The ACGME Case Log System May Not Accurately Represent Operative Experience Among General Surgery Interns

Comparing Graduating Plastic Surgery Residents' Case Logs With Accreditation Council for Graduate Medical Education Requirements, Content at National Meetings, and In-Service Examination Test Items

BACKGROUND

The importance of adaptable and up-to-date plastic surgery graduate medical education (GME) has taken on new meaning amidst accelerating surgical innovation and increasing calls for competency-based training standards. We aimed to examine the extent to which the procedures plastic surgery residents perform, as represented in case log data, align with 2 core standardized components of plastic surgery GME: ACGME (Accreditation Council for Graduate Medical Education) minimum procedure count requirements and the PSITE (Plastic Surgery In-Service Training Examination). We also examined their alignment with procedural representation at 2 major plastic surgery meetings.

METHODS

Nine categories of reconstructive and aesthetic procedures were identified. Three-year averages for the number of procedures completed in each category by residents graduating in 2019-2021 were calculated from ACGME national case log data reports. The ACGME procedure count minimum requirements were also ascertained. The titles and durations of medical programming sessions scheduled for Plastic Surgery The Meeting (PSTM) 2022 and the Plastic Surgery Research Council (PSRC) Annual Meeting 2022 were retrieved from online data. Finally, test items from the 2020 to 2022 administrations of the PSITE were retrieved. Conference sessions and test items were assigned to a single procedure category when possible. Percent differences were calculated for comparison.

RESULTS

The distribution of procedures on plastic surgery resident case logs differs from those of the major mechanisms of standardization in plastic surgery GME, in-service examination content more so than ACGME requirements. Meeting content at PSTM and PSRC had the largest percent differences with case log data, with PSTM being skewed toward aesthetics and PSRC toward reconstructive head and neck surgery.

DISCUSSION

The criteria and standards by which plastic surgery residents are evaluated and content at national meetings differ from the procedures they actually complete during their training. Although largely reflecting heterogeneity of the specialty, following these comparisons will likely prove useful in the continual evaluation of plastic surgery residency training, especially in the preparation of residents for the variety of training and practice settings they pursue.

Cross-Sectional Analysis of Neurosurgical Residency Websites During the Virtual Interview Cycle

BACKGROUND

The loss of in-person interviews during the COVID-19 pandemic warrants an investigation into what information is provided to applicants through neurosurgery residency program websites (NRPWs). This study examines NRPWs across the United States and Canada to determine what details are provided to applicants through their respective websites.

METHODS

Accreditation Council for Graduate Medical Education accredited neurologic surgery residency programs were identified through the American Association of Neurological Surgeons (AANS) website. NRPWs were searched for 48 criteria, including program overview, application requirements, and curriculum information. Small programs were defined as 1-2 residents per class, while large programs were classified as those with 3-4 residents per year. Content differences were analyzed between the top 20 and remaining programs per the Doximity Residency Navigator Rankings.

RESULTS

The most prevalent information among 122 NRPWs was the neurosurgery residency overview (95%), names of faculty members (95%), and names of current residents (94%). Top-20 NRPWs were more likely to include post PGY-7 fellowships (90% vs. 61% P = 0.0108), operating room virtual reality experience (35% vs. 12% P = 0.0160), and faculty research (90% vs. 62% P = 0.0182) than the remainder of the programs.

CONCLUSIONS

This study investigates NRPW content after the COVID-19 pandemic. We report broad variability in content provided by various neurosurgical training programs. Higher-ranked neurosurgery programs are more likely to include fellowship information, operating room virtual reality experience, and faculty research than lower-ranked programs.

General Surgery Trainee Cases Over Time: Postgraduate Year Matters

BACKGROUND

Trainees and attending surgeons alike have concerns about resident and fellow operative volume/breadth, competency, and overall readiness for practice. This is an important topic within surgical graduate medical education. Our goal was to analyze the change in general surgery trainee operative experience over time by postgraduate year.

METHODS

Institutional operative records from two corresponding three-month time periods in 2009 and 2018 at the residency program's main hospital site were reviewed. Cases assisted on by general, vascular, or thoracic surgery trainees were included. The number of cases per level, combination of trainees in each case, and categories of cases were compared over time.

RESULTS

There were 1940 cases in 2009 and 1967 cases in 2018 over the respective time periods. The distribution of trainees was different (P < .001), with a similar number of PGY-1 and fellow cases, a decrease in PGY-2 and PGY-5 cases, and an increase in PGY-3 and PGY-4 cases. The number of cases with two trainees, double scrubbed cases, increased from 19.6% to 26.8% (P < .001). In addition, there were differences in the resident years that double scrubbed cases together, an increase in robotic and endovascular surgery, and a decrease in open cases.

