Training general surgery residents in pediatric surgery: A Canadian survey

Resident Exposure and Involvement in Core Procedural Competencies within Pediatric Plastic Surgery

Introduction: The implementation of competency-based residency training in plastic surgery is underway. Key competencies in plastic surgery have been previously identified, however, within the domain of pediatrics, data suggest limited exposure throughout training for Canadian graduates. This study aims to identify the exposure and involvement of residents in core pediatric cases. Methods: We performed a retrospective, multicenter review of plastic surgery resident case logs (T-Res, POWER, New Innovations) across 10 Canadian, English-speaking training programs between 2004 and 2014. Case logs were coded according to the 8 core pediatric competencies previously identified by a modified Delphi technique. Results: A total of 3061 of 59 405 cases (5.2%) logged by 55 graduating residents were core pediatric procedures with an average of 55.6 ± 23.0 cases logged per resident. The top 3 most commonly logged procedures were cleft lip repair, cleft palate repair, and setback otoplasty. The number of cases per program varied widely with the most at 731 and least at 85 logged cases. Roles across procedures have wide variation and residents are most commonly identified as the assistant rather than surgeon or co-surgeon. Conclusion: These findings highlight variability both within and across residency programs with a paucity of exposure and involvement in pediatric plastic surgery cases. This may present a conflict between current recommendations for residency-specific procedural competencies and true clinical exposure. Further curriculum development and simulation may be of benefit.

Variability among Canadian pediatric surgeons and pediatric urologists in the management of cryptorchidism in boys before the publication of major guidelines: a retrospective review of a single tertiary centre

Background

Before 2014, there was a lack of recommendations on managing cryptorchidism, or undescended testis (UDT), from a large pediatric urological or surgical organization. We assessed the variability in management of UDT among pediatric urologists and pediatric surgeons at a single tertiary pediatric referral centre before publication of major guidelines.

Methods

We performed a retrospective review of the electronic records of patients who underwent primary unilateral or bilateral orchidopexy at our centre between January 2012 and January 2014.

Results

A total of 488 patients (616 testes) were identified, of whom 405 (83.0%) and 83 (17.0%) were managed by pediatric urologists and pediatric surgeons, respectively. There was no difference in baseline characteristics, including age seen in clinic or at surgery, testis location/palpability and availability of preoperative ultrasonograms, of patients seen by the 2 groups. Pediatric surgeons ordered preoperative ultrasonography more often than pediatric urologists (25.3% v. 3.7%, p < 0.001). With palpable UDTs, although both groups used open approaches, pediatric urologists preferred a scrotal approach (56.9%), and pediatric surgeons approached most testes inguinally (98.8%). With nonpalpable UDTs, laparoscopic approaches were preferred by both groups; however, pediatric urologists used a 2-stage Fowler–Stephens approach more often than pediatric surgeons (48.4% v. 15.8%, p < 0.001).

Conclusion

There was wide variation in the management of primary UDT between pediatric urologists and pediatric surgeons before the publication of guidelines. The most prominent difference between the 2 groups was in the ordering of preoperative ultrasonography. Future assessment of change in practice patterns may elucidate whether guidelines are an effective tool for standardization of practice.

Resident perceptions and evaluations of fellow-led and resident-led surgical services

BACKGROUND

The impact of fellowship training on general surgery residency has remained challenging to assess. Surgical resident perceptions of fellow-led and resident-led surgical services have not been well described.

METHODS

Retrospective cross-sectional data were collected from residents' service evaluations from 7/2014 through 7/2017. Surgical services were categorized as resident-led or fellow-led. 31 variables were evaluated and collapsed into 7 factors including clinical experience, educational experiences, clinical staff, workload, feedback, treatment of residents, and overall rotation.

RESULTS

Among all PGY levels, fellow-led surgical services were rated significantly higher (p < 0.05) regarding clinical experience, clinical staff, treatment of residents, and overall rotation. PGY1-2 residents rated resident-led services significantly higher in the area of educational experiences, while PGY 3 residents rated resident-led services higher in the area of workload. However, PGY4-5 residents rated fellow-led services significantly higher in all 7 categories. Individual fellow-led services were rated significantly higher for various categories at different PGY levels.

CONCLUSIONS

Surgical residents appear to value the educational experiences of fellow-led services. Each fellow-led service may ultimately provide unique educational opportunities and resources for different PGY levels.

Can laparoscopy be part of a paediatric surgery outreach service?

INTRODUCTION The aim of this study was to assess the outreach laparoscopic service delivered by four paediatric surgeons to a district general hospital (DGH). METHODS A retrospective review was carried out of all laparoscopic procedures performed in a single DGH between January 2004 and November 2014 by the four paediatric surgeons providing the outreach service. All operations were identified from the electronic theatre system and archived correspondence. Demographic and clinical details were obtained from contemporaneous records. RESULTS Over the 11-year study period, 1,339 operations were performed as part of the outreach paediatric surgery service, with 128 patients (9.6%) undergoing laparoscopy. The indications for laparoscopic surgery were impalpable unilateral or bilateral undescended testes (UDT) (n=79, 62%) or request for insertion of a feeding gastrostomy (n=49, 38%). All but six UDT cases (96%) were performed as day surgery and the median length of stay for gastrostomy patients was 3 days (interquartile range: 2-3 days). There were three UDT cases with surgical complications and one had complications related to the anaesthesia. One gastrostomy case required transfer to our tertiary centre for management of postoperative urinary retention and urethral injury. CONCLUSIONS Elective laparoscopic procedures in young children can be provided safely as components of an outreach paediatric surgery service in a DGH setting as part of an increasing volume of operations performed by specialist paediatric surgeons. This enables children to have a high quality service as close to their home as possible.

