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

See one, do one, teach one - Trends in resident autonomy and teaching assistant cases during general surgery residency in the United States: A nationwide retrospective analysis

INTRODUCTION

Autonomy during residency is crucial to the training and development of competent surgeons. An essential component of this process is the 'teaching assistant (TA)' case, an indispensable opportunity for residents to gain confidence and hone intraoperative skills. However, high-quality data on the volume and diversity of cases that graduates perform are scarce.

METHODS

A retrospective analysis was performed from publicly collected data of operative case logs from general surgery residents graduating from ACGME-accredited programs from 2006 to 2023. Data on the median overall number of surgeon chief and TA cases were retrieved. Collected data were organized based on sub-specialties. The Mann-Kendall trend test was used to investigate trends in TA cases and surgeon chief operative volume.

RESULTS

Between 2007 and 2023, the surgeon chief cases gradually increased from 229 to 274 (19.6 ​% increase; τ ​= ​0.610, p ​= ​0.001). There was a concurrent 72.7 ​% increase in TA cases from a median of 22-38 (τ ​= ​0.574, p ​= ​0.001). Surgeon chief (283 per resident) and TA cases (43 per resident) peaked in 2018-2019 and 2016-2017. The uptrend in TA cases was associated with the significant increase in colorectal (τ ​= ​0.559, p ​= ​0.001), general surgery-other (τ ​= ​0.404, p ​= ​0.018), and hepatopancreaticobiliary (HPB) (τ ​= ​0.596, p ​= ​0.001) subspecialties. Trauma and vascular surgery did not change significantly. With respect to total chief cases, general surgery-other (τ ​= ​0.956, p=<0.001), HPB (τ ​= ​0.713, p=<0.001) and colorectal (τ ​= ​0.522, p ​= ​0.004) volume increased. There was no significant change in trauma and foregut volume, while the volume of endocrine (τ ​= ​-0.485, p ​= ​0.006) and vascular surgery (τ ​= ​0.603, p ​= ​0.001) dropped significantly. The procedural category with the highest chief and TA volume was 'colorectal tract - large intestine.' Most procedural categories (53.49 ​%) retained a median of 0 teaching cases. No chief cases were logged for the specialties generally not considered part of general surgery (genitourinary, nervous system, orthopedics, and gynecology), although a median of 1 surgeon chief genitourinary case was recorded from 2018 to 2023.

CONCLUSIONS

Over the past seventeen years, there has been a gradual uptrend in the number of surgeon chief and TA cases. While this is a positive indicator of improved autonomy, further research must focus on strategies to improve resident autonomy to train well-rounded surgeons safely.

Educational Value of Surgical Residents Operating as Teaching Assistant

OBJECTIVE

To assess the educational of value of teaching assistant (TA) cases from the perspectives of attending, chief resident, and junior resident. We hypothesized the greatest educational value of TA cases would be for chief residents more so than other team members.

DESIGN

A prospective survey was designed and collected for TA cases separately from attendings, chief residents, and junior residents to assess operative details and educational value. The study period ran from August 2021 through December 2022. Qualitative and quantitative analysis was undertaken to compare answers and discover themes in the free-text responses of attendings and residents.

SETTING

Single center, tertiary care institution, Maine Medical Center, Department of Surgery, Portland, ME PARTICIPANTS: Sixty-nine teaching assistant cases were captured from a total of 117 completed surveys that were completed by 44 chief residents, 49 junior residents, 22 attendings (n = 22) and 2 APPs.

RESULTS

A wide variety of TA cases were included in the study with the most common reason for performing a TA case being resident request 68%. Operative complexity was most commonly rated easiest third (50%) and middle third (41%) of overall cases. Both junior and chief residents felt that compared to working with an attending alone, TA cases contributed more or much more to their procedural independence >80% of the time. Attendings reported learning something about the resident's skills that they were not expecting in 59% of the cases. Thematic analysis: attendings focused on the steps of the procedure, including the technical aspects, particularly regarding opening while residents largely focused on communication and preparation.

CONCLUSIONS

Teaching assistant cases seem to have more educational value for chief and junior residents than attendings. Both junior and chief residents felt that compared to working with an attending alone, TA cases contributed more or much more to their procedural independence >80% of the time.

COVID-19 Did Not Stop the Rising Tide: Trends in Case Volume Logged by Surgical Residents

INTRODUCTION

The coronavirus pandemic has profoundly impacted all facets of surgical care, including surgical residency training. The objective of this study was to assess the operative experience and overall case volume of surgery residents before and during the pandemic.

METHODS

Using data from the Accreditation Council for Graduate Medical Education annual operative log reports, operative volume for 2015 to 2021 graduates of Accreditation Council for Graduate Medical Education -accredited general, orthopedic, neuro- and plastic surgery residency programs was analyzed using nonparametric Kendall-tau correlation analysis. The period before the pandemic was defined as AY14-15 to AY18-19, and the pandemic period was defined as AY19-20 to AY20-21.