CONCLUSIONS

This analysis of cases shows that resident operative volume over approximately a decade has been largely preserved, with some change in the distribution of cases based on trainee level, an increase in cases with more than one trainee, and a rise of minimally invasive surgery with a corresponding decrease in open cases.

Uses of Electronic Health Record Data to Measure the Clinical Learning Environment of Graduate Medical Education Trainees: A Systematic Review

PURPOSE

This study systematically reviews the uses of electronic health record (EHR) data to measure graduate medical education (GME) trainee competencies.

METHOD

In January 2022, the authors conducted a systematic review of original research in MEDLINE from database start to December 31, 2021. The authors searched for articles that used the EHR as their data source and in which the individual GME trainee was the unit of observation and/or unit of analysis. The database query was intentionally broad because an initial survey of pertinent articles identified no unifying Medical Subject Heading terms. Articles were coded and clustered by theme and Accreditation Council for Graduate Medical Education (ACGME) core competency.

RESULTS

The database search yielded 3,540 articles, of which 86 met the study inclusion criteria. Articles clustered into 16 themes, the largest of which were trainee condition experience (17 articles), work patterns (16 articles), and continuity of care (12 articles). Five of the ACGME core competencies were represented (patient care and procedural skills, practice-based learning and improvement, systems-based practice, medical knowledge, and professionalism). In addition, 25 articles assessed the clinical learning environment.

CONCLUSIONS

This review identified 86 articles that used EHR data to measure individual GME trainee competencies, spanning 16 themes and 6 competencies and revealing marked between-trainee variation. The authors propose a digital learning cycle framework that arranges sequentially the uses of EHR data within the cycle of clinical experiential learning central to GME. Three technical components necessary to unlock the potential of EHR data to improve GME are described: measures, attribution, and visualization. Partnerships between GME programs and informatics departments will be pivotal in realizing this opportunity.

Experience of surgical subspecialty residents on general surgery rotations

BACKGROUND

Surgical subspecialty residents complete 5-6 years of training which includes general surgery rotations. A lack of data exists evaluating these rotations. This study aims to identify discrepancies in subspecialty training and improve the quality of surgical education.

METHODS

Case logs for surgical subspecialty residents and general surgery residents at our institution were analyzed and queried for cases performed on general surgery rotations. A survey was distributed to subspecialty residents regarding their perceptions of these rotations.

RESULTS

50 residents were included in the study and the majority were male (n = 27, 54%). Subspecialty residents perform fewer cases per month compared to general surgery residents (13 vs 21, p < 0.001). 75% of subspecialty residents were satisfied with their experience on general surgery rotations.

CONCLUSIONS

Subspecialty residents perform fewer operations on general surgery rotations. Despite this, most are satisfied with off-service rotations and believe they are an important part of their education.

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.

Pediatric Shoulder Arthroscopy Case Volume Is Uniformly Low for Graduating Orthopaedic Residents

Purpose

To evaluate shoulder arthroscopy case volume for graduating United States orthopaedic surgery residents.

Methods

We used the Accreditation Council for Graduate Medical Education case log records to evaluate reports from academic years 2016 to 2020. Logs were queried for pediatric, adult, and total (pediatric and adult) cases. The 10th, 30th, 50th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability.

Results

There was a significant increase in the average number of total (70.7 ± 35 vs 81.8 ± 45; P < .001), adult (69 ± 34 vs 79.7 ± 44; P < .001), and pediatric (1.8 ± 2 vs 2.2 ± 3; P = .003) shoulder arthroscopy cases performed by orthopaedic surgery residents between the academic year 2016 and 2020. Residents were involved in more than 36 times the number of adult cases compared with pediatric cases in 2020 (79.7 ± 44 vs 2.2 ± 3; P < .001). The 90th percentile of residents performed 6 pediatric cases in 2020, compared with zero cases in the 30th percentile and lower.

Conclusions

Approximately one-third of orthopedic surgery residents graduate without having performed a pediatric shoulder arthroscopy.

Clinical Relevance

The findings from this study could help guide the revision of current Accreditation Council for Graduate Medical Education guidelines for orthopaedic surgery residents.

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.

A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume

Introduction

Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic.

Materials and methods

A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys.

Results

Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01).

Conclusions

Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Implementation and Evaluation of Integrating an Electronic Health Record With the ACGME Case Log System

BACKGROUND

It is essential to log resident-performed procedures to assess training programs and fulfill specialty requirements, but resident case numbers are often underreported. Current systems require inefficient data entry steps, and residents and fellows report that user interfaces and administrative burden contribute to logging inaccuracy.

OBJECTIVE

To determine the accuracy, feasibility, and acceptability of a single logging approach for resident case logging.

