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Engelhardt M, Schmid R, Kölbel B, Hyhlik-Dürr A, Zerwes S, Zischek C. Training in vascular trauma surgery for non-vascular surgeons: Vascular trauma surgery skills course. Eur Surg 2023; 55:89-93. [PMID: 37206194 PMCID: PMC10123566 DOI: 10.1007/s10353-023-00800-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 03/15/2023] [Indexed: 05/21/2023]
Abstract
Background The experience of general and trauma surgeons in vascular trauma management has decreased with sub-specialization of surgery and working hours restrictions. We introduce a vascular trauma surgery skills course established to train German military surgeons prior to their deployment to conflict areas. Methods The intention and implementation of the vascular trauma course for non-vascular surgeons is described in detail. Results In hands-on courses, participants learn and train basic vascular surgical techniques on more realistic extremity, neck, and abdominal models with pulsatile vessels. A fundamental and an advanced course each provide military as well as civilian surgeons from different non-vascular specialties with a surgical skill set including direct vessel sutures, patch angioplasty, anastomosis, thrombectomy, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in order to render them capable of managing major vascular injuries. Conclusion The experiences of this vascular trauma surgical skills course, initially established for military surgeons, can also be of use to all civilian general, visceral, and trauma surgeons occasionally facing traumatic or iatrogenic vascular injuries. Thus, the introduced vascular trauma course is valuable for all surgeons working in trauma centers.
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Affiliation(s)
- M. Engelhardt
- Department of Vascular and Endovascular Surgery, Centre for Vascular Medicine, Military Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - R. Schmid
- Department of Vascular and Endovascular Surgery, Centre for Vascular Medicine, Military Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - B. Kölbel
- Department of Vascular and Endovascular Surgery, Centre for Vascular Medicine, Military Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - A. Hyhlik-Dürr
- Medical Faculty, University of Augsburg, Augsburg, Germany
| | - S. Zerwes
- Medical Faculty, University of Augsburg, Augsburg, Germany
| | - C. Zischek
- Department of Vascular and Endovascular Surgery, Centre for Vascular Medicine, Military Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
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The Impact of Endovascular Repair of Abdominal Aortic Aneurysms on Vascular Surgery Training in Open Aneurysm Repair. Ann Vasc Surg 2023; 92:1-8. [PMID: 36754163 DOI: 10.1016/j.avsg.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/12/2023] [Accepted: 01/15/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Since the introduction of endovascular aneurysm repair (EVAR) in 1992, the number of open AAA repair (OAR) cases continue to decline. The consequence of reduced OAR cases raises valid concerns related to patient safety and the future training of vascular surgeons that need to be appropriately addressed. Our objective is to analyze trends in OAR and EVAR cases and to assess their implications on the quality of vascular surgery training. METHODS We analyzed the Accreditation Council for Graduate Medical Education (ACGME) case log database for total clinical experience in OAR and EVAR for graduating vascular surgery fellows (VSFs) finishing 5 + 2 programs between 2002 and 2019 and vascular surgery integrated residents (VSRs) between 2013 and 2019. VSF case totals were calculated by combining average total cases of open and endovascular supra- and infrarenal AAA repair during fellowship years combined with total cases performed during their general surgery residency. VSR case totals included only the cases performed during the 5-year residency period. Isolated Iliac and thoracic aortic aneurysms were excluded from our analysis. RESULTS The average number of OAR cases per trainee has decreased by 60% (from 36.9 to 14.7) with a rate of 1.4 cases per year (P < 0.001) for VSF. Meanwhile, EVAR average cases have increased by 102% (from 22 to 44.4). However, there were 2 different trends exhibited with EVAR over the study period. Between 2002 and 2007, EVAR cases tended to increase by 5.9 cases per year (P < 0.001). Whereas, between 2007 and 2019, there was a slightly decreased trend in EVAR cases by 0.3 cases per year (P = 0.01). For VSR, while no significant trend was observed in the mean number of OAR cases (Coef. -0.3, P = 0.2) due to the limited time frame, the proportion of open cases was significantly lower compared to endovascular cases. Additionally, there were 2 different trends exhibited with EVAR over the study period. Between 2013 and 2015, EVAR cases tended to increase by 1.7 cases per year (P = 0.1). Whereas, between 2015 and 2019, there was a slightly decreased trend in EVAR cases by 0.2 cases per year (P = 0.007). CONCLUSIONS A significant reduction in average OAR cases and an increase in EVAR cases were observed over the study period. Vascular surgery training programs may need to introduce further training programs in open surgical repair to ensure vascular surgery trainees have the required technical skills and expertize to perform such a high-risk procedure safely and independently.