RESULTS

Operative data for 8556 general, 5113 orthopedic, 736 plastic, and 1278 neurosurgery residency graduates were included. Between 2015 and 2021, total case volume increased significantly for general surgery graduates (Kendall's tau-b: 0.905, p = 0.007), orthopedic surgery graduates (Kendall's tau-b: 1.000, p = 0.003), neurosurgery graduates (Kendall's tau-b: 0.905, p = 0.007), and plastic surgery graduates (Kendall's tau-b: 0.810, p = 0.016). Across all specialties, the mean total number of cases performed by residents graduating during the pandemic was higher than among residents graduating before the pandemic, though no formal significance testing was performed. Among general surgery residents, the number of cases performed as surgeon chief among residents graduating in AY19-20 decreased for the first time in 5 years, though the overall volume remained higher than the prior year, and returned to prepandemic trends in AY20-21.

CONCLUSIONS

Over the past 7 years, the case volume of surgical residents steadily increased. Surgical trainees who graduated during the coronavirus pandemic have equal or greater total operative experience compared to trainees who graduated prior to the pandemic.

Trends in pancreatic surgery experience in general surgery residency in the US, 1990–2021

BACKGROUND

We hypothesized a decline in resident pancreatic operative experience. The study assesses trends in that experience since 1990.

METHODS

Accreditation Council for Graduate Medical Education (ACGME) national case log data of general surgery residency graduates from 1990 to 2021 were reviewed. Collected and analyzed were the mean and median total number of pancreatic operations per resident, the mean number of specific case types performed, and the annual number of residency graduates. For selected procedures, the mean number of cases by resident role (Surgeon-Chief and Surgeon-Junior) was also analyzed.

RESULTS

Both the mean and median total number of resident pancreatic operations has declined since 2009 as have the mean number of several specific pancreatic case types, including resections. The annual number of residency graduates has significantly increased since 1990, and particularly since 2009.

CONCLUSIONS

Resident volume in pancreatic operations has significantly declined over the last decade.

Graded operative autonomy in emergency appendectomy mirrors case-complexity: surgical training insights from the SnapAppy prospective observational study

INTRODUCTION

Surgical skill, a summation of acquired wisdom, deliberate practice and experience, has been linked to improved patient outcomes. Graded mentored exposure to pathologies and operative techniques is a cornerstone of surgical training. Appendectomy is one of the first procedures surgical trainees perform independently. We hypothesize that, given the embedded training ethos in surgery, coupled with the steep learning curve required to achieve trainer-recognition of independent competency, 'real-world' clinical outcomes following appendectomy for the treatment of acute appendicitis are operator agnostic. The principle of graded autonomy matches trainees with clinical conditions that they can manage independently, and increased complexity drives attending input or assumption of the technical aspects of care, and therefore, one cannot detect an impact of operator experience on outcomes.

MATERIALS AND METHODS

This study is a subgroup analysis of the SnapAppy international time-bound prospective observational cohort study (ClinicalTrials.gov Trial #NCT04365491), including all consecutive patients aged ≥ 15 who underwent appendectomy for appendicitis during a three-month period in 2020-2021. Patient- and surgeon-specific variables, as well as 90-day postoperative outcomes, were collected. Patients were grouped based on operating surgeon experience (trainee only, trainee with direct attending supervision, attending only). Poisson and quantile regression models were used to (adjusted for patient-associated confounders) assess the relationship between surgical experience and postoperative complications or hospital length of stay (hLOS), respectively, adjusted for patient-associated confounders. The primary outcome of interest was any complications within 90 days.

RESULTS

A total of 4,347 patients from 71 centers in 14 countries were included. Patients operated on by trainees were younger (Median (IQR) 33 [24-46] vs 38 [26-55] years, p < 0.001), had lower ASA classifications (ASA ≥ 3: 6.6% vs 11.6%, p < 0.001) and fewer comorbidities compared to those operated on by attendings. Additionally, trainees operated alone on fewer patients with appendiceal perforation (AAST severity grade ≥ 3: 8.7% vs 15.6%, p < 0.001). Regression analyses revealed no association between operator experience and complications (IRR 1.03 95%CI 0.83-1.28 for trainee vs attending; IRR 1.13 95%CI 0.89-1.42 for supervised trainee vs attending) or hLOS.

CONCLUSION

The linkage of case complexity with operator experience within the context of graduated autonomy is a central tenet of surgical training. Either subconsciously, or by design, patients operated on by trainees were younger, fitter and with earlier stage disease. At least in part, these explain why clinical outcomes following appendectomy do not differ depending on the experience of the operating surgeon.

Unreasonable Expectations: A Call for Training and Educational Transparency in Gender-affirming Surgery

Although in most areas of practice, there is a reasonable expectation that doctors are sufficiently trained to offer care, this is not true in the case of gender-affirming procedures, which are not required learning in any surgical residency. At the current time, the field of gender surgery is too rapidly evolving, with available resources too scarce for fellowship or residency training to be a realistic requirement for offering these procedures, as the demand already outstrips the available workforce. However, patients are currently given too little information about surgeons' history with these procedures to provide truly informed consent. There is, as such, an ethical mandate to mold the culture of gender-affirming surgery such that surgeons are expected to routinely disclose relevant information about their training, experience, and outcomes to facilitate patient decision-making about care.