METHODS

In 2018, we implemented a case logging system integrated with the institutional electronic health record (EHR) and the Accreditation Council for Graduate Medical Education (ACGME) case log system to record procedures performed by ophthalmology residents. We compared the proportion of resident-performed cataract extractions in the EHR that were reported to ACGME for 3 periods: before the deployment of the new system (6 months), during the transition (6 months), and after the change (2 years). Resident satisfaction with the new system was evaluated using surveys.

RESULTS

An analysis of resident cataract surgeries showed that the percentage of resident cases logged increased from 85% prior to implementation to 91% after implementation. The integrated system became the preferred case logging method, with 100% of all logged cases being entered using the new platform. Surveys showed that the percentage of trainees who were moderately or very satisfied with the case log process increased from 55% before implementation to 100% after implementation.

CONCLUSIONS

A resident case log system integrated with an EHR more accurately reflects resident operative volume and increases trainee satisfaction with the logging process.

Overcoming Systems Factors in Case Logging with Artificial Intelligence Tools

INTRODUCTION

Case logs are foundational data in surgical education, yet cases are consistently under-reported. Logging behavior is driven by multiple human and systems factors, including time constraints, ease of case data retrieval, access to data-entry tools, and procedural code decision tools.

METHODS

We examined case logging trends at three mid-sized, general surgery training programs from September 2016-October 2020, January 2019-October 2020 and May 2019-October 2020, respectively. Across the programs we compared the number of cases logged per week when residents logged directly to ACGME versus via a resident education platform with machine learning-based case logging assistance tools. We examined case logging patterns across 4 consecutive phases: baseline default ACGME logging prior to platform access (P0 "Manual"), full platform logging assistance (P1 "Assisted"), partial platform assistance requiring manual data entry without data integrations (P2 "Notebook"), and resumed fully integrated platform with logging assistance (P3 "Resumed").

RESULTS

31,385 cases were logged utilizing the platform since 2016 by 171 residents across the 3 programs.Intelligent case logging assistance significantly increased case logging rates, from 1.44 ± 1.48 cases by manual entry in P0 to 4.77 ± 2.45 cases per resident per week via the platform in P1 (p-value < 0.00001). Despite the burden of manual data entry when the platform's data connectivity was paused, the tool helped to increase overall case logging into ACGME to 2.85 ± 2.37 cases per week (p-value = 0.0002). Upon resuming the data connectivity, case logging levels rose to 4.54 ± 3.33 cases per week via the platform, equivalent to P1 levels (insignificant difference, p-value = 0.57).

CONCLUSIONS

Mapping the influence of systems and human factors in high-quality case logs allows us to target interventions to continually improve the training of surgical residents. System level factors such as access to alternate automation-drive tools and operative schedule integrated platforms to assist in ACGME case log has a significant impact on the number of cases captured in logs.

Resident Endoscopy Experience Correlates Poorly with Performance on a Virtual Reality Simulator

Background  Endoscopy training has become increasingly emphasized during general surgery residency as reflected by introduction of the Fundamentals of Endoscopic Surgery (FES) examination, which includes testing of skills on virtual reality (VR) simulators. Although studies exist to assess the ability of the simulator to differentiate between novices and experienced endoscopists, it is not well understood how simulators can differentiate skills among resident cohort.

Objective  To assess the utility of the VR simulator, we evaluated the correlation between resident endoscopy experience and performance on two VR simulator colonoscopy modules on the GI-BRONCH Mentor (Simbionix Ltd, Airport City, Israel).

Methods  Postgraduate years 2 to 5 residents completed “easy” and “difficult” VR colonoscopies, and performance metrics were recorded from October 2017 to February 2018 at Rutgers' two general surgery residency programs. Resident endoscopy experience was obtained through Accreditation Council for Graduate Medical Education case logs. Correlations between resident endoscopy experience and VR colonoscopy performance metrics were assessed using Spearman's rho (ρ) correlation statistic and bivariate logistic regression.

Results  Fifty-five residents out of 65 (84.6%) eligible participants completed the study. There were limited correlations found between resident endoscopy experience and FES performance metrics and no correlations were found between resident endoscopy experience and binary metrics of colonoscopy—ability to complete colonoscopy, ability to retroflex, and withdrawal time of less than 6 minutes.

Conclusion  The VR simulator may have a limited ability to discriminate between experience levels among resident cohort. Future studies are needed to further understand how well the VR simulator metrics correlate with resident endoscopy experience.