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Zambare WV, Hess DT, Kenzik K, Pernar LI. Outcomes in Laparoscopic Roux-en-Y Gastric Bypass and Implications for Surgical Resident Education. JOURNAL OF SURGICAL EDUCATION 2021; 78:e161-e168. [PMID: 34219036 DOI: 10.1016/j.jsurg.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/12/2021] [Accepted: 06/08/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Some surgery residents feel inadequately prepared to perform advanced operations, partly due to losing operative opportunities to fellows. In turn, they are prompted to pursue fellowships. Allowing residents the opportunity to participate in advanced procedures and complex cases may alleviate this cycle, if their participation is safe. This study examined the effects of resident participation in laparoscopic Roux-en-Y gastric bypass procedures (LRYGBs). DESIGN Our MBSAQIP database was used to identify LRYGBs performed at our institution between 2015 and 2018. Operative notes were reviewed to determine training level of the assistant. Patient comorbidities and outcomes (duration of surgery, length of stay, post-operative complications, readmissions, and reoperations) were stratified by assistant level of training for comparison. SETTING Urban tertiary care hospital. PARTICIPANTS Trainees and attending surgeons acting as assistants during LRYGBs. RESULTS Among 987 total cases, the assistants for the procedures were chief residents (n = 549, 56%), fourth-year residents (n = 258, 26%), attending surgeons (n = 143, 14%), and third-year residents (n = 37, 4%). Attending surgeons assisted more often when patients had a BMI ≥ 45 (38% attendings vs. 25% residents, p = 0.007), ≥ 2 comorbidities (54% vs. 40%, p = 0.007), or had a history of prior bariatric surgery (22% vs. 3%, p < 0.0001).Post-operative complication rate was low (4%) and did not differ significantly between all training levels (p = 0.86). Average length of stay, readmission rates, and reoperation rates were not significantly different across training levels (p = 0.75, p = 0.072, and p = 0.91 respectively). CONCLUSION Complication rates, hospital length of stay, readmission rates, and reoperation rates were equivalent for patients regardless of the level of training of the assistant for LRYGBs. Involving residents in complex bariatric procedures such as LRYGB is a safe model of education that does not compromise patient safety or hospital outcomes. Involvement in advanced cases allows general surgery residents to more confidently move toward independent practice.
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Affiliation(s)
| | - Donald T Hess
- Boston University School of Medicine, Boston, MA; Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | - Kelly Kenzik
- Department of Surgery, Boston Medical Center, Boston, Massachusetts; Institute for Cancer Outcomes and Survivorship; University of Alabama at Birmingham, Birmingham, Alabama
| | - Luise I Pernar
- Boston University School of Medicine, Boston, MA; Department of Surgery, Boston Medical Center, Boston, Massachusetts.
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Nooromid MJ, Thomas MA, Yoon DY, Eskandari MK, Peabody TD, Rodriguez HE. Outcomes of Sarcoma Resections Requiring Vascular Surgical Assistance: A Single-Center Experience. Vasc Endovascular Surg 2020; 54:579-585. [PMID: 32744174 DOI: 10.1177/1538574420942334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: To describe the types of intervention and determine patency and survival after arterial and venous reconstruction after surgical excision of sarcomas. Methods: Between November 2001 and July 2015, 42 patients with sarcomas and vascular involvement underwent surgical oncologic resection followed by arterial or venous reconstruction or preservation of the native vascular bundle. Univariate, multivariate, and Kaplan-Meier survival analyses were performed on abstracted data, which included demographics, risk factors, oncologic and vascular treatment modalities, postoperative complications, graft patency, and survival outcomes. Results: A total of 42 sarcomas required vascular assistance for oncologic removal. The majority of sarcomas were malignant fibrous histiocytoma (23.8%), and the most common anatomic location was the retroperitoneum (48%). A total of 12 revascularizations procedures were performed, including 5 arterial, 3 venous, and 2 concomitant arterial and venous. In 32 cases, a vascular surgeon was needed for vessel ligation, repair, or mobilization. The overall 2- and 5-year survival was 77.7% and 26.2%, respectively, with no significant survival difference between patients who underwent revascularization compared to those without revascularization. There was a 100% patency rate in all cases at last follow-up, regardless of the type of vascular reconstruction (median 18 months, range 1-29 months). On multivariate analysis, chronic obstructive pulmonary disease (COPD; P = .002) and positive surgical margins (P = .003) were associated with decreased survival. Most cases were performed in the last 5 years of the study (n = 27, 64.3%). Conclusions: Vascular reconstruction is feasible after surgical oncologic resection of sarcomas with good mid-term patency and limb preservation. Factors independently associated with mortality included COPD and positive surgical margins.