Autonomía y supervisión operatorias del residente de cirugía: Una mirada en la pandemia por COVID-19

Introducción. Al declararse la pandemia por SARS-CoV-2, se establecieron múltiples cambios en los sistemas de salud y en las instituciones hospitalarias, influyendo en la actividad quirúrgica global. El objetivo de este estudio fue evaluar el impacto de la pandemia en los niveles de autonomía y supervisión operatorias de los residentes de cirugía. Métodos. Estudio analítico cuasi-experimental, que incluyó los procedimientos quirúrgicos registrados por residentes de cirugía general de la Universidad de La Sabana, de febrero de 2019 a agosto de 2021. Se analizaron la autonomía y la supervisión mediante la escala Zwisch en los periodos prepandemia y pandemia. Resultados. Se recolectaron datos de 10.618 procedimientos en el periodo establecido, la mayoría realizados con abordaje abierto (57,4 %) y en rotaciones tronculares de cirugía general (65 %). Los procedimientos realizados más frecuentes fueron apendicectomía (18,6 %), colecistectomía (18,4 %) y herniorrafías (8,6 %). Se encontró una disminución estadísticamente significativa en los niveles globales de autonomía y supervisión entre los periodos analizados de 2, 4/4, 0 a 2, 2/4, 0 (p<0,001). Discusión. La disminución en la autonomía percibida por los residentes podría corresponder al impacto negativo en la motivación intrínseca de los individuos, en la disminución objetiva en el logro de las competencias esperadas en su proceso de formación quirúrgica y a la pérdida del relacionamiento colectivo propiciado por los aislamientos y limitaciones vividos. Conclusión. La pandemia por COVID-19 impactó negativamente en la autonomía y supervisión operatoria de los residentes de cirugía general de la Universidad de La Sabana, Chía, Colombia.

Teaching assistant cases in general surgery training - A literature review

BACKGROUND

There is a lack of understanding of the scope and purpose of teaching assistant cases, impact on patients and safety, as well as the facilitators or barriers to resident participation in these cases.

METHODS

Four databases (PubMed, Embase, Web of Science, and the Education Resources Information Center), were searched. The references of identified resources were additionally hand-searched. 10 articles were identified and considered in the literature review.

RESULTS

The TA case literature focuses on case numbers and safety. The discussions of papers allude to perceived benefits of TA cases. The literature review reveals that residents are more likely to be granted TA opportunities if they show themselves worthy of entrustment.

CONCLUSIONS

The work elucidates aspects of TA cases that have not previously been emphasized or highlighted. The literature review can serve to inform attending surgeons and trainees how to optimize the opportunities teaching assistant cases can afford.

Evaluating chief resident readiness for the teaching assistant role: The Teaching Evaluation assessment of the chief resident (TEACh-R) instrument

BACKGROUND

The American Board of Surgery has mandated chief residents complete 25 cases in the teaching assistant (TA) role. We developed a structured instrument, the Teaching Evaluation and Assessment of the Chief Resident (TEACh-R), to determine readiness and provide feedback for residents in this role.

METHODS

Senior (PGY3-5) residents were scored on technical and teaching performance by faculty observers using the TEACh-R instrument in the simulation lab. Residents were provided with their TEACh-R scores and surveyed on their experience.

RESULTS

Scores in technical (p < 0.01) and teaching (p < 0.01) domains increased with PGY. Higher technical, but not teaching, scores correlated with attending-rated readiness for operative independence (p 0.02). Autonomy mismatch was inversely correlated with teaching competence (p < 0.01). Residents reported satisfaction with TEACh-R feedback and desire for use of this instrument in operating room settings.

CONCLUSION

Our TEACh-R instrument is an effective way to assess technical and teaching performance in the TA role.

Impact of Robotic Surgery on Residency Training for Herniorrhaphy and Cholecystectomy

Robotic surgery has increased for common general surgery procedures. This study evaluates how robotic use affects the case distributions of herniorrhaphy and cholecystectomy for general surgery residents according to postgraduate year (PGY). We reviewed Accreditation Council for Graduate Medical Education (ACGME) biliary or hernia cases logged by surgical residents in the academic year 2017-2018. Operative reports were reviewed to compare approaches (robotic, laparoscopic, and open) by resident role and PGY level. Open cholecystectomies were excluded. Overall, 470 hernia and 657 cholecystectomy cases were logged. Hernia repairs were performed robotically in 15.9%, laparoscopically in 9.5%, and open in 74.7%. Cholecystectomies were performed robotically in 16.4% and laparoscopically in 83.6%. Residents were teaching assistants in 1.8% of hernia repairs and 1.5% of cholecystectomies. Distribution of cases by technique and PGY level was significantly different for both procedures, with chief residents performing the majority of robotic cholecystectomies (52.6%, P < .0001) and hernia repairs (59.7%, P < .0001). Migration of robotic cases to senior resident level and low percentage of teaching assistant roles held by residents suggest exposure to common operations may be delayed during general surgery residency training. Introduction of new technology in surgical training should be carefully reviewed and may benefit from a structured curriculum.