ACGME Case Log Reminder Does Not Improve Resident Accuracy in Logging Cases

To assess competency of residents prior to graduation, the Accreditation Council for Graduate Medical Education (ACGME) maintains a case log system, where residents self-report cases they perform. This mechanism results in underreporting of resident involvement in patient care. To determine if an intraoperative case log reminder would increase the frequency of ACGME case logging amongst anesthesiology residents. An intraoperative ACGME case log reminder was implemented on March 13, 2019. The authors collected data for all 53 PGY2-4 anesthesiology residents at the authors' institution from July 14, 2018 to July 16, 2019 from the electronic medical record and ACGME system to calculate the proportion of cases logged and the "lag time" between case occurrence and logging. Data was analyzed for all residents, classes, and individuals. A total of 16,342 anesthetics were performed, and a total of 11,713 cases were logged. The reminder did not improve overall logging rates. Case-logging rates amongst PGY2 residents remained unchanged and declined for PGY3 and PGY4 residents. The lag time between case occurrence and logging increased. An automatic reminder did not improve logging frequency. This may be because residents are unable to log cases intraoperatively in many instances, or they may not feel as though they have participated enough in a case to log it. Additionally, senior residents may log cases less frequently once they have met required case minimums. An automatic case-logging system that transmits resident information directly to the ACGME may be the best way to increase logging accuracy.

Correlation of Supervised Independence and Performance with Procedure Difficulty amongst Surgical Residents Stratified by Post Graduate Year

PURPOSE

This study investigates the role of procedure difficulty on attending ratings of supervised levels of independence and procedural performance amongst general surgery residents, while accounting for case complexity.

METHODS

Attending ratings for residents were obtained from System for Improving and Measuring Procedural Learning (SIMPL) database. Current procedural terminology (CPT) codes were used to match procedures to a corresponding work relative value unit (wRVU) as a surrogate for procedure difficulty. Three categories of wRVU (<13.07, 13.07-22, >22) were identified using recursive partitioning. Procedures were also divided into 'Core' or 'Advanced' as defined by the American Board of Surgery Surgical Council on Resident Education (SCORE). Temporal advancement in resident skill was accounted for through academic quarterly analysis. A generalized estimating equations (GEE) approach was used to form separate multivariable logistic regression models for meaningful autonomy (MA) and satisfactory performance (SP) adjusted for potential clustering by program, subject, and rater. Models were further adjusted for core/advanced procedures, attending rated complexity, and academic quarter.

RESULTS

A total of 33,281 ratings were analyzed. Overall, 51.6% were rated as MA and 44.4% as SP. For core procedures, surgical residents rated as MA (53.5%) and SP (45.7%), which was twice as high as those for advance procedures (MA-29.2%, SP-29.0%). MA and SP both decreased with increasing wRVU (Figure 2 &3). Using a wRVU<13.07 as a reference, the adjusted odds ratios of MA and SP were significantly lower with increasing procedure difficulty, 0.44 for wRVU 13.07-22.0 and 0.24 for wRVU >22.00 (Table 3). Post graduate year (PGY) 5 residents in the final quarter of training obtain MA in 95.5% and SP 92.9% for core procedures with wRVU <13.07 (Table 4).

CONCLUSION

Increasing procedural difficulty is independently associated with decreases in meaningful autonomy and satisfactory performance. As residents approach graduation the level of meaningful autonomy and satisfactory performance both reach high levels for common core procedures but decrease as procedural difficulty increases.

Examining the impact of COVID-19 restrictions on the operative volumes of US general surgery residents

BACKGROUND

In March 2020, the COVID-19 virus global pandemic forced healthcare systems to institute regulations including the cancellation of elective surgical cases, which likely decreased resident operative experience. The objective of this study was to determine whether the COVID-19 pandemic affected operative experiences of US general surgery residents.

METHODS

The operative experience of general surgery residents was examined nationally and locally. Aggregate Accreditation Council for Graduate Medical Education (ACGME) case logs for 2018 to 2019 (pre-COVID) and 2019 to 2020 (COVID) graduates were compared using national mean cumulative operative volume for total major and surgeon chief cases. Locally, ACGME case logs were used to analyze the operative experience among residents at a single, academic center. Average operative volumes per month per resident during peak COVID-19 quarantine months were compared with those the previous year.

RESULTS

Compared with 2019 graduates, 2020 graduates completed 1.5% fewer total major cases (1055 ± 155 vs 1071 ± 150, P = .011). This was most evident during chief year, with 8.4% fewer surgeon chief cases logged in 2020 compared with 2019 (264 ± 67 vs 289 ± 69, P < .001). Institutional data revealed that during the peak of the pandemic, residents across all levels completed 42.5% fewer total major operations (12 ± 11 vs 20 ± 14, P < .001). This effect was more pronounced among junior residents compared with senior and chief residents.

CONCLUSION

The COVID-19 pandemic was associated with decreased resident case volume. The ramifications of the COVID-19 pandemic for operative competency and autonomy should be carefully examined.