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Affiliation(s)
- Michael J Nooromid
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael A Thomas
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dustin Y Yoon
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark K Eskandari
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Terrance D Peabody
- Department of Orthopedic Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Heron E Rodriguez
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Abstract
BACKGROUND Due to the increasing threat of terrorist attacks and assassinations even in Europe, the interest in management of severe vascular injuries, which, with an increased incidence of 10% are to be expected with such penetrating wounds, is also growing; however, with increasing subspecialization in surgery there is a threat that the know-how in vascular surgery will become lost among non-vascular surgical specialists. Therefore, the Germany military established an educational program, the so-called DUOplus concept, to ensure that future military surgeons acquire and retain the experience and skills to fulfill the demanding role of a deployed surgeon. OBJECTIVE The DUOplus concept of the German Medical Forces is introduced with a special focus on vascular surgery training. RESULTS All trainee German military surgeons attain a second specialization alongside general surgery. This residency includes several courses in various surgical specialties as well as a 12-month rotation in a vascular surgery department. The core elements of vascular trauma training are two practical courses on life-like models. In these courses, which were developed especially for the needs of non-vascular surgeons in hands-on training, open surgical techniques and damage control measures including resuscitative endovascular balloon occlusion of the aorta (REBOA) are taught on suitable models and intensively practiced. CONCLUSION All surgeons potentially confronted with traumatic and iatrogenic vascular injuries should have some basic competence in the management of vascular trauma. Especially the courses in vascular surgery for non-vascular surgeons offer such a skill set for every surgeon. Next to the German military surgeons, the courses are attended more and more by civilian and military surgeons from different surgical specialties and nationalities.
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Shannon AH, Robinson WP, Hanks JB, Potts JR. Impact of New Vascular Fellowship Programs on Vascular Surgery Operative Volume of Residents in Associated General Surgery Programs. J Am Coll Surg 2019; 228:525-532. [DOI: 10.1016/j.jamcollsurg.2018.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
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Williams AM, Bhatti UF, Barrett M, Nikolian VC, Han B, Matusko N, Sung RS, Reddy RM, Newman EA, Woodside KJ, Sandhu G. Resident perceptions and evaluations of fellow-led and resident-led surgical services. Am J Surg 2018; 217:373-381. [PMID: 30224072 DOI: 10.1016/j.amjsurg.2018.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/06/2018] [Accepted: 09/01/2018] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Aaron M Williams
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Umar F Bhatti
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Meredith Barrett
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Britta Han
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Niki Matusko
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Randall S Sung
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Erika A Newman
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Gurjit Sandhu
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Grodstein EI, Little C, Molmenti EP, Mezrich JD. Renal Transplantation as a Platform for Teaching Residents Open Vascular Surgical Techniques: Effects on Early Graft Function. JOURNAL OF SURGICAL EDUCATION 2018; 75:964-967. [PMID: 29361509 DOI: 10.1016/j.jsurg.2018.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/28/2017] [Accepted: 01/01/2018] [Indexed: 06/07/2023]
Abstract
BACKGROUND Over the past decade, increases in vascular fellowships and the use of endovascular technology have decreased the general surgery residents' exposure to open vascular surgery. We sought to elucidate whether renal transplant is a safe way to teach general surgery residents the essential tenants of vascular surgery without adversely affecting early patient outcomes. METHODS All solitary, adult deceased donor kidney transplants performed at the University of Wisconsin from 2011 through 2016 were identified and divided into a resident-assist (RA) and fellow-assist cohorts (FA). DGF, defined by the requirement of dialysis within 1 week of transplant, was the primary outcome. Early graft survival and postoperative complications were considered the secondary endpoints. RESULTS Of the 774 total cases, there were 228 (29.5%) in the RA cohort and 546 (70.5%) in the FA cohort. The RA and FA cohorts had comparable characteristics, except for a nonclinically significant difference in mean donor creatinine (0.96 vs 0.88mg/dL, p = 0.03). RA cases had a similar DGF rate compared to FA cases (25% vs 26%, p = 0.93). Additionally, there was no difference in 2-year graft survival (93.7% vs 95.5%, p = 0.38), nor the rates of graft thromboses (0.4% vs 0.7%, p = 0.65), incisional hernias (0.9% vs 1.8%, p = 0.35), and ureteral strictures (2.2% vs 1.6%, p = 0.55) between the 2 cohorts. CONCLUSIONS Resident involvement in renal transplantation has no effect on DGF and early allograft function. Though the procedural involvement of each resident in a case is variable, it seems to be a safe way to teach retroperitoneal vascular exposure and anastomotic techniques.
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Affiliation(s)
- Elliot I Grodstein
- Department of Surgery, University of Wisconsin, Madison, Wisconsin; Department of Surgery, Northwell Health, Sandra Atlas Bass Center for Liver Diseases, Manhasset, New York.
