Impact of Integrated Vascular Surgery Residency on General Surgery Resident and Vascular Fellow Operative Volume: A National Analysis

BACKGROUND

The impact of integrated vascular surgery (VS) residency (0 + 5) programs on general surgery (GS) resident and VS fellow (5 + 2) operative volume has not been investigated on a national scale.

METHODS

Accreditation Council for Graduate Medical Education (ACGME) case logs were reviewed for GS resident, VS resident, and VS fellow operative volume from 2001-2021. Integrated VS resident data was available from 2012-2021, corresponding with the introduction of the 0 + 5 paradigm. Trends in operative volume were evaluated via linear regression analysis.

RESULTS

The national cohort of chief GS resident graduates increased from 1005 to 1357 per year. Total operative volume also increased from 932 to 1039 cases (+7.4 cases/yr, R2 = .80, P < .0001) among GS residents. Major vascular cases decreased among GS residents from 138 to 101 cases (-2.4 cases/yr, R2 = .58, P < .0001) with a decrease in proportion of chief-level vascular cases from 30.4% to 11.9% (-1.0%/yr, R2 = .92, P < .0001). Palliative procedures (amputations and hemodialysis access) comprised a significant proportion of GS cases (median 44.7%). Concurrently, integrated VS graduates increased from 11 to 37 per year, with an increase in major vascular case volume from 506 to 658 cases (+18.4 cases/yr, R2 = .63, P = .01). Total VS fellow major case volume also increased from 369 to 444 cases (+3.5 cases/yr, R2 = .73, P < .0001).

CONCLUSIONS

The introduction of the 0 + 5 intgrated VS residency paradigm has correlated with a significant decrease in GS operative experience in major vascular procedures on a national level. Traditional VS fellow case volume does not appear to be impacted by 0 + 5 integrated residents. Further analysis with program-level data may help to explain the causative relationship of these findings.

ACGME Operative Case Log Accuracy Varies Among Surgical Programs

OBJECTIVE

This study evaluates the accuracy of reported the Accreditation Council for Graduate Medical Education (ACGME) operative case logs from graduated residents compared to institutional operating room electronic records (ORER). We hope this will help guide review committees and institutions develop complete, accurate resident case logs.

DESIGN

This is a retrospective, cross-sectional study of general surgery (GS), neurosurgery (NS), and orthopedic surgery (OS) resident physicians. ACGME and ORER cases from 2009 to 2010 were analyzed and each case and current procedural terminology (CPT) code directly compared (ORER vs. ACGME).

SETTING

Single academic tertiary-care medical center (University of Kentucky, Lexington, KY).

PARTICIPANTS

Eleven thousand nine hundred and twenty-three cases for 46 residents among the 3 residency programs were analyzed.

RESULTS

There was an overall logging accuracy of 72% for ORER cases reflected in the ACGME case logs. OS residents had a higher rate of logging accuracy (OS 91%, GS 69%, NS 58%, chi-square p = 0.014) and mean annual number of cases compared to the other 2 programs (OS 452, GS 183, NS 237, ANOVA p = 0.001). NS residents had higher accuracy of CPT codes than post-graduate years 2 to 5 in other programs (p < 0.017). There was a strong positive correlation between the number of cases completed per resident and case logging accuracy, (rho = 0.769, p < 0.001) consistent for NS and GS, but not OS.

CONCLUSIONS

This study shows only 72% of a residents' operative experience is captured in the ACGME case log across 3 surgical programs. There is significant variability among surgical programs and among post-graduate year cohorts regarding case log and CPT code accuracy. There is a strong correlation with the total number of cases performed and increasing case log accuracy. Low case log accuracy may reflect individual resident behavior instead of program operative exposure. Further studies are needed to determine if ORER may serve as a more complete assessment of the operative experience of a resident and program.

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.

Variable Operative Experience in Hand Surgery for Plastic Surgery Residents

BACKGROUND

Efforts to standardize hand surgery training during plastic surgery residency remain challenging. We analyze the variability of operative hand experience at U.S. plastic surgery residency programs.

