General surgery vs fellowship: the role of the Independent Academic Medical Center

Hepatopancreatic Surgeons Versus Pancreatic Surgeons: Does Surgical Subspecialization Impact Patient Care and Outcomes?

BACKGROUND

Hepatopancreatic (HP) surgeon and hospital procedural volume may vary relative to liver or pancreas cases. We sought to investigate the impact of surgeon and hospital pancreatic subspecialization on patient outcomes.

METHODS

Patients who underwent pancreatic surgery between 2013-2017 were identified from the Medicare Standard Analytic Files. The surgery subspecialization index (SSI) was calculated to signify surgeon and hospital pancreatic subspecialization, and categorized as low, intermediate, and high SSI. The association of SSI with Textbook Outcome (TO) and its components, failure to rescue (FTR), discharge to home and index admission expenditures was assessed with mixed-effects multivariable logistic regression.

RESULTS

Among 19,625 patients, most pancreatic procedures were characterized by high SSI (Low SSI: 27.7%, Intermediate SSI: 34.7%, High SSI: 37.7%). Notably, higher SSI was associated with greater odds of achieving a TO [Intermediate SSI: OR 1.16 (95%CI 1.06-1.27); High SSI: OR 1.23 (95%CI 1.11-1.35)] as well as being discharged home, and  lower odds of experiencing FTR. Furthermore, this association persisted in both low-volume [referent: Low SSI; Intermediate SSI: OR 1.14 (95%CI 1.01-1.28); High SSI: OR 1.15 (95%CI 1.02-1.31)] and high-volume hospitals [referent: Low SSI; Intermediate SSI: OR 1.16 (95%CI 1.01-1.32); High SSI: OR 1.26 (95%CI 1.09-1.45)].

CONCLUSIONS

Greater pancreatic subspecialization was associated with improved postoperative outcomes following pancreatic resection. Amidst increasing efforts to improve quality of care, surgical subspecialization may play a role in determining patient outcomes regardless of total surgeon or hospital volume.

SAGES white paper on the current state of community practice surgeons: re-discovering the value of our community practice surgeons

BACKGROUND

The Community Practice (CP) surgeon is the first point of access to surgical care globally and performs the majority of procedures in the USA. CP surgeons include those of various practice models, locations and communities, education and training, and much more. It is a diverse group that drives quality, access to care, research, and innovation. The SAGES CP Committee was formed to better define the role and highlight the contribution of the CP surgeon, as well as advocate for the position of CP surgeons in our society.

METHODS

In 2018, a survey was distributed to the SAGES membership asking members to self-identify as either a Community Surgeon or Academic Surgeon.

RESULTS

The majority (71%) of SAGES members surveyed self-identified as "Community Surgeons." This was in stark contrast to the distribution of Community versus Academic Surgeons in SAGES leadership (25% versus 75%, respectively).

CONCLUSION

By better defining the characteristics and role of the CP, SAGES will be better informed on how to effectively engage with this large group within the society and increase its representation within the leadership. The CP Committee met on a biannual basis over a period of two years focusing on assessing their role in the SAGES organization. The committee members created the following initial goals: (1) define in a broad sense the characteristics of a CP Surgeon, (2) discuss and characterize the value of the CP surgeons, (3) highlight past and future areas of contributions of the group, and (4) delineate ways to engage and represent this subgroup. This manuscript is a culmination of the work of this committee while also serving as a way to support the initiatives and direction of SAGES leadership.

Knowledge survey regarding blast wound education of student doctors at a local academic medical university in Japan

Objective: To improve knowledge about blast injury for medical student doctors or surgeons. In the modern uncertain era, education and training programs for blast injuries for medical student doctors or surgeons are recently necessary worldwide.

Material and Methods: To understand primary corresponding ability to treat blast injuries, leading to improvement of the trauma education curriculum, a retrospective study by a knowledge survey was performed between 2018 and 2019. The subject had the title of Student Doctor (SD) at university.