Robotic Cholecystectomy Is a Safe Educational Alternative to Laparoscopic Cholecystectomy During General Surgical Training: A Pilot Study

OBJECTIVE

The role of robotic surgery in general surgery (GS) continues to expand. Several programs have integrated robotic-based simulators and models into surgical education; however, residents' robotic experience in the operating room is currently limited. We sought to assess the safety and feasibility of robotic cholecystectomy (RC) when independently performed by GS chief residents.

METHODS

From June 2016 to October 2018, RC and laparoscopic cholecystectomies (LC) performed independently by chief residents on a resident staff surgical service were prospectively included. Patient demographics, intraoperative variables, and postoperative complications were analyzed and compared between both cohorts.

RESULTS

A total of 20 RC and 70 LC were included. Patient characteristics, indications for surgery, and comorbidities were similar in both groups. RC was more likely to be performed electively (95% vs. 17.1%, p < 0.001). No difference in operative time, estimated blood loss, intraoperative bile duct injury, or conversion to open was observed. Patients undergoing LC had an overall longer mean length of hospital stay (2.7 days ± 2.1 vs. 0.8 days ± 0.4, p < 0.001); however, length of hospital stay was similar between RC and LC performed electively (p = 0.946). No difference in postoperative complications and 30-day readmission was observed.

CONCLUSIONS

RC can be safely and independently performed by GS residents with similar outcomes as LC. Efforts should be directed toward creating a platform to bridge competent simulator skills into safe performance in the operating suite. The integration of robotic training into the core GS curriculum should be encouraged.

Variability in gynecologic case volume of obstetrician-gynecologist residents graduating from 2009 to 2017

BACKGROUND

Residency training in obstetrics-gynecology has changed significantly over time, with residents expected to master an increasing number of surgical procedures. Residency operative case logs are tracked by the Accreditation Council for Graduate Medical Education, which sets case minimums for all procedures. In 2018, the Accreditation Council for Graduate Medical Education created a combined minimally invasive hysterectomy category and now requires graduating residents to complete a minimum of 70 minimally invasive hysterectomies.

OBJECTIVES

The objectiges of the study were to evaluate the range of operative gynecological experience across graduating obstetrician-gynecologist residents in the United States and to estimate the number of residents able to meet new Accreditation Council for Graduate Medical Education minimum hysterectomy cases.

STUDY DESIGN

Accreditation Council for Graduate Medical Education surgical case logs of graduating obstetrician-gynecologist residents from 2009 to 2017 were analyzed for case volume trends.

RESULTS

The average total number of gynecological cases per resident decreased from 438.2 to 431.5 (P < .0001). Minimally invasive hysterectomy averages increased from 43.6 to 69.3 (P < .0001), a trend driven principally by an increase in total laparoscopic hysterectomies. Mean case log decreases were noted in invasive cancer (70.7 to 54.3), incontinence and pelvic floor (85.6 to 56.7), and total abdominal hysterectomies (74.4 to 42.9); (P < .0001 for all). Mean increases were seen in total laparoscopic (118.8 to 146.3) and operative hysteroscopy (68.6 to 77.1) cases (P < .0001 for all). The ratio of the 90th percentile to the 10th percentile of resident case logs showed substantial variation in surgical volume for all procedures, although this ratio decreased over time. Graduates who logged 70 minimally invasive hysterectomy cases were estimated to fall at the 51st percentile in 2017; this was down from the 91st percentile in 2009.

CONCLUSION

Nationwide, graduates of obstetrician-gynecologist residency experience significant variability in their surgical training. Based on our extrapolation of Accreditation Council for Graduate Medical Education data, approximately half of residency graduates fell below the 70 case minimally invasive hysterectomy minimum in 2017. Meeting the new Accreditation Council for Graduate Medical Education hysterectomy minimums may be challenging for a significant proportion of residency programs. Understanding the scope and variability of gynecology training is needed to continue to improve and address gaps in resident education.

Current status of pain medicine training in anesthesiology and pain medicine residency programs in university hospitals of Korea: a survey of residents’ opinions

Background

In Korea, anesthesiologists are expected to be mainstream pain medicine (PM) practitioners. However, anesthesiology and pain medicine (APM) residency programs mostly emphasize anesthesia learning, leading to insufficient PM learning. Therefore, this study evaluated the current status of PM training in APM residency programs in 10 Korean university hospitals.

Methods

Overall, 156 residents undergoing APM training participated anonymously in our survey, focusing on PM training. We assessed the aim, satisfaction status, duration, opinion on duration, desired duration, weaknesses of the training programs and plans of residents after graduating. We divided the residents into junior (first and second year) and senior (third and fourth year). Survey data were compared between groups.

Results

Senior showed significantly different level of satisfaction grade than did junior (p=0.026). Fifty-seven (81.4%) residents in junior and forty (46.5%) residents in senior underwent PM training for ≤2 months. Most (108; 69.2%) residents felt that the training period was too short for PM learning and 95 (60.9%) residents desired a training period of ≥6 months. The most commonly expressed weakness of the training was low interventional opportunity (29.7%), followed by short duration (26.6%). After residency, 80 (49.1%) residents planned to pursue a fellowship.