METHODS

Operative case logs of chief residents in accredited U.S. plastic surgery residency programs were analyzed (2011-2015). Trends in fold differences of hand surgery case volume between the 10th and 90th percentiles of residents were assessed graphically. Percentile data were used to calculate the number of residents achieving case minimums in hand surgery for 2015.

RESULTS

Case logs from 818 plastic surgery residents were analyzed of which a minority were from integrated (35.7%) versus independent/combined (64.3%) residents. Trend analysis of fold differences in case volume demonstrated decreasing variability among procedure categories over time. By 2015, fold differences for hand reconstruction, tendon cases, nerve cases, arthroplasty/arthrodesis, amputation, arterial repair, Dupuytren release, and neoplasm cases were below 10-fold. Congenital deformity cases among independent/combined residents was the sole category that exceeded 10-fold by 2015. Percentile data suggested that approximately 10% of independent/combined residents did not meet case minimums for arterial repair and congenital deformity in 2015.

CONCLUSIONS

Variable operative experience during plastic surgery residency may limit adequate exposure to hand surgery for certain residents. Future studies should establish empiric case minimums for plastic surgery residents to ensure hand surgery competency upon graduation.

Resident and Attending Perceptions of Resident Involvement: An Analysis of ACGME Reporting Guidelines

OBJECTIVE

For general surgery residents (Residents) to log an operation, the ACGME requires "significant involvement" in diagnosis (DX), operation selection (SEL), operation (OPR), preoperative (PRE), and postoperative (POC) care. We compared how residents and attending surgeons (Attendings) perceived residents' role in each of these core requirements.

DESIGN

Residents and attendings completed surveys postoperatively regarding responsibility for each core requirement on a 5-point Likert scale from "Completely Attending" to "Completely Resident." Significance was determined using Chi-square analysis (p < 0.05) and degree of agreement was calculated using Spearman's rank correlation (r_s).

SETTING

Boston Medical Center, Boston, MA (tertiary institution).

RESULTS

A total of 302 paired surveys were analyzed. Residents more often performed a significant portion of the later stages of care (DX = 27%, PRE = 29%, SEL = 27%, OPR = 87%, and POC = 84%). Residents completed the majority of each requirement more frequently in operations performed in the acute setting compared to elective operations: DX (70% vs 8%, p < 0.01), PRE (74% vs 10%, p < 0.01), SEL (65% vs 11%, p < 0.01), OPR (100% vs 89%, p = 0.02), POC (100% vs 77%, p < 0.01). Resident participation was inversely related to operational complexity for DX (p < 0.01), PRE (p < 0.01), SEL (p < 0.01), and OPR (p = 0.01). Resident involvement in OPR increased at the end of the academic year (p = 0.05) and when working with junior attendings (<5 years in practice) (p = 0.01). Interpair agreement was greatest for DX (r_s = 0.70) and lowest for POC (r_s = 0.35). When residents and attendings did not agree in their answers, residents generally overstated their contribution to the DX (68%), PRE (58%), and SEL (64%) but understated their contribution in OPR (63%) and POC (62%).

CONCLUSIONS

Residents and attendings demonstrated reliable agreement for most core requirements, but residents were often unable to be involved in all 5 core requirements. Resident involvement was weighted toward later stages of patient care, yet residents often underestimated their contributions. Operational acuity, complexity, and attending experience correlated with resident operative involvement.

