Effect of the new standards for case logging on resident operative volume: doing better cases or better numbers?

Do Orthopaedic Resident and Fellow Case Logs Accurately Reflect Surgical Case Volume?

OBJECTIVE

The purpose of this study is to determine whether orthopedic resident and fellow case logs accurately reflect trainee case volume.

DESIGN

For each orthopedic case performed at our institution between 7/1/14 and 10/31/14, the names of trainees who participated were obtained from the chart. The trainee Accreditation Council for Graduate Medical Education case logs were queried to determine if the procedure in question was logged and, if so, which current procedural terminology (CPT) codes were reported. The CPT codes reported by the trainees were compared to those reported by the attendings in the billing database. To ascertain the opinions of trainees regarding coding, a survey was conducted.

SETTING

University of Maryland Medical Center (Baltimore, MD), a tertiary and quaternary care center which features a state-wide trauma referral center as well as orthopedic residency and fellowship training programs.

PARTICIPANTS

All orthopedic surgery residents and fellows present at the institution during the study period.

RESULTS

Trainees failed to log their cases 24% of the time (465/1925), including 25% (283/1117) for residents and 23% (182/808) for fellows (p = 0.16). Among cases that were logged, CPT codes were missed 46% of the time (673/1460) and extra codes were added 28% of the time (412/1460) compared to the attendings. In the survey, most trainees stated that it was "extremely" or "very" important for them to be able to code correctly (83%; 29/35).

CONCLUSIONS

In this study of orthopedic trainee case logging practices, cases were not logged 24% of the time. Caution should be taken with activities which rely on trainee case logs given the potential for inaccuracy.

Accreditation Council for Graduate Medical Education (ACGME) Surgery Resident Operative Logs: The Last Quarter Century

STUDY OBJECTIVE

To describe secular trends in operative experience for surgical trainees across an extended period using the most comprehensive data available, the Accreditation Council for Graduate Medical Education (ACGME) case logs.

BACKGROUND

Some experts have expressed concern that current trainees are inadequately prepared for independent practice. One frequently mentioned factor is whether duty hours' restrictions (DHR) implemented in 2003 and 2004 contributed by reducing time spent in the operating room.

METHODS

A dataset was generated from annual ACGME reports. Operative volume for total major cases (TMC), defined categories, and four index laparoscopic procedures was evaluated.

RESULTS

TMC dropped after implementation of DHR but rebounded after a transition period (949 vs 946 cases, P = nonsignificance). Abdominal cases increased from 22% of overall cases to 31%. Alimentary cases increased from 21% to 26%. Trauma and vascular surgery substantially decreased. For trauma, this drop took place well before DHR. The decrease in vascular surgery also began before DHR but continued afterward as well: 148 cases/resident in the late 1990s to 107 currently.

CONCLUSIONS

Although total operative volume rebounded after implementation of DHR, diversity of operative experienced narrowed. The combined increase in alimentary and abdominal cases is nearly 13%, over a half-year's worth of operating in 5-year training programs. Bedrock general surgery cases-trauma, vascular, pediatrics, and breast-decreased. Laparoscopic operations have steadily increased. If the competence of current graduates has, in fact, diminished. Our analysis suggests that operative volume is not the problem. Rather, changing disease processes, subspecialization, reductions in resident autonomy, and technical innovation challenge how today's general surgeons are trained.

The general surgery chief resident operative experience: 23 years of national ACGME case logs

IMPORTANCE

The chief resident (CR) year is a pivotal experience in surgical training. Changes in case volume and diversity may impact the educational quality of this important year.

OBJECTIVE

To evaluate changes in operative experience for general surgery CRs.

DESIGN, SETTING, AND PARTICIPANTS

Review of Accreditation Council for Graduate Medical Education case logs from 1989-1990 through 2011-2012 divided into 5 periods. Graduates in period 3 were the last to train with unrestricted work hours; those in period 4 were part of a transition period and trained under both systems; and those in period 5 trained fully under the 80-hour work week. Diversity of cases was assessed based on Accreditation Council for Graduate Medical Education defined categories.

MAIN OUTCOMES AND MEASURES

Total cases and defined categories were evaluated for changes over time.

RESULTS

The average total CR case numbers have fallen (271 in period 1 vs 242 in period 5, P < .001). Total CR cases dropped to their lowest following implementation of the 80-hour work week (236 cases), but rebounded in period 5. The percentage of residents' 5-year operative experience performed as CRs has decreased (30% in period 1 vs 25.6% in period 5, P < .001). Regarding case mix: thoracic, trauma, and vascular cases declined steadily, while alimentary and intra-abdominal operations increased. Recent graduates averaged 80 alimentary and 78 intra-abdominal procedures during their CR years. Compared with period 1, in which these 2 categories represented 47.1% of CR experience, in period 5, they represented 65.2% (P < .001). Endocrine experience has been relatively unchanged.

CONCLUSIONS AND RELEVANCE

Total CR cases declined especially acutely following implementation of the 80-hour work week but have since rebounded. Chief resident cases contribute less to overall experience, although this proportion stabilized before the 80-hour work week. Case mix has narrowed, with significant increases in alimentary and intra-abdominal cases. Broad-based general surgery training may be jeopardized by reduced case diversity. Chief resident cases are crucial in surgical training and educators should consider these findings as surgical training evolves.