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

Defining the Disparity: A Multi-Institutional Analysis of Factors Associated With Decreased Resident Operative Experience

INTRODUCTION

Technical learning in surgical training is multifaceted and existing literature suggests a positive relationship between case volume and proficiency. Little is known about factors associated with a decreased volume of operative experience. This study aimed to identify resident and program factors associated with general surgery residents (GSR) in the bottom quartile of logged case volume upon program completion.

METHODS

A post hoc analysis of a multicenter study was used to examine case logs for categorical GSR. Participants included graduates between 2010 and 2020 from 20 programs. Residents below and above the 25th percentile for total operative volume were compared.

RESULTS

The present study includes 1343 GSR who graduated over the 11-y period. In total, 336 residents were below the 25th percentile and 1007 residents were above the 25th percentile. Those below the 25th percentile were more likely to be female (41% versus 34%, P = 0.02), identify as underrepresented in medicine (22% versus 14%, P < 0.01), and pursue fellowship (86% versus 80%, P = 0.01) compared to those above the 25th percentile. Residents below the 25th percentile were more likely to have graduated from a low volume program (55% versus 25%, P < 0.01) and from top National Institutes of Health funded institutions (57% versus 52%, P = 0.01).

CONCLUSIONS

This study identified individual and program characteristics associated with lower operative volume of GSR. Understanding such characteristics will aid surgical educators to achieve better equity in training.

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

BACKGROUND

Endovascular and hybrid interventions have played an increasingly prominent role in the treatment of peripheral arterial disease (PAD) in the past decade. This shift has prompted concerns about the adequacy of open surgical training for current surgical residents. Moreover, the recent Best Surgical Therapy in Patients With Critical Limb Ischemia trial has further emphasized the importance of open surgical techniques in the treatment of peripheral arterial disease. The purpose of this study was to examine national temporal trends in peripheral operative volume among integrated vascular surgery residents.

METHODS

Data was obtained from the Accreditation Council for Graduate Medical Education national data reports for integrated vascular surgery residents. Case volumes for surgeon chief or surgeon junior cases were collected from academic years 2012 to 2013 and 2021 to 2022. Trends in case-mix and volume were evaluated using linear regression analysis.

RESULTS

The mean total vascular operative volume increased from 851.2 to 914.3 cases among graduating chief residents, with an annual growth of 8.5 ± 1.7 cases/year (R2 = 0.77; P < .0001). Major vascular case volume also increased at a rate of 5.7 ± 1.2 cases/year (R2 = 0.74; P < .001). Among operative categories, peripheral cases were the most frequent (n = 232.2 [26.6%]) and demonstrated the greatest annual growth (+8.0 ± 0.8 cases/year, R2 = 0.93; P < .001). No changes were seen in volume of open peripheral cases, including suprainguinal bypass (+0.1 ± 0.2 cases/year; R2 = 0.08; P = .40) or femoropopliteal bypass procedures (-0.1 ± 0.2 cases/year; R2 = 0.17; P = .20). Infrapopliteal bypass (+0.4 ± 0.1 cases/year; R2 = 0.48; P = .006), iliac/femoral endarterectomy (+1.3 ± 0.2 cases/year; R2 = 0.82; P < .001), and leg thromboembolectomy (+0.4 ± 0.1 cases/year; R2 = 0.64; P < .001) all demonstrated annual growth. For endovascular peripheral cases, aortoiliac revascularization (+3.4 ± 0.3 cases/year; R2 = 0.94; P < .001), femoropopliteal revascularization (+5.4 ± 0.2 cases/year; R2 = 0.98; P < .001), and tibioperoneal revascularization (+2.0 ± 0.2 cases/year; R2 = 0.92; P < .001) all increased in volume. Lower extremity amputations, including above-knee amputation (+0.6 ± 0.2 cases/year; R2 = 0.65; P < .001) and below-knee amputation (+0.9 ± 0.2 cases/year; R2 = 0.72; P < .001) also demonstrated an increase in volume.

CONCLUSIONS

Current graduating residents have higher open and endovascular case volumes for peripheral artery disease on a national level, despite the increasing popularity of endovascular techniques. Further studies are needed to identify how these trends may impact current vascular surgery milestones. These trends may also influence the rising interest in competency-based training programs.

Resident Operative Experience in Hepatopancreatobiliary Surgery: Exposing the Divide

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) requires an experience in hepatopancreatobiliary (HPB) surgery as part of general surgery residency training. The composition of this experience, however, is unclear. We set out to evaluate current trends in the HPB experience of US general surgery residents.

METHODS

National ACGME operative case logs from 1990 to 2016 were examined with a focus on the HPB operative domains. Time-trend analysis was performed using ANOVA and linear regression analysis.

RESULTS

Median biliary, liver, and pancreatic operative volumes increased by 30%, 33%, and 27% over the 27-year study period (all p < 0.05). Both core and advanced HPB cases increased, but the rate of increase for core was four times greater than that of advanced. However, when cholecystectomy was excluded, this trend reversed such that HPB core operations decreased by 11 cases over the study period. Further analysis demonstrated that laparoscopic cholecystectomy comprised 90% of all biliary cases and 77% of all HPB cases for graduates in 2016. Finally, operative volume variability-the difference in case numbers between high and low volume residents-increased by 16%, 21%, and 73% for the biliary, liver, and pancreatic domains, respectively (all p < 0.05).

CONCLUSIONS

Despite increases in overall HPB operative volume, the HPB experience is changing for today's surgical trainees. Moreover, the HPB experience is comprised largely of a single operation-the cholecystectomy. Awareness of these trends is important for surgical educators to facilitate adequate exposure to HPB surgery among general surgery residents.