Extremes in Otolaryngology Resident Surgical Case Numbers: An Update

Objectives The purpose of this study is to examine the effect of minimum case numbers on otolaryngology resident case log data and understand differences in minimum, mean, and maximum among certain procedures as a follow-up to a prior study. Study Design Cross-sectional survey using a national database. Setting Academic otolaryngology residency programs. Subjects and Methods Review of otolaryngology resident national data reports from the Accreditation Council for Graduate Medical Education (ACGME) resident case log system performed from 2004 to 2015. Minimum, mean, standard deviation, and maximum values for total number of supervisor and resident surgeon cases and for specific surgical procedures were compared. Results The mean total number of resident surgeon cases for residents graduating from 2011 to 2015 ranged from 1833.3 ± 484 in 2011 to 2072.3 ± 548 in 2014. The minimum total number of cases ranged from 826 in 2014 to 1004 in 2015. The maximum total number of cases increased from 3545 in 2011 to 4580 in 2015. Multiple key indicator procedures had less than the required minimum reported in 2015. Conclusion Despite the ACGME instituting required minimum numbers for key indicator procedures, residents have graduated without meeting these minimums. Furthermore, there continues to be large variations in the minimum, mean, and maximum numbers for many procedures. Variation among resident case numbers is likely multifactorial. Ensuring proper instruction on coding and case role as well as emphasizing frequent logging by residents will ensure programs have the most accurate data to evaluate their case volume.

An Analysis of Operative Experiences of Junior General Surgical Residents and Correlation With the SCORE Curriculum

OBJECTIVE

Junior surgical resident education at academic institutions is traditionally focused to preoperative and postoperative patient management. Our objective was to investigate the number and type of surgical procedures performed by junior general surgery residents in comparison with the American Board of Surgery requirements and the Surgical Council on Resident Education (SCORE) curriculum.

DESIGN

This was a retrospective study using the Accreditation Counsel for Graduate Medical Education (ACGME) operative case logs of junior surgical residents.

SETTING

The Ohio State University Wexner Medical Center, Columbus, OH; a tertiary academic medical center.

PARTICIPANTS

We performed, an institutional review board approved, retrospective review of logged surgical cases from general surgical residents during postgraduate year (PGY) 1 and 2 from 2009 to 2015 at an academic medical center. Summary case logs were accessed from the ACGME. Procedures were extracted from the SCORE curriculum and correlated to corresponding ACGME defined procedures for total cases, major cases, and endoscopy. Minor cases and patient care cases were excluded as they were not clearly defined on the category report. SCORE procedures were excluded if there was not a corresponding ACGME procedure on the summary report. SCORE procedures and ACGME procedures were combined with each other if there was overlap with correlation. Statistics were performed on individual and total resident data. One-sample student's t-test was used to compare total number of cases logged with the 250 case log ABS requirement and to compare the total major cases and endoscopy performed with those represented on SCORE.

RESULTS

Overall, 26 residents completed both PGY-1 and 2 years from 2009 to 2015, and remained at the same institution for case logs to be accessed during the study period. A total of 21 residents (80.76%) completed 250 cases or more after their first 2 years of residency. Across all years, the mean case log was 349 cases (p = 0.20), and was statistically more than than 250 cases in 3 of the 5 class years. Junior residents completed a total mean of 312 major and endoscopy cases (89%) at the end of 2 years, which was statistically higher than the 75% testing hypothesis across all years (p < 0.01). Of major and endoscopy cases performed in total by the completion of the PGY-2 year, a mean of 275 cases (88%) were included in the SCORE curriculum. Using one-sample t-test, SCORE procedures represented more than 85% of the major and endoscopy cases logged (p < 0.01). Of all major and endoscopy cases logged that correlate to a SCORE procedure, 95% were found to be "core" and 5% were "advanced."

CONCLUSIONS

Our study demonstrates that junior surgical residents meet the 250 case log requirement put forth by the ABS, and most major procedures and endoscopy performed correspond with the core cases of the SCORE curriculum at our institution. This study aid in the confirmation of the SCORE curriculum for junior residents, and those procedures which should be designated as core.

Surgical Case Logging Habits and Attitudes: A Multispecialty Survey of Residents

OBJECTIVE

The Accreditation Council for Graduate Medical Education measures surgical residents' experience in the United States by mandating that residents log each procedure in which they have participated. This system is the primary mechanism by which breadth and depth of surgical training are documented, and data are used for program accreditation and by individual program directors to assess resident preparedness. The study objective was to learn from residents across surgical specialties how this system is being used, and whether they believe these data are reliable.