Conclusions

Dissatisfaction with PM training was probably due to a structural tendency of the current program towards anesthesia training and insufficient clinical experience, which needs to be rectified, with a change in PM curriculum.

Variations in Teaching Assistant Case Experience during General Surgical Residency

In 2014 to 2015, the American Council for Graduate Medical Education required that graduating surgical residents must complete 25 cases as a teaching assistant (TA). The definition of TA varies among programs. The purpose of this study is to gain insight into how many cases residents log as a TA, the operative setting, and the types of cases performed. An online survey of 21 questions was sent via email to all general surgery program directors across the nation between August and October of 2015. Questions regarding the number of cases performed as TA, types of cases performed, and the operative setting were asked. We received 88 responses of 200 surveys sent. Fifty-two per cent of programs stated that their graduating residents log more than 25 cases as TA on graduating. All 88 respondents stated that senior residents acted as TAs in the operating room; of these respondents, 59 per cent stated that senior residents acted as TAs in the clinic also, 66 per cent on floors, and 70 per cent in the emergency room. The definition of TA differs among programs. Also, the types of cases that residents log as TA varies among programs as there are no clear guidelines set by the American Council for Graduate Medical Education as to what constitutes a TA case. Nonetheless, in most programs, senior residents perform more than 25 TA cases.

What They May Not Tell You and You May Not Know to Ask: What is Expected of Surgeons in Their First Year of Independent Practice

OBJECTIVE

The objective of this study was to explore the views and expectations that practicing general surgeons have of their junior colleagues who have recently finished training.

DESIGN

This is a qualitative study performed using focus group data consisting of open-ended questions concentrating on essential qualities and attributes of surgeons, behaviors observed in newly-graduated surgeons, and appropriate oversight of junior partners. Qualitative analysis was performed using grounded theory methodology with transcripts coded by 3 independent reviewers.

SETTING

Focus groups were conducted with surgeons practicing in rural and urban community settings.

PARTICIPANTS

Focus groups consisted of practicing general surgeons throughout the state of Oregon.

RESULTS

Focus groups were comprised of 31 practicing surgeons (10 female, 21 male) with varying ages and levels of experience practicing in both rural and urban environments. Qualitative analysis revealed the need for surgeons with strong interpersonal skills, teamwork, judgment, and broad technical skills who possess the appropriate amount of confidence and know when to ask for help. Frequently noted themes identified, included not knowing when to ask for help, overconfidence or underconfidence, as well as lack of judgment and lack of either quality or breadth of technical skill. Current oversight included direct observation, subjective evaluations from staff and colleagues, analysis of outcomes/quality, and either formal or informal mentorship arrangements.

CONCLUSIONS

This study highlights the need for graduating surgeons to be competent in multiple domains. The importance of knowing when to ask for help was stressed by practicing surgeons in both the rural and urban community setting, but is underemphasized in residency training, possibly due to less indirect resident supervision. Surgeons also emphasized the importance of mentorship, as professional growth continues long after completion of training.

Is There an Influence of Surgeon's Experience on the Clinical Course in Patients With a Proximal Femoral Fracture?

OBJECTIVES

Teaching of surgical procedures is of paramount importance. However, it can affect patients outcome. The aim of this study was to evaluate if teaching of hip fracture surgery is an independent predictor for negative in-hospital outcome.

DESIGN AND SETTING

Retrospectively, we analyzed all hip fracture patients between 2008 and 2013 recorded in a national quality measurement database (AQC). Inclusion criteria were proximal femoral fracture (ICD-10 diagnostic codes S72.00-S72.11), surgical care of those fracture and a documented teaching status of the intervention. Variables were sought in bivariate and multivariate analyses. Teaching status was entered in multiple regression analysis models for in-hospital death, complications and length of stay while controlling for confounders.

PARTICIPANTS

In the 6-year study period, a total of 4397 patients at a mean age of 80 years met the inclusion criteria. Totally, 48% (n = 2107) of the procedures were conducted as teaching interventions. The rest of our examined cases (n = 2290) were conducted as nonteaching procedures.

RESULTS

There was no association between teaching and mortality, but complications (odds ratio = 1.3; 95% CI: 1.04-1.5; p = 0.018) and prolonged hospitalization (standardized beta = 0.045, p = 0.002) were more likely to occur in the teaching group while controlling for confounders.

CONCLUSIONS

There appears to be no effect of the educational status on the in-hospital death in patients with a proximal femoral fracture. However, teaching was an independent predictor of complications and longer length of stay. Although the differences were significant, the clinical outcome was comparable in both groups, thus justifying the benefits of resident teaching.

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

BACKGROUND

Although overall operative volume has remained stable since the implementation of duty hours, more detailed analyses suggest shifts in the resident operative experience. Understanding these differences allows educators to better appreciate the impact of the current training environment on resident preparation for practice.

