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

Tracking Residents' Surgical Outcomes Using Data from the Quality In-Training Initiative

OBJECTIVES

Monitoring resident trainees' patient outcomes is essential to improving surgical performance; however, resident-specific follow-up is rarely provided in the current surgical training environment. Whether there is a correlation between individual resident's surgical performance and patients' clinical outcomes remains undefined. In this study, we aimed to use risk-adjusted patient outcomes as an educational tool to track individual surgical trainee performance.

STUDY DESIGN

American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) appendectomy and partial colectomy operations (2013-2021) were examined. Residents performing ≥25 operations were included. The primary outcome was ACS NSQIP-defined morbidity adjusted using estimated probability of morbidity. Observed-to-expected ratios (O/E) of morbidity measured overall performance and risk-adjusted cumulative sum (RA-CUSUM) methodology represented surgical resident's performance over time.

SETTING

Academic quaternary care institution.

PARTICIPANTS

Highest-ranking surgical resident participating in an operation and included in Quality In-Training Initiative.

RESULTS

A total of 449 operations were examined. 12 residents performed 343 appendectomy operations. 7 residents (29.3 ± 5.1 operations each) did not have any postoperative morbidity and demonstrated better-than-expected patient outcomes. Three residents did not have morbidity after their seventh/eleventh/fifteenth appendectomies. Two residents (case volume 29, 33) had an O/E ratio > 3. Partial colectomy (n = 106) performed by 4 residents had 2 residents (case volume 30, 26) with better-than-expected outcomes and 2 with worse-than-expected (case volume 25, 25).

CONCLUSION

Longitudinal monitoring of postoperative patient outcomes provides an opportunity for trainee self-reflection and system examination. RA-CUSUM methodology offers sequential monitoring allowing for early evaluation and intervention when RA-CUSUM results for a trainee demonstrate higher-than-expected morbidity.

Co-Existing Vascular Surgery Integrated Residencies are Associated with Increased General Surgery Resident Proficiency and Autonomy in Vascular Cases

BACKGROUND

Integrated vascular surgery residency positions have doubled more than the last decade. Studies have investigated the impact of co-existing subspecialty surgical training programs on case volume of general surgery residents (GSRs). However, no studies have explored the impact of subspecialty training on GSR operative competency. The aim of this study is to understand the impact of integrated residencies on operative performance and autonomy of GSR performing vascular procedures.

METHODS

Autonomy and performance ratings of GSR participating in vascular surgery cases were collected from all institutions participating in the Society for Improving Medical Professional Learning application database from 2015 to 2023. Faculty and self-assessments of autonomy and performance on vascular cases performed by GSRs at programs with co-existing vascular integrated residency (VIR), vascular surgery fellowship (VSF), or no subspecialty vascular training (VX) were compared using Fisher's exact tests with Bonferroni corrections across training levels and case complexity.

RESULTS

Eleven thousand one hundred seventy five assessments (26% at institutions with VIR, 46% VSF, and 28% VX) were submitted by 920 GSRs and 343 faculty. Senior GSRs at programs with VSF achieved lower autonomy than those with VIR (P = 0.049) or VX (P = 0.042) based on faculty assessment. GSRs achieved a level of "practice ready" at significantly higher rates when training at programs with VIR, and at the lowest rates with VSF (P < 0.001). However, self-perception of autonomy and performance was highest among GSRs at programs with VX compared with VIR and VSF (P < 0.001).

CONCLUSIONS

The presence of VIR was associated with higher achievement of "practice ready" competency and higher levels of operative autonomy among senior GSRs performing vascular procedures. Shared-learning among peers and faculty expertise in teaching resident-level trainees may contribute to this finding.

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.

Quality Metrics and Indicators for Surgical Training: A Scoping Review

BACKGROUND

Surgical training quality is critical to ensure that trainees receive adequate preparation to perform surgical procedures independently and that patients receive safe, effective, and high-quality care. Numerous surgical training quality indicators have been proposed, investigated and implemented. However, the existing evidence base for these indicators is limited, with most studies originating from English-speaking, high-income countries.

OBJECTIVES

This scoping review aimed to identify the range of quality indicators that have been proposed and evaluated in the literature, and to critically evaluate the existing evidence base for these indicators.

METHODS

A systematic literature search was conducted using MEDLINE and Embase databases to identify studies reporting on surgical training quality indicators. A total of 68 articles were included in the review.

RESULTS

Operative volume is the most commonly cited indicator and has been investigated for its effects on trainee exam performance and career progression. Other indicators include operative diversity, workplace-based assessments, regular evaluation and feedback, academic achievements, formal teaching, and learning agreements, and direct observation of procedural skills. However, these indicators are largely based on qualitative analyses and expert opinions and have not been validated quantitatively using clear outcome measures for trainees and patients.

CONCLUSIONS

Future research is necessary to establish evidence-based indicators of high-quality surgical training, including in low-resource settings. Quantitative and qualitative studies are required to validate existing indicators and to identify new indicators that are relevant to diverse surgical training environments. Lastly, any approach to surgical training quality must prioritize the benefit to both trainees and patients, ensuring training success, career progression, and patient safety.

Advancing Urology Resident Surgical Autonomy

PURPOSE OF REVIEW

This paper aims to survey current literature on urologic graduate medical education focusing on surgical autonomy.

RECENT FINDINGS

Affording appropriate levels of surgical autonomy has a key role in the education of urologic trainees and perceived preparedness for independent practice. Recent studies in surgical resident autonomy have demonstrated a reduction in autonomy for trainees in recent years. Efforts to advance the state of modern surgical training include creation of targeted curricula, enhanced with use of surgical simulation, and structured feedback. Decline in surgical autonomy for urology residents may influence confidence after completion of their residency. Further study is needed into the declining levels of urology resident autonomy, how it affects urologists entering independent practice, and what interventions can advance autonomy in modern urologic training.

Advancing Surgical Education: The Use of Artificial Intelligence in Surgical Training

The technology of artificial intelligence (AI) has made significant in-roads into the field of medicine over the last decade. With surgery being a discipline where repetition is the key to mastery, the scope of AI presents enormous potential for resident education through the analysis of technique and delivery of structured feedback for performance improvement. In an era marred by a raging pandemic that has decreased exposure and opportunity, AI offers an attractive solution towards improving operating room efficiency, safe patient care in the hands of supervised residents and can ultimately culminate in reduced health care costs. Through this article, we elucidate the current adoption of the artificial intelligence technology and its prospects for advancing surgical education.

A patient reads the medical literature

A 45-year-old male with no significant past medical history presented with a lump in his right groin. Outpatient computed tomography imaging ordered by his primary care physician demonstrated moderate right inguinal hernia containing nonobstructed distal descending/proximal sigmoid colon. Surgical repair of the hernia was recommended and the patient was referred for consultation with a general surgeon. The patient then conducted a search of current medical literature and, upon reflection, refused to let the consulted surgeon operate upon him. After identifying a significantly more experienced surgeon, the patient underwent office consultation and, later, uneventful surgical repair of his inguinal hernia. To follow is a case description with a review of the relevant literature read by the patient that informed his decision to be operated upon only by a more senior general surgeon.