Improving ACGME Compliance for Obstetric Anesthesiology Fellows Using an Automated Email Notification System

BACKGROUND

The Accreditation Council for Graduate Medical Education establishes minimum case requirements for trainees. In the subspecialty of obstetric anesthesiology, requirements for fellow participation in nonobstetric antenatal procedures pose a particular challenge due to the physical location remote from labor and delivery and frequent last-minute scheduling.

OBJECTIVES

In response to this challenge, we implemented an informatics-based notification system, with the aim of increasing fellow participation in nonobstetric antenatal surgeries.

METHODS

In December 2014 an automated email notification system to inform obstetric anesthesiology fellows of scheduled nonobstetric surgeries in pregnant patients was initiated. Cases were identified via daily automated query of the preoperative evaluation database looking for structured documentation of current pregnancy. Information on flagged cases including patient medical record number, operating room location, and date and time of procedure were communicated to fellows via automated email daily. Median fellow participation in nonobstetric antenatal procedures per quarter before and after implementation were compared using an exact Wilcoxon-Mann-Whitney test due to low baseline absolute counts. The fraction of antenatal cases representing nonobstetric procedures completed by fellows before and after implementation was compared using a Fisher's exact test.

RESULTS

The number of nonobstetric antenatal cases logged by fellows per quarter increased significantly following implementation, from median 0[0,1] to 3[1,6] cases/quarter (p = 0.007). Additionally, nonobstetric antenatal cases completed by fellows as a percentage of total antenatal cases completed increased from 14% in preimplementation years to 52% in postimplementation years (p < 0.001).

CONCLUSION

Through an automated email system to identify nonobstetric antenatal procedures in pregnant patients, we were able to increase the number of these cases completed by fellows during 3 years following implementation.

A 20-year review of surgical training case logs: Is general surgery still general?

BACKGROUND

Surgical training has undergone many facets of restructuring over the most recent decades, with critiques of the quality and variability of training as well as the competency of recent graduates. This study examines the changes in surgical training in operative volume and breadth in the past 2 decades.

METHODS

The Accreditation Council for Graduate Medical Education Case Log Statistics Reports from 1999 to 2019 were reviewed. Case logs were grouped into defined case categories and group levels of postgraduate training. Descriptive analyses and multiple linear regressions were performed.

RESULTS

General surgery residents are graduating with 10.7% more cases, owing to increases in mostly junior year cases (P < .001). The breadth of specialty cases has decreased, while there was an increase in alimentary and abdominal cases to 58.4% from 47.2% 20 years ago. A decrease in vascular surgery cases from 19.9% to 10.7% of all cases was noted. Analysis of the distribution of defined categories showed right skewness in many categories with mode being much lower than reported mean.

CONCLUSION

Evaluation of trends, despite residents graduating with higher case volume than the minimum required, shows that the breadth and variety of cases has narrowed significantly in the past 20 years, providing a case for general surgery training restructuring.

ACGME Case Volume Minimums Decrease the Number of Shoulder and Knee Arthroscopies Performed by Residents

Purpose

The purpose of this study was to examine how the implementation of Accreditation Council of Graduate Medical Education (ACGME) case minimums in 2013 has affected the number of shoulder and knee arthroscopies performed by orthopaedic surgery residents during their clinical training.

Methods

The ACGME orthopaedic surgery case log data from graduation years 2007 to 2019 was used to evaluate the number of shoulder and knee arthroscopies performed. The mean and median number of cases performed per resident were compared for the years prior to implementation of the ACGME case minimum (2007-2012) and after (2013-2019).

Results

The ACGME orthopaedic surgery case minimums resulted in a significant decrease in the mean number of shoulder and knee arthroscopies performed. The mean number of shoulder arthroscopies performed in the years before and after the case minimum requirement were 109.8 and 82.0 (P = .025), respectively. The mean number of knee arthroscopies performed in the years before and after the case minimum requirement were 178.6 and 124.8 (P = .006), respectively. Residents in the tenth percentile of cases performed still met the required ACGME case minimums each year. The mean total of all cases performed in the years before and after the case minimum requirement were 2045.5 and 1699.3 (P = .038), respectively.

Conclusions

The number of shoulder and knee arthroscopies performed by orthopaedic surgery residents significantly decreased after the implementation of ACGME case minimums, which may be due to underreporting of cases.

Clinical Relevance

This study may demonstrate the effect of the implementation of the ACGME case minimums on the number of shoulder and knee arthroscopies performed by orthopaedic surgery residents.

Automated Procedure Logs for Cardiology Fellows: A New Training Paradigm in the Era of Electronic Health Records

BACKGROUND

Procedural experience for residents and fellows is critical for achieving competence, and documentation of procedures performed is required. Procedure logs serve as the record of this experience, but are commonly generated manually, require substantial administrative effort, and cannot be corroborated for accuracy.