Pediatric inguinal and scrotal surgery - Practice patterns in U.S. academic centers

PURPOSE

Both pediatric urologists and pediatric surgeons perform hernia repairs, hydrocelectomies and orchiopexies. We hypothesized that surgeons perform more incarcerated and female hernia repairs while urologists perform more orchiopexies and hydrocelectomies.

METHODS

The Vizient-AAMC Faculty Practice Solutions Center® database was queried from January 2009 to December 2014 to identify patients 10years or younger who underwent the above procedures performed by pediatric specialists. Age, gender, race, insurance, geographic region and surgeon volume were examined.

RESULTS

In the study 55,893 surgeries were identified: 26,073 primary hernia repairs, 462 recurrent hernia repairs, 3399 laparoscopic hernia repairs, 9414 hydrocele repairs and 16,545 orchiopexies. Pediatric surgeons performed 89% of primary hernia repairs with an annual median surgeon volume of 4 cases/year. Pediatric urologists performed 62% of hydrocelectomies and 83% of orchiopexies with annual median surgeon volumes of 6 and 24, respectively. Pediatric surgeons performed all procedures in younger patients and performed more female and incarcerated hernia repairs.

CONCLUSIONS

Pediatric surgeons operate on younger patients and treat more patients with inguinal hernias while pediatric urologists care for more boys with undescended testes and hydroceles. This knowledge of referral patterns and care between specialties with overlapping expertise will allow improvements in training and access.

LEVELS OF EVIDENCE

Cost Effectiveness Study, Level of Evidence III.

Symbiotic or parasitic? A review of the literature on the impact of fellowships on surgical residents

OBJECTIVE

We conducted a systematic review of published literature to gain a better understanding of the impact of advanced fellowships on surgical resident training and education.

BACKGROUND

As fellowship opportunities rise, resident training may be adversely impacted.

METHODS

PubMed, MEDLINE, Scopus, BIOSIS, Web of Science, and a manual search of article bibliographies. Of the 139 citations identified through the initial electronic search and screened for possible inclusion, 23 articles were retained and accepted for this review. Data were extracted regarding surgical specialty, methodology, sample population, outcomes measured, and results.

RESULTS

Eight studies retrospectively compared the eras before and after the introduction of a fellowship or trended data over time. Approximately half used data from a single institution, whereas the other half used some form of national data or survey. Only 3 studies used national case data. Fourteen studies looked at general surgery, 6 at obstetrics-gynecology, 2 at urology, and 1 at otolaryngology. Only one study concluded that fellowships have a generally positive impact on resident education, whereas 9 others found a negative impact. The remaining 13 studies found mixed results (n = 6) or minimal to no impact (n = 7).

CONCLUSIONS

The overall impact of advanced surgical fellowships on surgical resident education and training remains unclear, as most studies rely on limited data of questionable generalizability. A careful study of the national database of surgery resident case logs is essential to better understand how early surgical specialization and fellowships will impact the future of general surgery education.

Competence in pediatric urology upon graduation from residency: perceptions of residents, program directors and pediatric urologists

OBJECTIVE

We aimed to clarify the scope of pediatric urological procedures that Canadian urology residents are perceived to be competent to perform upon graduation.

METHODS

We conducted a survey from April 2005 to June 2006 of urology residency program directors (UPDs), senior urology residents (SURs) and Pediatric Urologists of Canada (PUC) members from all 12 Canadian training programs. Questions focused on which of 23 pediatric urological procedures the 3 study groups perceived urology residents would be competent to perform upon completion of residency without further fellowship training. Procedures were based on the "A," "B" and "C" lists of procedures (least complex to most complex) as outlined in the Royal College of Physicians and Surgeons of Canada Objectives of Training in Urology.

RESULTS

Response rates were 12/12 (100%), 41/53 (77%) and 17/23 (74%) for UPDs, SURs and PUC members, respectively. Average exposure to pediatric urology during residency was 5.4 (range 3-9) months and considered sufficient by 75% of UPDs and 69% of SURs, but only 41% of PUC members (p = 0.05). Overall, the 3 groups disagreed on the level of competence for performing level "A" and "B" procedures, with significant disagreement between PUC members and UPDs as well as SURs (p < 0.005).

CONCLUSION

PUC members perceive Canadian urology residents' exposure to pediatric urology as insufficient and their competence for procedures of low to moderate complexity as inadequate. Further investigation regarding exposure to and competence in other emerging subspecialty spheres of urology may be warranted. Ongoing assessment of the objectives for training in pediatric urology is required.