Results: The answers of 183 participants who answered the interview questionnaire with 16 questions were summarized. Although most SDs received basic lectures for trauma medicine and majority of SDs knew about mass casualty incidents and primary treatment, the existence of knowledge on soft targets is limited. One-fourth of the SDs knew the characteristics of blast wounds. Most SDs understood priority triage for a conscious person with massive bleeding from a limb with hemostasis to save lives. The 17% selected cardiopulmonary resuscitation first and 72% of SDs could explain hemorrhagic shock; however, only four could explain adequate hemostatic procedures. Most had no interest regarding necessity of their knowledge in the field of serious blast trauma wounds.

Conclusion: Experience in trauma surgery training from stages in SDs and authorized education are important for raising students’ knowledge of unexpected serious blast incidents.

A Dual-Institutional Study on First Year Practice Outcomes of Pediatric Surgeons Who Trained in the Era of Work Hour Restrictions

BACKGROUND

In July 2003, an 80-h work week restriction for residencies was mandated. This was met with skepticism regarding its potential impact on operative training. We hypothesized no difference in outcomes for pediatric surgeons who trained under duty hour restrictions compared to historical complication rates.

METHODS

Dual-institutional review of pediatric patients who underwent five of the most common operations (2013-2018) by first-year pediatric surgeons who trained under duty hour restrictions was performed. Tests of proportions were used to compare complication rates to published rates on data collected prior to 2003.

RESULTS

Patient mean age was 10.1 years. No significant differences (p values > 0.05) were found in laparoscopic appendectomy rates of infection, bleeding or intra-abdominal abscess compared to previously published rates. Pyloromyotomy rates of infection or duodenal perforation were not different. No differences were detected in rates of infection, recurrence or testicular atrophy for inguinal hernia repair. Umbilical hernia rates of infection, bleeding, and recurrence were also not different. There was no difference in CVC rates of hemopneumothoraces; significantly more bleeding events were detected (1.2% vs. 0.1%; p value = 0.04).

CONCLUSION

In this study, first-year complication rates of pediatric surgeons who trained under duty hour restrictions were not significantly different when compared to published rates.

A needs assessment of Canadian general surgery postgraduate trauma training

BACKGROUND

Clinical exposure to operative trauma cases for general surgery residents has decreased over recent decades. However, trainees are still expected to demonstrate competency in trauma care and injury management.

METHODS

A prospective survey based on preliminary qualitative analysis and a trauma education conceptual framework was distributed to general surgery educators, trauma surgeons, and general surgery residents across the country. Participants were asked to describe their trauma training experience, the educational resources available at their training programs, and their level of support for potential curriculum components.

RESULTS

45% (31/69) of educators and 14% (58/405) of trainees responded to the survey. Perceived deficiencies were identified in the operative management of thoracic (educators 13%, trainees 28%), mediastinal (3%, 14%), neck (16%, 33%), and vascular (26%, 47%) injuries. Additional educational deficiencies were also identified in the domains of trauma systems and epidemiology, research and quality improvement, and injury prevention. Educators identified more inadequacies in training than trainees. Both groups supported participation in radiology (77%, 85%) and guideline (74%, 90%) reviews, journal clubs (84%, 81%), education rounds (90%, 88%), leading trauma resuscitations (94%, 98%), and trauma resuscitation simulations (90%, 95%) as valuable educational initiatives.

CONCLUSIONS

Trauma training in Canada is currently perceived to be inadequate to support resident education. The development and implementation of competency-based curricular components will be essential to address the identified deficiencies. This data will be used to inform the development of a national trauma training curriculum and initiatives to enhance resident education.

Ten Year Trends in Minimally Invasive Surgery Fellowship

Background

Minimally Invasive Surgery (MIS) is one of the more recently established surgical fellowships, with many candidates applying due to a perception of inadequate exposure to advanced MIS during residency. The desire for advanced training should be reflected in increased competitiveness for fellowship positions. The aim of this study is to determine the desirability of MIS fellowships over time through review of national application data.

Methods

We reviewed the fellowship match statistics obtained from The Fellowship Council, the organizing body behind the MIS fellowship match. Data from January 1, 2008 - December 31, 2019 were included. We compared match rates to other specialties using the National Resident Matching Program, a nonprofit organization established for US residency and some fellowship programs.