DESIGN

Investigators developed and administered a voluntary, 45-item survey. Resident demographic data, program details, logging behaviors, and attitudes were examined using descriptive statistics. Authors used multivariate logistic regression to assess respondent and program characteristics associated with logging habits.

SETTING

The survey was administered at a large academic medical center.

PARTICIPANTS

All general surgery, obstetrics and gynecology, orthopedics, urology, neurosurgery, otolaryngology, and plastic surgery residents were eligible. Of 126 surgical residents, 82 participated, yielding a response rate of 65%.

RESULTS

Overall, 7.5% considered the case log system highly inaccurate, 28.8% somewhat inaccurate, 52.5% somewhat accurate, and 11.3% highly accurate. Nearly half (48.1%) use an incorrect metric to log their role as surgeon or assistant. Half logged monthly or less frequently. The longest time residents reported falling behind ranged from less than a week to more than a year, with about half (51.4%) reporting backlogs of 3 months or longer. Approximately two-thirds considered the system difficult to navigate (64.2%) and burdensome (68.8%). Departmental training and reminders to log were associated with high fidelity logging habits.

CONCLUSIONS

Inconsistency of logging habits and perceived lack of accuracy raise concerns about use of the system for assessing surgical preparedness or accrediting training programs. Academic departments playing an active role may benefit from more reliable data to guide improvements in surgical training.

National operative case log growth charts in otolaryngology-head and neck surgery training

OBJECTIVE

To report national standard case log growth curves for operative procedures in otolaryngology and to describe a method by which program directors can chart surgical case numbers over resident training to longitudinally assess sufficiency of cases and parity between residents.

STUDY DESIGN

Data visualization and analysis.

SETTING

American Council for Graduate Medical Education (ACGME) national case log data for otolaryngology residency.

SUBJECTS

National data set; no individual subjects.

METHODS

National statistical case log reports for otolaryngology were obtained from the ACGME for each postgraduate year (PGY) level in 2009, 2010, and 2011. Estimated means and standard deviations were calculated. The mean and increments of standard deviation were graphed against time to create case log growth charts, similar to pediatric growth charts.

RESULTS

Case log growth charts were made for each ACGME Otolaryngology Residency Review Committee key indicator procedure. Progress of an individual resident or of a cohort of residents may be graphed against this growth chart background over their training time.

CONCLUSIONS

National operative case log growth charts allow residents and program directors to graphically assess progress in obtaining a sufficient variety and number of operative procedures over time throughout training. This can provide early identification when residents begin to fall below the growth curve during training.

Enhancing the case log by coding the level of trainee participation in vascular interventional radiology procedures

OBJECTIVE

The purpose of this article is to describe a new method for coding trainee participation in vascular interventional radiology procedures.

MATERIALS AND METHODS

From July 2008 through June 2009, all interventional radiology fellows maintained an enhanced case log at our institution; 748 unique cases were logged by procedure type, supervising physician, and level of participation in the case. Level of participation was classified on a 5-point scale that included designations for observation, first assistant, performance of basic techniques, performance of advanced techniques, and primary operation. Descriptive statistics of participation scores were calculated for each quarter and were analyzed by procedure type and by teaching faculty member.

RESULTS

As expected, analysis by procedure type showed that average participation scores increased from one quarter to the next in most cases. By the fourth quarter, the modal participation score was 5, indicating primary operation or performance of multiple critical steps. Analysis by teaching faculty member revealed three patterns: those attending physicians facilitating increasing levels of participation in every quarter, those facilitating maximal growth within the first 6 months, and those with irregular trainee participation profiles.

CONCLUSION

Data from a 5-point participation scale add information to the procedure case log that could be used to quantitatively track the technical progress of trainees while providing education quality feedback to both teaching physicians and program directors.