Thoracic surgery training in Canada according to the residents: the thoracic surgery resident survey, of the Canadian thoracic manpower and education study (T-Med)

OBJECTIVE

The resident component of the Canadian Thoracic Manpower and Education Study (T-MED) was conducted to understand the basic demographic of Canadian thoracic surgery residents, the factors influencing their selection of training programs, current work conditions, training and competencies, and opinions in regard to the manpower needs for the specialty.

DESIGN

A modified Delphi process was used to develop a survey applicable to thoracic surgery residents. In May and June 2009, residents completed the voluntary anonymous Internet-based survey. All Canadian residents participated in the survey, providing a 100% response rate.

RESULTS

Most respondents were male (11/12), and the average age was 34 years old with an anticipated debt greater than $50,000 on graduation. All residents worked more than 70 hours per week, with most doing 1 : 3 or 1 : 4 on-call. Two-thirds of respondents reported being satisfied or very satisfied with their training program. Rates of anticipated competence in performing various thoracic surgeries on graduation differed between residents and program directors. Two-thirds (8/12) of residents planned to practice thoracic surgery exclusively, and hoped to practice in an academic setting. Most residents (10/12) agreed or strongly agreed that not enough jobs are available in Canada for graduating trainees and that the number of residency positions should reflect the predicted availability of jobs.

CONCLUSIONS

This study has provided detailed information on thoracic surgery resident demographics and training programs. Most thoracic surgery residents are satisfied with their current training program but have concerns about their job prospects on graduation, and they believe that the number of training positions should reflect potential job opportunities. This survey represents the first attempt to characterize the current state of thoracic surgery training in Canada from the resident's perspective and may help in directing educational and manpower planning.

Factors Influencing Involvement in Research and Career Choice: A Survey of Graduating Physical Medicine and Rehabilitation Residents

OBJECTIVE

To assess the extent to which physical medicine and rehabilitation (PM&R) residents' involvement in research and selection of postgraduate practice may be related to residency program research requirements and support for presentations.

DESIGN

Internet-based survey.

SETTING

Anonymous access to Web form.

PARTICIPANTS

PM&R residents graduating in June 2004 and 2005.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Involvement in research, postgraduate practice setting and planned research effort, residency research requirement, and support for scientific presentations.

RESULTS

One hundred sixty (24%) of the 657 graduating residents, representing 25 states, the District of Columbia, and Puerto Rico, responded. Eighty-five percent indicated research involvement, with 74% reporting a research requirement and 85% residency program financial support for presentations. On average, respondents planned to devote 7% (95% confidence interval, 5%-9%) of their time to research once in practice. There was a statistically significant association between the existence of a research requirement and involvement in research (P < .001). However, there was no evidence of a statistically significant association between either the existence of a research requirement or presentation support and the selection of an academic career. There were no significant regional disparities for the existence of a research requirement, travel support, or number of presentations. However, there was a statistically significant regional difference in the proportion of postgraduate practice time that the respondents planned to devote to research.

CONCLUSIONS

A requirement for PM&R residents to be involved in research may influence research activity during residency but may not be associated with selection of an academic or research-oriented practice.

Vascular surgery training in general surgery residency programs: the Canadian experience

OBJECTIVES

Vascular surgery is traditionally considered a component of general surgery. There is growing evidence of improved patient outcome related to surgeon volume and vascular certification status. The American Board of Surgery in the United States, as well as until recently the Royal College of Physicians and Surgeons in Canada, requires that vascular surgery be considered an essential content area of general surgery training. This requirement is controversial. The purpose of this study was to describe experience and perceived competence in common vascular surgery procedures during general surgery residency training in Canada.

METHODS

This web-based survey was conducted between January and June 2002. General surgery program directors (GSPDs), vascular surgeons involved in general surgery training programs (VSs), and senior general surgery residents (SRs) from the 13 English-speaking general surgery programs in Canada were surveyed. Questions were asked regarding which vascular surgery procedures are appropriate for general surgeons to perform, which procedures SRs are trained to perform, and which procedures SR intend to perform.

RESULTS

The response rate was 62% for GSPDs, 57% for VSs, and 45% for SRs. Overall, 49% of SRs did not intend to perform any vascular procedures after training. GSPDs, VSs, and SRs indicated that most SRs should be and are trained to perform varicose vein surgery, leg amputation, and femoral embolectomy (P >.05). In addition, GSPDs, VSs, and SRs indicated that SRs should not be and are not trained to perform infrainguinal bypass grafting, carotid endarterectomy, or abdominal aortic aneurysm (AAA) repair (P >.05). There were significant differences with respect to ruptured AAA repair: 49% of SRs, 25% of PDs, and only 12% of VSs believe that general surgeons should be trained to perform ruptured AAA repair (P <.05). Overall, 76% of VSs believe SRs receive too little vascular training.

CONCLUSION

There is similarity between GSPDs, VSs, and SRs with respect to vascular surgery training in Canadian general surgery programs. Vascular surgery training cannot be considered a component of general surgery. More rotations or fellowship training is required to become competent in management of common vascular surgery procedures. Perhaps this level of competence should not be an objective of general surgery training.