Results

In the period of 2008 to 2019, the number of certified MIS fellowship programs increased from 124 to 141. While this program expansion was associated with a 19% increase in available positions, the number of applications increased 36%. As a result, the number of positions filled increased from 83% to 97%, but the match rate among US applicants fell from 82% to 71% during this interval. In comparison, the match rates for pediatric surgery, surgical oncology, vascular surgery, and surgical critical care fellowships remained largely unchanged, most recently 50%, 56%, 99%, and 100% respectively.

Conclusion

Over the last decade, US residents have shown an increased interest in pursuing MIS fellowship positions. As a consequence, the match process for MIS fellowships is becoming increasingly competitive.

Case distributions in general surgery residency: Subspecialization occurs before fellowship

BACKGROUND

In the era of subspecialization and duty-hour restrictions, many General Surgery residents desire additional training in their future subspecialty areas. This study examines the relationship between case distributions performed by General Surgery residents and their chosen future subspecialty.

METHODS

A retrospective review of Accreditation Council for Graduate Medical Education case logs of 101 graduated General Surgery residents at a single academic institution (2002-2018) was performed. The total number of operative cases performed during General Surgery residency overall and in Accreditation Council for Graduate Medical Education-defined categories were compared between residents with differing areas of future subspecialization.

RESULTS

Residents pursuing surgical fellowships in Endocrine, Cardiothoracic, Vascular, and Trauma/Critical Care Surgery logged respectively more endocrine (63 [11] vs 32 [13]; P < .001), thoracic (61 [15] vs 41 [13]; P < .001), vascular (225 [38] vs 162 [38]; P < .001), and operative trauma (83 [29] vs 71 [25]; P = .045) cases, compared with program average. Residents pursuing General Surgery (no fellowship) performed significantly more endoscopies (131 [47] vs 105 [28]; P = .029) than peers. Residents pursuing Breast, Oncology, Colorectal, and Pediatric Surgery fellowships performed numerically (non-significantly) more breast (94 [16] vs 78 [20]; P = .180), liver/pancreas (39 [3.1] vs 33 [8.0]; P = .173), large intestinal (132 [30] vs 125 [24]; P = .507), and pediatric (173 [27] vs 155 [37]; P = .832) cases, respectively, compared with peers. The majority of these additional cases were performed in postgraduate years 3 to 5.

CONCLUSION

In this single-institution study, many General Surgery residents perform more cases than peers in respective areas of future subspecialization. This may reflect residents at the reporting institution, and similar large, university-based programs seeking focused training in preparation for fellowship while still meeting case-volume minimums in all Accreditation Council for Graduate Medical Education-defined categories.

An assessment of the online presentation of MIS fellowship information for residents

INTRODUCTION

Residents often utilize internet resources to evaluate and search for fellowship programs within their desired field. The presence of these resources and the information available through them has the potential to influence applicant decisions. The objective of this study was to analyze the online MIS fellowship information relevant to resident applicants provided by the Fellowship Council Directory (FCD) and institutionally based program webpages.

MATERIALS AND METHODS

The programs evaluated were chosen based on their inclusion in the FCD, the accrediting body for MIS fellowships. The FCD provides each program a template through which program directors detail information for applicants. This information is publicly accessible through the directory, with each program having a specific page. These webpages were assessed for the presence or absence of 21 previously established individual content criteria. In addition, the presence or absence of a functional link to an institutionally based, program-specific webpage was determined. These program-specific, institutional webpages were then independently accessed via Google® search and separately assessed for the presence or absence of the same 21 previously established content criteria.

RESULTS

In total, the FCD listed 144 programs. Each program had a dedicated page within the directory itself with 104 (72%) having functional links listed. Ninety-six (66.6%) of the FCD links were identified as being specific webpages to the fellowship program, verified through a Google® search. Less than half of the programs fulfilled over 50% of identified criteria through the FCD templated directory, with one-third of programs listed failing to provide any program-specific information via a webpage outside the FCD.

CONCLUSION

Information available online for MIS fellowship programs is lacking, with many institutionally supported webpages absent altogether outside of the FCD. Templated formats seem to assist in this deficiency, but should be used cautiously as they also can potentially omit relevant information.

Association of Surgical Practice Patterns and Clinical Outcomes With Surgeon Training in University- or Nonuniversity-Based Residency Program

Importance

Important metrics of residency program success include the clinical outcomes achieved by trainees after transitioning to practice. Previous studies have shown significant differences in reported training experiences of general surgery residents at nonuniversity-based residency (NUBR) and university-based residency (UBR) programs.