METHODS

National Accreditation Council for Graduate Medical Education case logs from 1990 to 2016 were reviewed. Statistical analysis was performed using analysis of variance and linear regression analysis.

RESULTS

Over the study period there was no change in total major cases. Subcategory analysis revealed an increase in skin and soft tissue, alimentary tract, abdomen, and endocrine with a concurrent decrease in breast, pediatrics, and trauma. During this time, residents completed fewer cases during their chief year, operated more during non-chief years, taught fewer operations, and assisted in minimal cases. Finally, a decrease in the variability of overall operative volume for total major cases was found as a result of 90th and 10th percentiles converging toward the median.

CONCLUSION

Although total major cases logged by residents have remained stable, the operative experience of general surgery residents has narrowed significantly. Residents are operating earlier and performing fewer teaching and first assistant cases. Surgical educators must look beyond total case numbers and be aware of these changes to ensure all residents achieve technical competency on graduation.

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

BACKGROUND

Although national operative volumes have remained stable, surgical educators should appreciate the changing experience of today's surgical residents. We set out to evaluate operative volume trends at our institution and study the impact of resident learning styles on operative experience.

MATERIALS AND METHODS

The Accreditation Council for Graduate Medical Education operative log data from 1999 to 2017 for a single general surgery residency program were examined. All residents completed the Kolb Learning Style Inventory. Statistical analyses were performed using linear regression analysis, Student's t-test, and Fischer's exact test.

RESULTS

Over the study period, 106 general surgery residents graduated from our program. There were 87% action learners and 13% observation learners. Although there was no change in total major, total chief, or total non-chief cases, a decrease in teaching assistant cases was observed. Subcategory analysis revealed that there was an increase in operative volume on graduation in the following categories: skin, soft tissue, and breast; alimentary tract; abdomen; pancreas; operative trauma; pediatric; basic laparoscopy; complex laparoscopy; and endoscopy with a concurrent decrease in liver, vascular, and endocrine. Learning style analysis found that action learners completed significantly more cases than observation learners in most domains in which operative volume increased.

CONCLUSIONS

While the operative volume at our center remained stable over the study period, the experience of general surgery residents has become narrowed toward a less subspecialized, general surgery experience. These shifts may disproportionally impact trainees as observation learners operate less than action learners. Residency programs should therefore incorporate methods such as learning style assessment to identify residents at risk of a suboptimal experience.

Supervision and autonomy of ophthalmology residents in the outpatient Clinic in the United States: a survey of ACGME-accredited programs

BACKGROUND

The development and demonstration of incremental trainee autonomy is required by the ACGME. However, there is scant published research concerning autonomy of ophthalmology residents in the outpatient clinic setting. This study explored the landscape of resident ophthalmology outpatient clinics in the United States.

METHODS

A link to an online survey using the QualtricsTM platform was emailed to the program directors of all 115 ACGME-accredited ophthalmology programs in the United States. Survey questions explored whether resident training programs hosted a continuity clinic where residents would see their own patients, and if so, the degree of faculty supervision provided therein. Metrics such as size of the resident program, number of faculty and clinic setting were also recorded. Correlations between the degree of faculty supervision and other metrics were explored.

RESULTS

The response rate was 94%; 69% of respondents indicated that their trainees hosted continuity clinics. Of those programs, 30% required a faculty member to see each patient treated by a resident, while 42% expected the faculty member to at least discuss (if not see) each patient. All programs expected some degree of faculty interaction based upon circumstances such as the level of training of the resident or complexity of the clinical situation. 67% of programs that tracked the contribution of the clinic to resident surgical caseloads reported that these clinics provided more than half of the resident surgical volumes. More ¾ of resident clinics were located in urban settings. The degree of faculty supervision did not correlate to any of the other metrics evaluated.

CONCLUSIONS

The majority of ophthalmology resident training programs in the United States host a continuity clinic located in an urban environment where residents follow their own patients. Furthermore, most of these clinics require supervising faculty to review both the patients seen and the medical documentation created by the resident encounters. The different degrees of faculty supervision outlined by this survey might provide a useful guide presuming they can be correlated with validated metrics of educational quality. Finally, this study could provide an adjunctive resource to current international efforts to standardize ophthalmic residency education.

Effectiveness of a Low-Cost Drilling Module in Orthopaedic Surgical Simulation

INTRODUCTION

Financial pressures and resident work hour regulations have led to adjunct means of resident education such as surgical simulation. The purpose of this study is to determine the effectiveness of a hands-on training session in orthopaedic drilling technique educational model during a surgical simulation on reducing drill plunging depth and to determine the effectiveness of senior residents teaching a hands-on training session in orthopaedic drilling technique.

METHODS

A total of 13 participants (5 orthopaedic interns and 8 medical students) drilled until they penetrated the far cortex of a synthetic bone model and the plunging depth (PD) was measured. They were then randomized and underwent an education session with an attending orthopaedic surgeon or a senior resident. Next, the subjects drilled again with the PD being calculated. The preeducational and posteducational session were compared to determine if there was any improvement in PD and if there was a difference between educators. The cost of the model was also determined.