| | | | - Ernesto P Molmenti
- Department of Surgery, Northwell Health, Sandra Atlas Bass Center for Liver Diseases, Manhasset, New York
| | - Joshua D Mezrich
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
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Mackenzie CF, Bowyer MW, Henry S, Tisherman SA, Puche A, Chen H, Shalin V, Pugh K, Garofalo E, Shackelford SA. Cadaver-Based Trauma Procedural Skills Training: Skills Retention 30 Months after Training among Practicing Surgeons in Comparison to Experts or More Recently Trained Residents. J Am Coll Surg 2018; 227:270-279. [PMID: 29733906 DOI: 10.1016/j.jamcollsurg.2018.04.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/19/2018] [Accepted: 04/19/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Long-term retention of trauma procedural core-competency skills and need for re-training after a 1-day cadaver-based course remains unknown. We measured and compared technical skills for trauma core competencies at mean 14 months (38 residents), 30 months (35 practicing surgeons), and 46 months (10 experts) after training to determine if skill degradation occurs with time. Technical performance during extremity vascular exposures and lower-extremity fasciotomy in fresh cadavers measured by validated individual procedure score (IPS) was the primary outcome. STUDY DESIGN We performed a prospective study between May 2013 and September 2016. RESULTS Practicing surgeons had lower IPS and IPS component scores (p = 0.02 to 0.001) than residents (p < 0.05) and experts (p < 0.002) for vascular procedures. Frequencies of errors were no different among residents and experts. Practicing surgeons made more critical errors (p < 0.05) than experts or residents. Experts had shortest time to proximal vascular control. Fasciotomy procedural errors occurred in all participants. Cluster analysis of anatomy vs procedural steps identified tertiles of performance and wide variance (32.5% practicing surgeons, 26.5% residents vs 13% experts) for vascular procedures. Vascular control duration > 20 minutes (n = 21) and failure to decompress fasciotomy compartments were correlated with incorrect landmarks and skin incisions. Modeling found interval trauma skills experience, not time since training, was associated with lower IPS. CONCLUSIONS Practicing surgeons with low trauma skills experience since training had lower IPS and component scores (p = 0.02 to 0.001) and more errors compared with experts and residents (p < 0.05). Surgeons, including experts with low interval experience performing trauma procedures, may benefit from refreshing of correct landmarks and skin incision placement identification.
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Affiliation(s)
- Colin F Mackenzie
- Shock Trauma Anesthesiology Research Center, Baltimore, MD; University of Maryland, School of Medicine, Baltimore, MD.
| | - Mark W Bowyer
- Department of Surgery, Uniformed Services University of Health Sciences, and the Walter Reed National Military Medical Center, Bethesda, MD
| | - Sharon Henry
- University of Maryland, School of Medicine, Baltimore, MD; Department of Surgery and Shock Trauma Center of the University of Maryland School of Medicine and Medical Center, Baltimore, MD
| | - Samuel A Tisherman
- Shock Trauma Anesthesiology Research Center, Baltimore, MD; University of Maryland, School of Medicine, Baltimore, MD; Department of Surgery and Shock Trauma Center of the University of Maryland School of Medicine and Medical Center, Baltimore, MD
| | - Adam Puche
- University of Maryland, School of Medicine, Baltimore, MD
| | - Hegang Chen
- University of Maryland, School of Medicine, Baltimore, MD
| | - Valerie Shalin
- Department of Psychology, Wright State University, Dayton, OH
| | - Kristy Pugh
- University of Maryland, School of Medicine, Baltimore, MD
| | - Evan Garofalo
- Department of Anatomy, University of Arizona School of Medicine, Phoenix, AZ
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Greenwood V, Shames B, Tanious A, Shames ML, Indes JE. Trends in open abdominal exposure among vascular surgery trainees. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.03.448] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Is your graduating general surgery resident qualified to take trauma call? A 15-year appraisal of the changes in general surgery education for trauma. J Trauma Acute Care Surg 2017; 82:470-480. [PMID: 28045741 DOI: 10.1097/ta.0000000000001351] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Trauma training in general surgery residency is undergoing an evolution. Hour restrictions, the growth of subspecialty care, and the trend toward nonoperative management have altered resident exposure to operative trauma. We sought to identify trends in resident trauma training since the inception of the 80-hour workweek. METHODS The Accreditation Council for General Medical Education Case Log Statistical Reports for Surgery was abstracted for general surgery resident trauma operative volume for the years 1999-2014. Resident trauma experience (operative caseload [OC]) was compared before inception of the 80-hour workweek (1999-2002) to after the 80-hour workweek began (2003 to current). RESULTS A trend toward decreased operative trauma for general surgery residents was observed (mean OC [before 80-hour workweek vs. 80-hour workweek], 39,252 ± 1,065.2 cases vs. 36,065 ± 1,291.8; p = 0.06). Trauma laparotomies increased (range, 5,446-9,364 cases) with corresponding decreases in vascular trauma (4,704 to 799 cases), neck explorations (1,876 to 1,370 cases), and thoracotomies (2,507 to 2,284 cases). By comparison, an increase in vascular/integrated cases was noted (mean OC [before 80-hour workweek vs. 80-hour workweek], 845 ± 44.2 vs. 1,465 ± 88.4 cases; p < 0.01). Resident deficiencies analyzed by time period (before 80-hour workweek vs. 80-hour workweek) demonstrated deficiencies in thoracic, abdominal, solid organ, and extremity-vascular trauma domains (p < 0.01 for each). Nontrauma cases were also on the decline, specifically in open thoracic, vascular, and solid organ surgery (p < 0.05 for each). Both 1- and 2-year fellowships offset deficiencies in trauma education. CONCLUSIONS Based on the data, an alarming number of graduates complete training with substantially less experience in defined trauma categories. Because of a decline in operative trauma volume, advanced fellowship training should be encouraged specifically for those interested in a career in trauma and acute care surgery.