OBJECTIVE

We developed and implemented a structured clinical-educational report template (CERT), which automatically generates procedure logs directly from the clinical record.

METHODS

Our CERT aimed to replace the post-procedure note template for our cardiac catheterization laboratory and was incorporated into the electronic health record system. Numbers of documented procedures in automated CERT-derived procedure logs over a 1-year post-intervention period (2018-2019) were compared to manual logs and corrected for clinical volume changes. The CERT's impact on fellowship experience was also assessed.

RESULTS

Automated CERT procedure logs increased weekly procedural documentation over manual procedure logs for total procedures (24.2 ± 6.1 vs 17.1 ± 6.8, P = .007), left heart catheterizations (14.5 ± 3.6 vs 10.8 ± 4.2, P = .039), total procedural elements (40.2 ± 11.4 versus 20.9 ± 12.5, P < .001), and captured procedural details not previously documented. The CERT also reduced self-reported administrative time and improved fellowship experience.

CONCLUSIONS

A novel CERT allows procedure logs to be automatically derived from the clinical record and increased the number of documented procedures, compared to manual logging. This innovation ensures an accurate record of procedural experience and reduces self-reported non-educational administrative time for cardiology fellows.

North American pediatric surgery fellows' preparedness for humanitarian surgery

INTRODUCTION

The overwhelming burden of pediatric surgical need in humanitarian settings has prompted mutual interest between humanitarian organizations and pediatric surgeons. To assess adequate fit, we correlated pediatric surgery fellowship case mix and load with acute pediatric surgical relief efforts in conflict and disaster zones.

METHODS

We reviewed pediatric (age < 18) cases logged by the Médecins Sans Frontières Operational Centre Brussels (MSF-OCB) from a previously validated and published database spanning 2008-2014 and cases performed by American College of Graduate Medical Education (ACGME) pediatric surgery graduates from 2008 to 2018. Non-operative management for trauma, endoscopic procedures, and basic wound care were excluded as they were not tracked in either dataset. ACGME procedures were classified under 1 of 32 MSF pediatric surgery procedure categories and compared using chi-squared tests.

RESULTS

ACGME fellows performed procedures in 44% of tracked MSF-OCB categories. Major MSF-OCB pediatric cases were comprised of 62% general surgery, 23% orthopedic surgery, 9% obstetrical surgery, 3% plastic/reconstructive surgery, 2% urogynecologic surgery, and 1% specialty surgery. In comparison, fellows' cases were 95% general surgery, 0% orthopedic surgery, 0% obstetrical surgery, 5% urogynecologic surgery, and 1% specialty surgery. Fellows more frequently performed abdominal, thoracic, other general surgical, urology/gynecologic, and specialty procedures, but performed fewer wound and burn procedures (all p < 0.05). Fellows received no experience in Cesarean section or open fracture repair. Fellows performed a greater proportion of surgeries for congenital conditions (p < 0.05).

CONCLUSION

While ACGME pediatric surgical trainees receive significant training in general and urogynecologic surgical techniques, they lack sufficient case load for orthopedic and obstetrical care - a common need among children in humanitarian settings. Trainees and program directors should evaluate the fellow's role and scope in a global surgery rotation or provide advanced preparation to fill these gaps. Upon graduation, pediatric surgeons interested in humanitarian missions should seek out additional orthopedic and obstetrical training, or select missions that do not require such skillsets.

LEVEL OF EVIDENCE

III.

Resident perception of standardization and credentialing for high-risk bedside procedures in cardiothoracic surgery: Results from an institutional pilot study

OBJECTIVES

Though clear-guidelines are set by the American Board of Thoracic Surgery (ABTS) for the operative cases that cardiothoracic surgery residents must perform to be board-eligible, no such recommendations exist to assess competency for the wide range of high-risk bedside procedures. Our department created and implemented a multidisciplinary course designed to standardize common high-risk bedside procedures and credential our trainees. The aim of this study was to survey the attitudes of residents towards and query the efficacy of such a course.

METHODS

The course was designed with the goal of standardizing endotracheal intubation, arterial line insertion (radial and femoral), central venous line insertion, pigtail tube thoracostomy, thoracentesis and nasogastric tube placement. The course consisted of an online module followed by a 4-hour hands-on simulation session. Knowledge-based pre- and post-evaluations were administered as well as a Likert-based survey regarding multiple aspects of the residents' perceptions of the course and the procedures.

RESULTS

Twenty-three (7 traditional and 16 integrated) cardiothoracic surgical residents participated in the course. Residents reported that 48% of the time, bedside procedures were historically taught by other trainees rather than by faculty. All residents endorsed increased standardization of all procedures after the course. Likewise, residents showed increased confidence in all procedures except for pigtail tube thoracostomy, thoracentesis as well as nasogastric tube placement. 43.5% of the participants demonstrated improvement in the pretest and posttest knowledge-based evaluations.