RESULTS

The mean maximum PD and mean PD before the education session was 1.58 (1.40-2.10) and 1.50cm (1.36-1.76), respectively. Following the educational session, the mean maximum PD and mean PD were 0.53 (0.42-0.75) and 0.50cm (0.40-0.72), respectively. These were both significantly lower than before the education session (p <0.05). After the educational session taught by the attending versus the session taught by the resident, the mean maximum PD was 0.59 (0.42-0.75) and 0.49cm. (0.45-0.75), respectively (p = 0.44). After the educational session taught by the attending versus the session taught by the resident, the mean PD was 0.54 (0.40-0.72) and 0.47cm. (0.40-0.65), respectively (p = 0.44). The cost of the station per participant was $5.44.

CONCLUSION

This study demonstrated a significant reduction in drilling PD with use of a low-cost training model and a formal didactic and skills session on proper drilling technique that can effectively be led by senior residents.

Resident and Attending Perceptions of Resident Involvement: An Analysis of ACGME Reporting Guidelines

OBJECTIVE

For general surgery residents (Residents) to log an operation, the ACGME requires "significant involvement" in diagnosis (DX), operation selection (SEL), operation (OPR), preoperative (PRE), and postoperative (POC) care. We compared how residents and attending surgeons (Attendings) perceived residents' role in each of these core requirements.

DESIGN

Residents and attendings completed surveys postoperatively regarding responsibility for each core requirement on a 5-point Likert scale from "Completely Attending" to "Completely Resident." Significance was determined using Chi-square analysis (p < 0.05) and degree of agreement was calculated using Spearman's rank correlation (r_s).

SETTING

Boston Medical Center, Boston, MA (tertiary institution).

RESULTS

A total of 302 paired surveys were analyzed. Residents more often performed a significant portion of the later stages of care (DX = 27%, PRE = 29%, SEL = 27%, OPR = 87%, and POC = 84%). Residents completed the majority of each requirement more frequently in operations performed in the acute setting compared to elective operations: DX (70% vs 8%, p < 0.01), PRE (74% vs 10%, p < 0.01), SEL (65% vs 11%, p < 0.01), OPR (100% vs 89%, p = 0.02), POC (100% vs 77%, p < 0.01). Resident participation was inversely related to operational complexity for DX (p < 0.01), PRE (p < 0.01), SEL (p < 0.01), and OPR (p = 0.01). Resident involvement in OPR increased at the end of the academic year (p = 0.05) and when working with junior attendings (<5 years in practice) (p = 0.01). Interpair agreement was greatest for DX (r_s = 0.70) and lowest for POC (r_s = 0.35). When residents and attendings did not agree in their answers, residents generally overstated their contribution to the DX (68%), PRE (58%), and SEL (64%) but understated their contribution in OPR (63%) and POC (62%).

CONCLUSIONS

Residents and attendings demonstrated reliable agreement for most core requirements, but residents were often unable to be involved in all 5 core requirements. Resident involvement was weighted toward later stages of patient care, yet residents often underestimated their contributions. Operational acuity, complexity, and attending experience correlated with resident operative involvement.

Meta-analysis of operative experiences of general surgery trainees during training

BACKGROUND

General surgical training curricula around the world set defined operative numbers to be achieved before completion of training. However, there are few studies reporting total operative experience in training. This systematic review aimed to quantify the published global operative experience at completion of training in general surgery.

METHODS

Electronic databases were searched systematically for articles in any language relating to operative experience in trainees completing postgraduate general surgical training. Two reviewers independently assessed citations for inclusion using agreed criteria. Studies were assessed for quantitative data in addition to study design and purpose. A meta-analysis was performed using a random-effects model of studies with appropriate data.

RESULTS

The search resulted in 1979 titles for review. Of these, 24 studies were eligible for inclusion in the review and data from five studies were used in the meta-analysis. Studies with published data of operative experience at completion of surgical training originated from the USA (19), UK (2), the Netherlands (1), Spain (1) and Thailand (1). Mean total operative experience in training varied from 783 procedures in Thailand to 1915 in the UK. Meta-analysis produced a mean pooled estimate of 1366 (95 per cent c.i. 1026 to 1707) procedures per trainee at completion of training. There was marked heterogeneity between studies (I²  = 99·6 per cent).

CONCLUSION

There is a lack of robust data describing the operative experiences of general surgical trainees outside the USA. The number of surgical procedures performed by general surgeons in training varies considerably across the world.

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

BACKGROUND

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.

METHODS

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 12 months of the service (June 2014 to June 2015).

RESULTS

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 average consult time of 22 minutes for operative consults and 25 minutes for nonoperative consults (range 5-90 minutes).

CONCLUSION

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.

Cadaver-Based Simulation Increases Resident Confidence, Initial Exposure to Fundamental Techniques, and May Augment Operative Autonomy

OBJECTIVE

Surgical simulation is an important adjunct in surgical education. The majority of operative procedures can be simplified to core components. This study aimed to quantify a cadaver-based simulation course utility in improving exposure to fundamental maneuvers, resident and attending confidence in trainee capability, and if this led to earlier operative independence.