Objective

To examine the differences in practice patterns and clinical outcomes between surgeons trained in NUBR and those trained in UBR programs.

Design, Setting, and Participants

This observational cohort study linked the claims data of patients who underwent general surgery procedures in New York, Florida, and Pennsylvania between January 1, 2012, and December 31, 2013, to demographic and training information of surgeons in the American Medical Association Physician Masterfile. Patients who underwent a qualifying procedure were grouped by surgeon. Practice pattern analysis was performed on 3638 surgeons and 1 237 621 patients, representing 214 residency programs. Clinical outcomes analysis was performed on 2301 surgeons and 312 584 patients. Data analysis was conducted from February 1, 2017, to July 31, 2017.

Exposures

NUBR or UBR training status.

Main Outcomes and Measures

Inpatient mortality, complications, and prolonged length of stay.

Results

No significant differences were observed between the NUBR-trained surgeons and UBR-trained surgeons in age (mean, 53.3 years vs 53.7 years), sex (female, 18.2% vs 16.9%), or years of clinical experience (mean, 16.5 years vs 16.5 years). Overall, NUBR-trained surgeons compared with UBR-trained surgeons performed more procedures (median interquartile range [IQR], 328 [93-661] vs 164 [49-444]; P < .001) and performed a greater proportion of procedures in the outpatient setting (risk difference, 6.5; 95% CI, 6.4 to 6.7; P < .001). Before matching, the mean proportion of patients with documented inpatient mortality was lower for NUBR-trained surgeons than for UBR-trained surgeons (risk difference, -1.01; 95% CI, -1.41 to -0.61; P < .001). The mean proportion of patients with complications (risk difference, -3.17%; 95% CI, -4.21 to -2.13; P < .001) and prolonged length of stay (risk difference, -1.89%; 95% CI, -2.79 to -0.98; P < .001) was also lower for NUBR-trained surgeons. After matching, no significant differences in patient mortality, complications, and prolonged length of stay were found between NUBR- and UBR-trained surgeons.

Conclusions and Relevance

Surgeons trained in NUBR and UBR programs have distinct practice patterns. After controlling for patient, procedure, and hospital factors, no differences were observed in the inpatient outcomes between the 2 groups.

The Change in Surgical Case Diversity over the past 15 Years and the Influence on the Pursuit of Surgical Fellowship

The surgical community has expressed concern that residents do not receive the same caliber training as their predecessors and the increase in fellowships have been described as secondary to perceived lack of preparation. Yet, data show no change in total cases even after implementation of the 80-hour workweek. It is hypothesized that the increasing subspecialization of general surgery may decrease in certain resident case numbers. Data were collected from the Accreditation Council for Graduate Medical Education (ACGME) General Surgery Case Logs National Data Report (1999–2014) of mean number of procedures per resident for 19 surgical categories. Statistical analysis was performed with analysis of variance over three time periods between 1999 and 2014. The number of total cases performed by residents has not changed significantly. There was a statistically significant difference observed in the variety of cases: vascular, esophageal, breast, and trauma cases decreased (P < 0.01), whereas major intestinal, hernia, liver, pancreatic, and biliary cases increased (P < 0.01). There are many reasons to pursue additional training after residency. The demonstrated change in case variability, presumably secondary to increasing fellowships, may play a significant role on training and preparation. Close monitoring of curriculums is essential to ensure a comprehensive general surgical education.

Evaluation of Accredited Trauma, Surgical Critical Care, and Acute Care Surgery Fellowship Websites

OBJECTIVES

Surgical residents are increasingly pursuing fellowships and rely heavily on fellowship programs' web sites as a primary source of information. Accessibility, quality, and content of a program web site can encourage or deter an applicant from applying to a particular program. The goal of this study was to perform an analysis of trauma, surgical critical care, and acute care surgery fellowship program web sites.

MATERIALS AND METHODS

A list of trauma, surgical critical care, and acute care surgery fellowship programs was obtained from the Eastern Association for the Surgery of Trauma (EAST) web site. The existence of a functional hyperlink in the EAST program directory and a systematic Google search was assessed to determine web site accessibility. Twenty-one content criteria were used to evaluate accessible web sites.