CONCLUSION

Cardiothoracic residents have favorable attitudes towards standardization and credentialing for high-risk bedside procedures and utilizing such courses may help standardize procedural techniques.

The Experiential Benefit of an Orthopedic Trauma Fellowship: An Analysis of ACGME Case Log Data From 2006 to 2017

OBJECTIVE

The Accreditation Council for Graduate Medical Education (ACGME) has published orthopedic case log data since the 2006/2007 academic year. Here, we use this data to analyze the variability in orthopedic trauma case experience reported by orthopedic trainees and to better understand the impact of an orthopedic trauma fellowship on orthopedic surgical training.

DESIGN, SETTING, AND PARTICIPANTS

Data were gathered from ACGME case log reports for orthopedic residents (reporting the cumulative case experience of graduating residents) and orthopedic trauma fellows (reporting the case experience of their fellowship year only) for all available years.

RESULTS

The average orthopedic trauma fellow reported significantly more trauma cases in multiple body regions ("Pelvis/Hip", "Femur/Knee", and "Foot/Toes") and "Open Complex" reductions (as defined by the ACGME) in their 1 year of fellowship than the average resident reported in their 5 years of residency.

CONCLUSION

On average, orthopedic trauma fellowships substantially increase the trauma case volumes of orthopedic trainees, especially with respect to lower extremity trauma.

See None, Do Some, Teach None: An Analysis of the Contemporary Operative Experience as Nonprimary Surgeon

OBJECTIVE

The operative experience of today's general surgery resident has changed, but little is known about the modern experience as nonprimary surgeon. We set out to explore changes in the operative experience of general surgery residents as first assistant (FA) and teaching assistant (TA).

DESIGN, SETTING, AND PARTICIPANTS

This is a review of ACGME national operative log reports from 1990 to 2018. TA and FA cases were analyzed. Statistical analysis was performed using polynomial regression analysis and Kruskal-Wallis test. Statistical significance was set at p < 0.05.

RESULTS

30,260 individuals completed general surgery residency during the study period with medians of 951 (interquartile range: 929-974) total major, 63 (31-184) FA, and 32 (25-48) TA cases. As a proportion of total cases completed, FA cases decreased from 21.8% of the total operative experience in 1990 to 2.5% in 2018, and TA cases declined from 7.4% of the total operative experience in 1990 to 3.5% in 2018. Regression modeling demonstrated that both operative roles decreased over time, but at a progressively decreasing rate, with FA cases reaching a "floor" around 2010 and TA cases reaching a "breakpoint" in 2008 at which time operative volume rebounded and began to increase. Among the core general surgery domains of abdomen and alimentary tract, compositional analysis revealed a decrease across each of the 11 operative subcategories (all p < 0.05) for FA, and for TA, a decrease in 6 of the 11 operative subcategories (stomach, small intestine, large intestine, anorectal, hernia, and biliary, all p < 0.05).

CONCLUSIONS

Over the past 3 decades, the resident operative experience as nonprimary surgeon has decreased dramatically, with today's residents graduating with fewer FA and TA cases. As surgical training has traditionally relied heavily on an apprenticeship model for learning technical skills, it is essential that surgical educators recognize and rectify these trends.

"What program directors think IV": Results of the 2017 Annual Survey of the Association of Program Directors in Radiology

RATIONALE AND OBJECTIVES

The Association of Program Directors in Radiology (APDR) regularly surveys its members to gather information regarding a broad range of topics related to radiology residency. The survey results provide insight into the opinions of residency program leadership across the country.

MATERIALS AND METHODS

This is an observational cross-sectional study using a web-based survey posed to the APDR membership in the fall of 2017. The final survey consisted of 53 items, 48 multiple choice questions and five write-in comments. An invitation to complete the survey was sent to all 319 active APDR members.

RESULTS

Deidentified responses were collected electronically, tallied utilizing Qualtrics software, and aggregated for the purposes of analysis and reporting at the 66th annual meeting of the Association of University Radiologists. The response rate was 36%.

CONCLUSION

Over the past 16 years, more PDs have assistant and APDs to administer growing residency programs, but the time allocation for these APDs has come from the PD's protected time. An overwhelming majority of PDs consider independent call beneficial to residents and most think a call assistant is desirable. The vast majority of PDs support a unified fellowship match and allow resident moonlighting. Most fourth year residents are actively or moderately involved in clinical work and teaching. The majority of PDs have lost or expect to lose DR training positions to the new IR/DR programs. In a competitive match, PDs do not rely on residency interviews in their selection process.