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Tanious A, Wooster M, Jung A, Nelson PR, Armstrong PA, Shames ML. Comparison of the integrated vascular surgery resident operative experience and the traditional vascular surgery fellowship. J Vasc Surg 2017; 66:307-310. [DOI: 10.1016/j.jvs.2017.03.414] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/03/2017] [Indexed: 10/19/2022]
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13
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Piazza M, Nayak N, Ali Z, Heuer G, Sanborn M, Stein S, Schuster J, Grady MS, Malhotra NR. Trends in Resident Operative Teaching Opportunities for Treatment of Intracranial Aneurysms. World Neurosurg 2017; 103:194-200. [DOI: 10.1016/j.wneu.2017.03.124] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/23/2017] [Accepted: 03/25/2017] [Indexed: 11/16/2022]
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Trends and outcomes in endovascular and open surgical treatment of visceral aneurysms. J Vasc Surg 2017; 66:195-201.e1. [DOI: 10.1016/j.jvs.2017.02.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 02/25/2017] [Indexed: 11/23/2022]
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15
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Chin JA, Skrip L, Sumpio BE, Cardella JA, Indes JE, Sarac TP, Dardik A, Ochoa Chaar CI. Percutaneous endovascular aneurysm repair in morbidly obese patients. J Vasc Surg 2017; 65:643-650.e1. [DOI: 10.1016/j.jvs.2016.06.115] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 06/27/2016] [Indexed: 12/17/2022]
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16
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Pedersen RC, Li Y, Chang JS, Lew WK, Patel K(K. Effect of Endovascular Interventions on General Surgery Trainee Operative Experience; a Comparison of Case Log Reports. Ann Vasc Surg 2016; 33:98-102. [DOI: 10.1016/j.avsg.2016.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 02/28/2016] [Accepted: 02/29/2016] [Indexed: 11/28/2022]
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17
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Assessment of open operative vascular surgical experience among general surgery residents. J Vasc Surg 2016; 63:1110-5. [DOI: 10.1016/j.jvs.2015.09.062] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 09/30/2015] [Indexed: 11/22/2022]
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18
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Patel M. Surgical dilemma: loss of open surgical skills to minimally invasive surgery. ANZ J Surg 2016; 86:7-8. [DOI: 10.1111/ans.13287] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Manish Patel
- Discipline of Surgery; The University of Sydney; Sydney New South Wales Australia
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Petrushnko W, Perry W, Fraser-Kirk G, Ctercteko G, Adusumilli S, O'Grady G. The impact of fellowships on surgical resident training in a multispecialty cohort in Australia and New Zealand. Surgery 2015; 158:1468-74. [DOI: 10.1016/j.surg.2015.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 06/17/2015] [Accepted: 07/01/2015] [Indexed: 11/30/2022]
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Yan H, Maximus S, Kim JJ, Smith B, Kim D, Koopmann M, DeVirgilio C. General Surgery Resident Vascular Operative Experience in the Era of Endovascular Surgery and Vascular Fellowships. Am Surg 2015. [DOI: 10.1177/000313481508101036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Advances in endovascular surgery have resulted in a decline in major open arterial reconstructions nationwide. Our objective is to investigate the effect of endovascular surgery on general surgery resident experience with open vascular surgery. Between 2004 and 2014, 112 residents graduated from two academic institutions in Southern California. Residents were separated into those who graduated in 2004 to 2008 (period 1) and in 2009 to 2014 (period 2). Case volumes of vascular procedures were compared using two-sample t test. A total of 43 residents were in period 1 and 59 residents were in period 2. In aggregate, there was no significant difference in open cases recorded between the two periods (84 vs 87, P = 0.194). Subgroup analysis showed period 2 recorded significantly fewer cases of open aneurysm repair (5 vs 3, P < 0.001), cerebrovascular (14 vs 10, P = 0.007), and peripheral obstructive procedures (16 vs 13, P = 0.017). Dialysis access procedures constituted the largest group of procedures and remained similar between the two periods (35 vs 42, P = 0.582). General surgery residents experienced a significant decline in several index open major arterial reconstruction cases. This decline was offset by maintenance of dialysis access procedures. If the trend continues, future general surgeons will not be proficient in open vascular procedures.