RESULTS

The EAST directory contained 102 fellowship programs. Ninety-one programs had web sites accessible through a Google search. No web site contained all 21 criteria. Only 29 web sites contained at least half of the evaluated content criteria. The most common data point included was program description (97%), while role of seeing patients in clinic (4%) was the least common criteria present.

CONCLUSIONS

Many programs in the EAST directory lack functional links and accessible web sites. Content that has been deemed important to applicants is lacking in varying degrees. Incorporation of this missing content may benefit both applicants and programs, allowing for more informed decision-making when choosing a program, thus promoting better fit of fellows with programs during the application process.

Resident Operative Experience at Independent Academic Medical Centers-A Comparison to the National Cohort

PURPOSE

Independent Academic Medical Centers (IAMCs) comprise one-third of U.S. general surgery training programs. It is unclear whether IAMCs offer qualitatively or quantitatively different operative experiences than the national cohort. We analyzed a large representative sample of IAMCs to compare operative volume and variety, with a focus on low-volume procedures.

METHODS

Accreditation Council for Graduate Medical Education Program Case Reports from 27 IAMCs were collected and analyzed for 3 academic years (2012-2015). IAMCs were compared to the national cohort for specific defined category volumes and selected low-volume cases. One-sample two-way t-tests were calculated comparing IAMC totals to national program averages.

RESULTS

IAMCs had a median of 3 chief residents per year (range: 1-6). IAMCs reported significantly more "total major" procedures in 2013-2014 (p = 0.046). Other case totals were statistically similar between IAMCs and the national cohort for "total major", "surgeon chief", "surgeon junior", and "teaching assistant" cases. In 2013-2014, IAMCs reported more laparoscopic complex (138.3 vs. 110.6, p = 0.010) and alimentary tract cases (276.5 vs. 253.5, p = 0.019). IAMC esophagogastroduodenoscopy case totals were higher in 2013-2014 (55.9 vs. 41, p = 0.038) and 2014-2015 (47.8 vs. 41, p = 0.047). IAMCs had fewer pancreas cases than the national cohort in all three years by about three cases per resident (p ≤ 0.026). In 2012-2013 IAMCs reported fewer (by about one) esophagectomy, gastrectomy, and abdominal perineal resections. No differences were observed in the following selected procedures: open common bile duct exploration, inguinal hernia, laparoscopic appendectomy, laparoscopic cholecystectomy, and colonoscopy.

CONCLUSIONS

The IAMCs studied appear to provide equivalent exposure to specific subcategories mandated by the Accreditation Council for Graduate Medical Education and American Board of Surgery. Graduates of IAMCs gain similar operative experience in low-volume, defined categories when compared to the national cohort. Certain specific cases subject to regionalization pressure are less well represented among IAMCs. This has important implications for medical students applying to surgery residency.

Characteristics of Independent Academic Medical Center Faculty

OBJECTIVE

Little is known about the characteristics of teaching faculty in US surgical residencies based at Independent Academic Medical Centers (IAMCs). The purpose of this study was to survey teaching faculty at IAMCs to better define their common characteristics.

STUDY DESIGN

An online, anonymous survey was distributed through program officials at 96 IAMCs to their faculty and graduates. Respondents were asked about their demographic information, training history, board certification, clinical practice, and exposure to medical students. Student t-tests and chi-square tests were calculated to evaluate associations between faculty characteristics.

SETTING

Independent Academic Medical Center general surgery training programs PARTICIPANTS: A total of 128 faculty at 14 IAMCs participated in the study.

RESULTS

In total, 128 faculty from 14 programs responded to the survey. The mean age of faculty respondents was 52 years and 81% were men. 58% were employed by a nonuniversity hospital, and 28% by a multispecialty practice. 79% of respondents were core faculty. The mean length of time since graduation from surgery residency was 19 years. 86% were currently board certified. 55% of those who were currently board certified had an additional certification. 45% had trained in an IAMC, 50% in an university program, and 5% in a military program. 73% were actively practicing general surgeons, with the majority (70%) performing between 101 and 400 cases annually. The vast majority of faculty (90%) performed <200 endoscopies annually, with 44% performing none. 84% and 35% provided ER and trauma coverage, respectively. 81% listed mentorship as their primary motivation for teaching residents. 23% received a stipend for this teaching. 95% were involved in medical student teaching. Faculty who completed training at university programs had more additional certifications compared with those with IAMC training (67% vs. 43%, p = 0.007). Certification differences by program type were consistent across age and time since residency completion. Age was not associated with residency program type (p = 0.87) nor additional certifications (p = 0.97).