Making EPAs a 59 minute objective measure for surgical trainees - A pilot study

INTRODUCTION

Accurately confirming surgical trainees have met the requirements of entrusted professional activities (EPAs) will require rigorous staff input. We pondered whether such simulation-driven evaluations might prove useful to the current ABS/APDS pilot effort on EPA analysis.

METHODS

Our surgical trainees participate biannually in a 59-min simulation-based assessment (X-Games) which covers surgical technique, knowledge and critical thinking in a host of domains. The content and difficulty of the stations differed between the PGY levels. Only 4 EPA topics (inguinal hernia repair, appendectomy, cholecystectomy, and trauma resuscitation) were tabulated for this study.

RESULTS

16-PGY-2s, 8-PGY-3s, 10-PGY-4s, and 10-PGY-5s surgical residents completed the X-Games. Performance within and between PGY levels was variable. The mean(SD) EPA scores for all PGY levels are listed in Table- 1.

CONCLUSION

Analysis gleaned from a 59-min OSCE in a simulated-setting offers objective data that appears to have construct-validity. Refining our Surgical X-Games to cater to the specific EPA scoring system may better allow objective analysis of when trainees cross the threshold from "can do with some help" to "can do autonomously".

Surgical Simulation: Markers of Proficiency

OBJECTIVE

Surgical simulation has become an integral component of surgical training. Simulation proficiency determination has been traditionally based upon time to completion of various simulated tasks. We aimed to determine objective markers of proficiency in surgical simulation by comparing novel assessments with conventional evaluations of technical skill.

DESIGN

Categorical general surgery residents completed 10 laparoscopic cholecystectomy modules using a high-fidelity simulator. We recorded and analyzed simulation task times, as well as number of hand movements, instrument path length, instrument acceleration, and participant affective engagement during each simulation. Comparisons were made to Objective Structured Assessment of Technical Skill (OSATS) and Accreditation Council for Graduate Medical Education Milestones, as well as previous laparoscopic experience, duration of laparoscopic cholecystectomies performed by participants, and postgraduate year. Comparisons were also made to Fundamentals of Laparoscopic Surgery task times. Spearman's rho was utilized for comparisons, significance set at >0.50.

SETTING

University of Missouri, Columbia, Missouri, an academic tertiary care facility.

PARTICIPANTS

Fourteen categorical general surgery residents (postgraduate year 1-5) were prospectively enrolled.

RESULTS

One hundred forty simulations were included. The number of hand movements and instrument path lengths strongly correlated with simulation task times (ρ 0.62-0.87, p < 0.0001), FLS task completion times (ρ 0.50-0.53, p < 0.0001), and prior real-world laparoscopic cholecystectomy experience (ρ -0.51 to -0.53, p < 0.0001). No significant correlations were identified between any of the studied markers with Accreditation Council for Graduate Medical Education Milestones, Objective Structured Assessment of Technical Skill evaluations, total previous laparoscopic experience, or postgraduate year level. Neither instrument acceleration nor participant engagement showed significant correlation with any of the conventional markers of real-world or simulation skill proficiency.

CONCLUSIONS

Simulation proficiency, measured by instrument and hand motion, is more representative of simulation skill than simulation task time, instrument acceleration, or participant engagement.

Minimally invasive surgical exposure among US and Canadian pediatric surgery trainees, 2004-2016

BACKGROUND

Minimally invasive pediatric surgery has increased in breadth and complexity over the past several decades, with little data on minimally invasive surgery (MIS) training in US and Canadian pediatric surgery fellowship programs.

METHODS

We performed a time series analysis of Accreditation Council for Graduate Medical Education pediatric surgery fellow case logs from 2003 to 2016. Proportions of cases performed in an MIS fashion as well as per-fellow MIS case averages were recorded over time.

RESULTS

There was a 30.9% increase in average number of MIS cases per fellow over the study time period. Twenty-three recorded procedures included MIS and open options (17 abdominal, three thoracic, and three genitourinary). The proportion of cases performed using a minimally invasive approach increased by an average of 29.0%, 14.6%, and 47.0% for each of these categories, respectively. Significant variability was observed in specific cases such as laparoscopic and open inguinal hernias, ranging from 0 to 85 and nine to 152 per trainee, respectively, in the final year of data collection. When examining pyloromyotomy, a high-volume procedure with a known increase in the MIS approach, the proportion of cases performed MIS increased by 83.3%. The minimum and maximum number of cases per fellow recorded ranged from 0 to 114 during the eight years in which MIS pyloromyotomy was recorded.

CONCLUSIONS

MIS case exposure among graduating US and Canadian pediatric survey fellows increased substantially during the study period. More granular data, however, are needed to better define the current operative experience and criteria for determination of competency in advanced MIS.