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Affiliation(s)
- Huan Yan
- Department of Surgery, Harbor-University of California Los Angeles Medical Center
| | - Steven Maximus
- Department of Anesthesia and Surgery, University of California at Irvine; and the Los Angeles Biomedical Research Institute at Harbor-University of California
| | - Jerry J. Kim
- Department of Surgery, Harbor-University of California Los Angeles Medical Center
| | - Brian Smith
- Department of Anesthesia and Surgery, University of California at Irvine; and the Los Angeles Biomedical Research Institute at Harbor-University of California
| | - Dennis Kim
- Department of Surgery, Harbor-University of California Los Angeles Medical Center
| | - Matthew Koopmann
- Department of Surgery, Harbor-University of California Los Angeles Medical Center
| | - Christian DeVirgilio
- Department of Surgery, Harbor-University of California Los Angeles Medical Center
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Batista P, Abai B, Salvatore D, DiMuzio P. The first assessment of operative logs for traditional vascular fellowship track versus integrated vascular training programs. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.05.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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The Evolving Integrated Vascular Surgery Residency Curriculum. Ann Vasc Surg 2014; 28:1761-8. [DOI: 10.1016/j.avsg.2014.02.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 02/11/2014] [Accepted: 02/21/2014] [Indexed: 11/19/2022]
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Eckstein HH, Schmidli J, Schumacher H, Gürke L, Klemm K, Duschek N, Meile T, Assadian A. Rationale, scope, and 20-year experience of vascular surgical training with lifelike pulsatile flow models. J Vasc Surg 2013; 57:1422-8. [DOI: 10.1016/j.jvs.2012.11.113] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Revised: 10/24/2012] [Accepted: 11/25/2012] [Indexed: 01/22/2023]
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Schwartz JJ, Thiesset HF, Bohn JA, Sloat B, Carricaburu M, Hatch J, Sorensen JB, Kim RD, Vargo D, Fryer JP. Perceived benefits of a transplant surgery experience to general surgery residency training. JOURNAL OF SURGICAL EDUCATION 2012; 69:371-384. [PMID: 22483141 DOI: 10.1016/j.jsurg.2011.10.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Revised: 10/06/2011] [Accepted: 10/27/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES The benefit of a solid-organ transplant experience during general surgical training has been questioned recently. In 2008, in response to an American Board of Surgery (ABS) directive, a survey was conducted by the Association of Program Directors in Surgery (APDS) in coordination with the American Society of Transplant Surgeons (ASTS) to determine the perceived value of a transplant surgery rotation to program directors and residents. With the aim of providing additional insight, we conducted a separate study, independent of the ABS and ASTS, to ascertain resident perceptions regarding the specific skill sets that they acquire during their transplant surgery rotations and their applicability to other surgical subspecialties. METHODS A preliminary, 51-item, web-based questionnaire was completed by 69.6% of residents in nationally accredited general surgery programs who accessed the survey. The results were examined using appropriate statistical methods to determine associations between answers. RESULTS Although only 16.6% of participants responded that they were considering a career in transplantation, 63.4% answered that the skill sets acquired during this rotation would assist them in their surgical careers regardless of their chosen specialty. Most (65.5%) respondents answered that the techniques learned were directly applicable to other specialties, such as vascular, urologic, trauma, and hepatobiliary surgery. Free response questions indicated that the most common criticisms of this rotation were the limited amount of operative participation, lack of teaching by attendings, and lifestyle limitations. CONCLUSIONS The results of this study indicate that surgery residents are conflicted regarding their transplant surgery experience but regard it as a beneficial addition to their training. Most respondents indicated also that these skills were transferable directly to other surgical specialties.
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Affiliation(s)
- Jason J Schwartz
- Department of General Surgery, Section of Transplantation, University of Utah School of Medicine, Salt Lake City, Utah 84132, USA
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Eidt JF, Mills J, Rhodes RS, Biester T, Gahtan V, Jordan WD, Hodgson KJ, Kent KC, Ricotta JJ, Sidawy AN, Valentine J. Comparison of surgical operative experience of trainees and practicing vascular surgeons: A report from the Vascular Surgery Board of the American Board of Surgery. J Vasc Surg 2011; 53:1130-9; discussion 1139-40. [DOI: 10.1016/j.jvs.2010.09.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 09/08/2010] [Accepted: 09/08/2010] [Indexed: 12/01/2022]
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Simien C, Holt KD, Richter TH. The Impact of ACGME Work-Hour Reforms on the Operative Experience of Fellows in Surgical Subspecialty Programs. J Grad Med Educ 2011; 3:111-7. [PMID: 22379533 PMCID: PMC3186271 DOI: 10.4300/jgme-d-10-00174.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) introduced a set of regulations that mandated a reduction in the number of hours that medical residents can work. These requirements have generated controversy among medical educators, with some expressing concern that reducing resident hours may limit clinical exposure and competency, particularly in surgical specialties. OBJECTIVE This study examines the impact of duty hour restrictions on resident operative experience in residents in 2 surgical subspecialties since the implementation of the ACGME duty hour limits. METHOD We examined operative log data for vascular surgery and pediatric surgery, using the academic year immediately preceding the duty hour restrictions, 2002 to 2003, as a baseline for comparison to subsequent academic years through 2006 to 2007 for vascular surgery and 2007 to 2008 for pediatric surgery. RESULTS Graduating fellows in pediatric surgery showed no change in their total operative volume following duty hour restrictions. The pediatric-defined category of neonate procedures showed an increase following duty hour restrictions. Graduating fellows in vascular surgery showed an increase in total major procedures as surgeon. The vascular-defined categories of endovascular-diagnostic, endovascular-therapeutic, and endovascular-graft procedures also increased. CONCLUSIONS The reduction of duty hours has not resulted in a decrease in operative volume as some have predicted. Operative volume in pediatric surgery remained mainly unchanged, whereas operative volume in vascular surgery increased. We explore possible explanations for the observed findings.