CONCLUSIONS

IAMC faculty and graduates are overwhelmingly involved in general surgery, and most faculty have additional certifications. 90% of faculty have clinical exposure to medical students. Faculty at IAMCs were as likely to have been trained at an university program as an IAMC. In a time of increasing surgeon subspecialization and anxiety about the ability of 5-year training programs to train well-rounded surgeons, IAMCs appear to be a repository of consistent general surgical training.

Residency Surgical Training at an Independent Academic Medical Center

Independent academic medical centers have been training surgeons for more than a century; this environment is distinct from university or military programs. There are several advantages to training at a community program, including a supportive learning environment with camaraderie between residents and faculty, early and broad operative experience, and improved graduate confidence. Community programs also face challenges, such as resident recruitment and faculty engagement. With the workforce needs for general surgeons, independent training programs will continue to play an integral role.

Factors and Influences That Determine the Choices of Surgery Residency Applicants

OBJECTIVE

We sought to evaluate characteristics of residency applicants selected to interview at independent general surgery programs, identify residency information resources, assess if there is perceived bias toward university or independent programs, and determine what types of programs applicants prefer.

STUDY DESIGN

An electronic survey was sent to applicants who were selected to interview at a participating independent program. Open-ended responses regarding reasons for program-type bias were submitted. Multivariable logistic regression models were estimated to identify applicant characteristics associated with program-type preference.

SETTING

Independent general surgery residency programs.

PARTICIPANTS

A total, of 1220 applicants were selected to interview at one of 33 independent programs.

RESULTS

In total, 670 surveys were completed (55% response rate). Demographics of respondents were similar to the full invited population. Median United States Medical Licensing Examination Step 1 and Step 2 scores were between 230 to 239 and 240 to 249, respectively. Most applicants reported receiving general information about surgery residency programs and specific information about independent programs from residency program websites. 34% of respondents perceived an imbalanced representation of program types, with 96% of those reporting bias toward university programs.

CONCLUSIONS

Applicants selected to interview at independent programs are competitive for general surgery training and primarily use residency program websites for information gathering. Bias is common toward university programs for a variety of perceived reasons. This information will be useful in applicant evaluation and selection, serve as a stimulus to update program websites, and challenge independent program directors to work to alleviate bias against their programs.

Applicant Characteristics Associated With Selection for Ranking at Independent Surgery Residency Programs

OBJECTIVES

This study evaluated characteristics of applicants selected for interview and ranked by independent general surgery residency programs and assessed independent program application volumes, interview selection, rank list formation, and match success.

DESIGN

Demographic and academic information was analyzed for 2014-2015 applicants. Applicant characteristics were compared by ranking status using univariate and multivariable statistical techniques. Characteristics independently associated with whether or not an applicant was ranked were identified using multivariable logistic regression modeling with backward stepwise variable selection and cluster-correlated robust variance estimates to account for correlations among individuals who applied to multiple programs.

SETTING

The Electronic Residency Application Service was used to obtain applicant data and program match outcomes at 33 independent surgery programs.

PARTICIPANTS

All applicants selected to interview at 33 participating independent general surgery residency programs were included in the study.

RESULTS

Applicants were 60% male with median age of 26 years. Birthplace was well distributed. Most applicants (73%) had ≥1 academic publication. Median United States Medical Licensing Exams (USMLE) Step 1 score was 228 (interquartile range: 218-240), and median USMLE Step 2 clinical knowledge score was 241 (interquartile range: 231-250). Residency programs in some regions more often ranked applicants who attended medical school within the same region. On multivariable analysis, significant predictors of ranking by an independent residency program were: USMLE scores, medical school region, and birth region. Independent programs received an average of 764 applications (range: 307-1704). On average, 12% interviews, and 81% of interviewed applicants were ranked. Most programs (84%) matched at least 1 applicant ranked in their top 10.