DESIGN

A list of fundamental surgical procedures was established by a faculty panel. Residents were assigned to a group led by a chief resident. Residents performed skills on cadavers appropriate for PGY level. A video-recorded examination where they narrated and demonstrated a task independently was then graded by attendings using standardized rubrics. Participants completed surveys regarding improvements in knowledge and confidence.

SETTING

The course was conducted at the Emory University School of Medicine and the T3 Laboratories in Atlanta, GA.

PARTICIPANTS

A total of 133 residents and 41 attendings participated in the course. 133 (100%) participating residents and 32 (78%) attendings completed surveys.

RESULTS

Resident confidence in completing the assigned skill independently increased from 3 (2-3) to 4 (3-4), p < 0.01. Residents stated that a median of 40% (interquartile range: 20%-60%) of procedures were performed for the first time in the course, and the same number had been performed only in the course. The percentage of skills attendings believed residents could perform independently increased from 40% (40%-60%) to 60% (60%->80%), p < 0.04. Attendings were more likely to grant autonomy in the operating room after this exercise (4 [3-5]).

CONCLUSIONS

A cadaveric skills course focused on fundamental maneuvers with objective confirmation of success is a viable adjunct to clinical operative experience. Residents were formally exposed to fundamental surgical maneuvers earlier as a result of this course. This activity improved both resident and attending confidence in trainee operative skill, resulting in increased attending willingness to grant a higher level of autonomy in the operating room.

Declining Operative Experience for Junior-Level Residents: Is This an Unintended Consequence of Minimally Invasive Surgery?

INTRODUCTION

Our group has previously demonstrated an upward shift from junior to senior resident participation in common general surgery operations, traditionally performed by junior-level residents. The objective of this study was to evaluate if this trend would correct over time. We hypothesized that junior resident case volume would improve.

METHODS

A sample of essential laparoscopic and open general surgery procedures (appendectomy, inguinal herniorrhaphy, cholecystectomy, and partial colectomy) was chosen for analysis. The American College of Surgeons National Surgical Quality Improvement Program Participant Use Files were queried for these procedures between 2005 and 2012. Cases were stratified by participating resident post-graduate year with "junior resident" defined as post-graduate year1-3. Logistic regression was performed to determine change in junior resident participation for each type of procedure over time.

RESULTS

A total of 185,335 cases were included in the study. For 3 of the operations we considered, the prevalence of laparoscopic surgery increased from 2005-2012 (all p < 0.001). Cholecystectomy was an exception, which showed an unchanged proportion of cases performed laparoscopically across the study period (p = 0.119). Junior resident participation decreased by 4.5%/y (p < 0.001) for laparoscopic procedures and by 6.2%/y (p < 0.001) for open procedures. The proportion of laparoscopic surgeries performed by junior-level residents decreased for appendectomy by 2.6%/y (p < 0.001) and cholecystectomy by 6.1%/y (p < 0.001), whereas it was unchanged for inguinal herniorrhaphy (p = 0.75) and increased for partial colectomy by 3.9%/y (p = 0.003). A decline in junior resident participation was seen for all open surgeries, with appendectomy decreasing by 9.4%/y (p < 0.001), cholecystectomy by 4.1%/y (p < 0.002), inguinal herniorrhaphy by 10%/y (p < 0.001) and partial colectomy by 2.9%/y (p < 0.004).

CONCLUSIONS

Along with the proliferation of laparoscopy for common general surgical procedures there has been a concomitant reduction in the participation of junior-level residents. As previously thought, familiarity with laparoscopy has not translated to redistribution of basic operations from senior to junior residents. This trend has significant implications for general surgery resident education.

An Objective Assessment of the Surgical Trainee in an Urban Trauma Unit in South Africa: A Pilot Study

BACKGROUND

Surgical outcomes are provider specific. This prospective audit describes the surgical activity of five general surgery residents on their trauma surgery rotation. It was hypothesized that the operating surgical trainee is an independent risk factor for adverse outcomes following major trauma.

MATERIALS AND METHODS

This is a prospective cohort study. All patients admitted, over a 6-month period (August 2014-January 2015), following trauma requiring a major operation performed by a surgical trainee at Groote Schuur Hospital's trauma unit in South Africa were included. Multiple logistic regression models were built to compare risk-adjusted surgical outcomes between trainees. The primary outcome measure was major in-hospital complications.

RESULTS

A total of 320 major operations involving 341 procedures were included. The mean age was 28.49 years (range 13-64), 97.2 % were male with a median ISS of 9 (IQR 1-41). Mechanism of injury was penetrating in 93.42 % of cases of which 51.86 % were gunshot injuries. Surgeon A consistently had the lowest risk-adjusted outcomes and was used as the reference for all outcomes in the regression models. Surgeon B, D, and E had statistically significant higher rates of major in-hospital complications than Surgeon A and C, after adjusting for multiple confounders. The final model used to calculate the risk estimates for the primary outcome had a ROC of 0.8649.

CONCLUSION

Risk-adjusted surgical outcomes vary by operating surgical trainee. The analysis thereof can add value to the objective assessment of a surgical trainee.