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Affiliation(s)
- Christopher Simien
- Corresponding author: Christopher Simien, PhD, Applications and Data Analysis Department, Accreditation Council for Graduate Medical Education, 515 N State Street, Suite 2000, Chicago, IL 60657, 312.755.7110,
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Resident Operative Experience in General Surgery, Plastic Surgery, and Urology 5 Years After Implementation of the ACGME Duty Hour Policy. Ann Surg 2010; 252:383-9. [DOI: 10.1097/sla.0b013e3181e62299] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kwolek CJ, Crawford RS. Training the next generation of vascular specialists: current status and future perspectives. J Endovasc Ther 2009; 16 Suppl 1:I42-52. [PMID: 19317585 DOI: 10.1583/08-2661.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Several challenges exist with respect to training the current and next generation of vascular specialists. Current advances in technology have led to changes in the length and type of training required to master new endovascular techniques. At the same time, the number of open surgical cases being provided to trainees may not be sufficient to allow them to manage complex open procedures. This growth is occurring at a time when increased external pressures are being applied to shorten training programs. Finally, the next generation of vascular specialists will come from medical students who are accruing a large educational debt during their course of training. Vascular specialists outside the US have already begun to successfully deal with many of these issues, and insight can be gained from their successes and difficulties. In this article, we review the current status of training for vascular and endovascular specialists and discuss the need for changes in current US training paradigms. While this will touch on initiatives in other specialties, including cardiology, vascular medicine, and interventional and neuroradiology, we will focus primarily on changes that are occurring with respect to the training of surgical specialists who manage vascular disease.
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Affiliation(s)
- Christopher J Kwolek
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital Center, Harvard Medical School, Boston, Massachusetts 02114, USA.
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Burkhardt GE, Rasmussen TE, Propper BW, Lopez PL, Gifford SM, Clouse WD. A national survey of evolving management patterns for vascular injury. JOURNAL OF SURGICAL EDUCATION 2009; 66:239-247. [PMID: 20005495 DOI: 10.1016/j.jsurg.2009.09.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Revised: 09/14/2009] [Accepted: 09/16/2009] [Indexed: 05/28/2023]
Abstract
BACKGROUND The modern era has witnessed an increase in endovascular techniques used by physicians to treat vascular injury and age-related disease. As a consequence, the number of open vascular operations available for general surgical education has decreased dramatically. This changing paradigm threatens competence in vascular injury management achieved during surgical residency. The objective of this study is to sample perceptions on vascular injury treatment in the United States to highlight the need for planning for this important tenet of surgical education. METHODS An electronic survey was extended to board-certified surgeons through 3 professional societies, the Peripheral Vascular Surgery Society (PVSS), the Eastern Association for the Surgery of Trauma (EAST), and the American College of Surgeons (ACS). RESULTS A total of 520 respondents were self-categorized as trauma (59%; n = 307), vascular (17%; n = 90), or general (19%; n = 99) surgeons. Respondents reported that general surgeons currently manage less than 10% of vascular injuries at their respective institutions. A 2.5-fold increase in endovascular treatment of vascular injury during the past decade was reported with interventional radiologists now involved in the management of up to 25% of injuries. Few general or trauma surgeons surveyed possessed a catheter-based skill set, although 38% of trauma surgeons expressed great interest in endovascular training. Additionally, a cadre of vascular surgeons (67%) affirmed a commitment to teaching vascular injury management. CONCLUSIONS The results of this study confirm a diminished role for non-fellowship-trained surgeons in managing vascular injury. Despite an increased acceptance of endovascular techniques to manage trauma, general and trauma surgeons do not possess the skill set. Collaboration between surgical communities will be especially important to maintain high standards in vascular injury management.
