the literature and supports the practice of hepatic resection as part of surgical training.

Selecting a residency training program in neurological surgery

Selecting a residency training program in neurological surgery

Selecting a residency training program in neurological surgery: some observations on certain nonquantifiable data.

Selecting a residency training program in neurological surgery: some observations on certain nonquantifiable data.