CONCLUSIONS

Participating independent programs attract a large volume of applicants and have high standards in the selection process. This information can be used by surgery residency applicants to gauge their candidacy at independent programs. Independent programs offer a select number of interviews, rank most applicants that they interview, and successfully match competitive applicants.

General Surgery Resident Case Logs: Do They Accurately Reflect Resident Experience?

INTRODUCTION

Operative experience during residency lays the foundation for independent practice and additional specialty training following general surgery residency. The aim of this study was to examine operative experience of general surgery residents and detail the results of an intervention aimed at improving resident record keeping in the Accreditation Council for Graduate Medical Education (ACGME) case log system to better reflect their experience.

METHODS

Residents were asked to characterize variances in recorded operative experience identified through an audit of operative logs. Based on the results of the audit, an intervention was designed to prompt timely record keeping by residents. The intervention included education and discussion of survey audit results, weekly presentation of graphs detailing operative experience, and possible missed cases in the ACGME logs and addition of a first assistant column in morbidity and mortality (M&M) logs.

RESULTS

The audit of case logs identified discrepancies in 24.2% of the 636 cases examined. Chief residents were significantly more accurate (95.9%) in recording operative experience in ACGME case logs, whereas 50.3% of junior resident case logs contained variances. Residents characterized discrepancies as "forgot to log" (9.6%), "staff did the case" (5.2%), "another resident did more of the case" (3.6%), "other" (3.6%), a "more advanced resident was present for the case" (1.6%), "not present for case" (0.6%), and "left for consult" (0.3%). Over the 4-week intervention period, residents logged between 72.7% and 94.0% of cases. A month following the intervention period, we observed a 13.3% increase in recorded cases compared with the intervention period. Review of first assistant case logging following inclusion of a "first assistant" column in M&M logs demonstrated a 70.5% increase in first assistant cases logged into the ACGME system compared with the same time period a year ago.

CONCLUSIONS

Based on our results, we found that weekly displays of cases improved resident record keeping in the ACGME case log system, especially by junior residents. We believe that the addition of first assistant column on M&M lists, periodic audits reviewed at conferences, and semiannual evaluations will help junior residents more accurately report their experience during training.

The subspecialization of surgery: a paradigm shift

General surgery has become increasingly fragmented into subspecialties and diseases previously treated by general surgeons are now managed by "specialists". The Resident Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) has reviewed the history of surgical training and factors that have contributed to this evolution to subsepcialization. As it is unlikely that this paradigm shift is reversible, a clear understanding of the contributing factors is essential. Herein, we present a timeline and taxonomy of forces in this evolution to subspecialization.

Recruitment of Young Medical Apprentices (RYOMA) project: a comprehensive surgical education program at a local academic institute in Japan

OBJECTIVES

The number of young surgeons in Japan has significantly decreased in recent years, which may lead to future problems in the medical field. Therefore, comprehensive training programs for young surgeons are needed.

DESIGN

Retrospective study

SETTING

We developed a specific education program called the "Recruitment of Young Medical Apprentices" (RYOMA) project.

PARTICIPANTS

We performed this project between January 2008 and August 2013 on fourth- to sixth-year medical students and internship doctors. The RYOMA project included step-by-step surgical education programs on open and scopic procedures as dry, wet, and animal laboratory training. Our goal was to increase the number of young and specialist surgeons.

RESULTS

Based on an interview questionnaire answered by 90 medical students, most young students were interested in surgical training and several chose to become surgeons in the future. The most positive opinions regarding the field of surgery were the impressive results achieved with surgery, whereas negative opinions included the difficulty of the surgical skill, physical concerns related to difficult work environments, and the severity of surgical procedures. The present program has begun to resolve negative opinions through adequate training or simulations. Of the 19 medical students and internship doctors who attended the RYOMA project in 2008, 17 trainees (90%) were satisfied with this special surgical program and 16 (88%) showed interest in becoming surgeons. The number of participants considering the field of surgery increased between 2008 and 2013. Of 23 participants, 19 (83%) had a positive opinion of the program after the training.

CONCLUSIONS

Gaining experience in surgical training from an early stage in medical school and step-by-step authorized education by teaching staff are important for recruiting students and increasing the number of young surgeons.