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Affiliation(s)
- Gabriel E Burkhardt
- San Antonio Military Medicine Consortium, Wilford Hall USAF Medical Center, 2200 Bergquist Drive, Lackland Air Force Base, Texas 78236, USA
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Joels CS, Langan EM, Daley CA, Kalbaugh CA, Cass AL, Cull DL, Taylor SM. Changing Indications and Outcomes for Open Abdominal Aortic Aneurysm Repair since the Advent of Endovascular Repair. Am Surg 2009. [DOI: 10.1177/000313480907500806] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The indications for open abdominal aortic aneurysm (AAA) repair have changed with the development of endovascular techniques. The purpose of this study is to clarify the indications and outcomes for open repair since endovascular aneurysm repair (EVAR) and to compare contemporary AAA repair with the pre-EVAR era. Patients undergoing open AAA repair were identified; the demographics, outcomes, and indications for open repair were reviewed. Outcomes were compared based on indication for open repair in the EVAR era and between the pre-EVAR and EVAR eras. Open indications in the EVAR era included: age younger than 65 years with minimal comorbidities (AGE, n = 24 [9.8%]), unfavorable anatomy (ANAT, n = 146 [59.3%]), aortoiliac occlusive disease (AIOD, n = 38 [15.4%]), and miscellaneous (OTHER, n = 38 [15.4%]). Mortality (30-day and 5-year) was affected by indication: AGE = 0 and 0 per cent, ANAT = 4.1 and 49.7 per cent, AIOD = 13.5 and 32.3 per cent, and OTHER = 5.3 and 41.8 per cent. Age, sex, race, coronary artery disease, and peripheral artery disease were similar between the pre-EVAR and EVAR eras. EVAR-era patients had more diabetes mellitus, hypertension, and hyperlipidemia and longer operative time. Mortality was not different, but complication rates were lower in the pre-EVAR era (23.7 vs 43.5%, P = 0.025). Patients undergoing open AAA repair in the EVAR era have more comorbidities, longer operative times, and more complications. Outcomes for EVAR-era patients are affected by the indication for open repair. A preference for open repair in younger patients with minimal comorbidities is justified.
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Affiliation(s)
- Charles S. Joels
- Academic Department of Surgery, Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - Eugene M. Langan
- Academic Department of Surgery, Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - Charles A Daley
- Academic Department of Surgery, Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - Corey A. Kalbaugh
- Academic Department of Surgery, Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - Anna L. Cass
- Academic Department of Surgery, Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - David L. Cull
- Academic Department of Surgery, Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - Spence M. Taylor
- Academic Department of Surgery, Greenville Hospital System University Medical Center, Greenville, South Carolina
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Prasad SM, Massad MG, Chedrawy EG, Snow NJ, Yeh JT, Lele H, Tarakji A, Maniar HS, Herren H, Gay WA. Weathering the storm: how can thoracic surgery training programs meet the new challenges in the era of less-invasive technologies? J Thorac Cardiovasc Surg 2009; 137:1317-25, discussion 1326. [PMID: 19464440 DOI: 10.1016/j.jtcvs.2009.02.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 01/07/2009] [Accepted: 02/16/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The introduction of new technologies has shifted some resident index procedures to nonsurgical specialists. We examined the operative case volume of thoracic surgery residents during the last 6 years to objectively identify changes and trends. METHODS Program and resident data from 2002 to 2007 were entered into a database and analyzed. Program match information was obtained from the National Resident Matching Program. Resident operative experience and board examination results were obtained from the American Board of Thoracic Surgery. RESULTS A total of 795 residents qualified for the written American Board of Thoracic Surgery examination; 627 residents graduated from 2-year programs, and 168 residents graduated from 3-year programs. The total number of resident cases was higher in 3-year programs compared with 2-year programs in all 10 index categories studied (P < .01). The total volume of cases has not significantly increased in 2-year programs. The volume of coronary artery bypass graft surgeries decreased in every resident program model studied. The volume of general thoracic cases increased in all program models. Two-year, 2-resident programs had the lowest volume in 5 of the 10 categories, reaching significance in 3 categories. The written board pass rate was lower among 2-year programs than among 3-year programs (86% vs 95%, respectively, P = .003). CONCLUSION Training programs have so far weathered the storm by maintaining index volume with a new case mix, but significant trends in revascularization procedures are concerning. This study indicates a significant advantage in case volume and board pass rates among 3-year programs. Thoracic residency programs should be reorganized so that the number of residents does not exceed the capacity of the program to provide a meaningful experience.
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Affiliation(s)
- Sunil M Prasad
- Division of Cardiothoracic Surgery, University of Illinois at Chicago, Chicago, Ill 60612, USA.
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Joels CS, Langan EM, Cull DL, Kalbaugh CA, Taylor SM. Effects of Increased Vascular Surgical Specialization on General Surgery Trainees, Practicing Surgeons, and the Provision of Vascular Surgical Care. J Am Coll Surg 2009; 208:692-7, quiz 697.e1; discussion reply 697-9. [DOI: 10.1016/j.jamcollsurg.2008.12.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Accepted: 12/05/2008] [Indexed: 11/27/2022]
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Kairys JC, DiMuzio PJ, Crawford AG, Grabo DJ, Yeo CJ. Changes in operative case experience for general surgery residents: has the 80-hour work week decreased residents' operative experience? Adv Surg 2009; 43:73-90. [PMID: 19845170 DOI: 10.1016/j.yasu.2009.02.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- John C Kairys
- Department of Surgery, Thomas Jefferson University, 1015 Walnut Street, Room 620, Philadelphia, PA 19107, USA.
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