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Cumulative Operative Experience Is Decreasing During General Surgery Residency: A Worrisome Trend for Surgical Trainees?
Cumulative Operative Experience Is Decreasing During General Surgery Residency: A Worrisome Trend for Surgical Trainees? John C Kairys, MD, Kandace McGuire, MD, Albert G Crawford, PhD, Charles J Yeo, MD, FACS The aim of this study was to quantify the changes over time in general surgical residents’ operative experience as surgeon, first assistant, and teaching assistant. The introduction of work hour restrictions in July 2003 raised concern that residents’ operative experience might decline. Early studies evaluating the mean number of operations performed as surgeon reported no major change. The experiences of residents as first assistant and teaching assistant have not been closely examined. STUDY DESIGN: The Accreditation Council for Graduate Medical Education Resident Statistics Summary reports from academic year 1992 to 1993 through the present were reviewed. The mean number of cases reported as total surgeon, surgeon chief, and surgeon junior for academic year 2001 to 2002 through 2005 to 2006 were analyzed for total major operations. The median number of cases reported as total surgeon, first assistant, and teaching assistant for academic year 1992 to 1993 through 2005 to 2006 were analyzed for total major operations. RESULTS: Since the implementation of the 80-hour work duty restrictions, the number of total major operations reported by residents as surgeon decreased from 930 to 909 (2.3% decrease, p ⬍ 0.0001), surgeon chief operations decreased from 252 to 231 (8.3% decrease, p ⬍0.0001), and surgeon junior operations remained essentially unchanged, from 677 to 678. From academic year 1992 to 1993 through 2005 to 2006, the median number of first assistant and teaching assistant cases declined from 231 to 49 (79% decrease) and from 67 to 23 (66% decrease), respectively. CONCLUSIONS: Since duty hour restrictions were introduced, there have been small but notable declines in the number of total surgeon and surgeon chief operative cases reported by graduating residents. Over a longer time period, operative cases reported by graduating residents in the roles of first assistant and teaching assistant declined dramatically. Although some of these declines were gradual, recent declines may have been accelerated by the 80-hour duty hour restrictions. These trends must be considered as we plan the education of present and future surgical residents. (J Am Coll Surg 2008;206:804–813. © 2008 by the American College of Surgeons) BACKGROUND:
Experience in the operating room is an essential component of the education and training of general surgical residents. Although a great deal of learning and professional development occurs in conferences, simulation laboratories, on hospital floors, and in the outpatient clinic, adequate exposure in the operating environment
remains critical to the development of the technical skills required to become a surgeon. It is also largely in the operating room that residents develop the surgical judgment that they require to ultimately practice competently and independently. There are many levels of involvement that a resident may have in the operating room. A resident, at the most basic level may serve as a “first assistant” (FA) to an attending or may “double scrub” with both an attending and a more senior resident. A resident, as a “surgeon junior” (SJ) or “surgeon chief ” (SC), not only assumes additional technical responsibilities, but also takes on a much greater responsibility for the overall care of the patient, both pre- and postoperatively, as mandated by the Accreditation Council for Graduate Medical Education (ACGME). At the senior-
Competing Interests Declared: None. Presented at the Southern Surgical Association 119th Annual Meeting, Hot Springs, VA, December 2007. Received December 13, 2007; Accepted December 28, 2007. From the Departments of Surgery (Kairys, McGuire, Yeo) and Health Policy (Crawford), Thomas Jefferson University, Philadelphia, PA. Correspondence address: John C Kairys, MD, Jefferson Medical College, Thomas Jefferson University, 1025 Walnut St, Room 100, Philadelphia, PA 19107.
© 2008 by the American College of Surgeons Published by Elsevier Inc.
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Abbreviations and Acronyms
ABS ⫽ American Board of Surgery ACGME ⫽ Accreditation Council for Graduate Medical Education FA ⫽ first assistant SC ⫽ surgeon chief SJ ⫽ surgeon junior TA ⫽ teaching assistant TS ⫽ total surgeon
level, a resident may also serve as a “teaching assistant” (TA), taking a junior resident through a procedure while under the watchful guidance of an experienced attending. Before implementation of the ACGME duty hour restrictions in 2003, surgical educators became concerned about the potential decrease in the number of operative cases performed by surgical trainees. Increasing numbers of studies appeared in the literature addressing the issue of surgeons’ attitudes and either perceived or actual changes in operative case volume for residents. Many early reports, which looked primarily at the early experience in New York State, reviewed single institution operative case volume reports.1,2 These data suggested that operative volume had remained unchanged. In a survey of residents, 50% of respondents subjectively thought that their case numbers had decreased.3 Jarman and colleagues4 reported on the number of cases that would potentially be lost after their program’s implementation of the duty hour restrictions. They calculated that without any changes made to their rotation and call schedule, up to 202 operations in the role as surgeon could be lost during a resident’s 5 years of training. But with implementation of a night float coverage scheme, the projected loss would be only 107 operations. A multiinstitutional survey of 80 programs performed by Mendoza and Britt,5 which included a review of operative log data before and after implementation of the duty hour restrictions, revealed no notable differences in the number of operative cases credited as total surgeon (TS), the sum of SC and SJ cases. Numerous other studies during this time examined single institution case volumes and similarly demonstrated no marked decrease in overall operative volume.6-11 Although some of these studies demonstrated trends or even some major variances up or down at individual postgraduate levels, no consistent patterns emerged. In addition to examining the number of cases credited as surgeon, a study by Feanny and associates12 examined the number of cases credited as FA or TA during this time and noted a considerable 34% decrease for both categories. Notably, there was a 50% drop in the number of FA cases credited by junior residents when working with a senior
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resident, and a 42% drop in the number of TA cases credited by senior residents. The drop in TA cases was even greater when only major abdominal trauma procedures were considered. In this situation, there was an 82% decrease in opportunities for a senior resident to act as a TA. The most definitive report on this issue originated from Bland and other members13 of the Residency Review Committee in Surgery (RRC-S). This study used the ACGME database to review data from the years 1997 to 2004. A perceived drop in the number of major cases reported as TS occurring in year 2001 to 2002 was attributed to changes made in procedural codes in the ACGME’s biostatistical database. A detailed statistical analysis of operations reported in years 2002 to 2003 and 2003 to 2004 both per resident and per program (including analysis of those programs with and without work hour exemptions) revealed no statistical variance in surgical case volumes. Recently published studies have demonstrated a variable picture. Schneider and colleagues14 detailed a redesign of their entire training program around the time of the enactment of the work hour restrictions to maximize the residents’ educational experience and optimize operative exposure. In part, their success was demonstrated by an increase in the overall number of cases for all residents in the program, with particularly dramatic increases at the junior levels. Carlin and coworkers15 used corporate operative reporting data from their institution over a 4-year period, spanning the introduction of the duty hour restrictions. They reported substantial decreases for the mean number of TS cases for PG 1, 2, and 4 residents of 37%, 75%, and 34%, respectively. But the change in mean numbers of TS cases for all postgraduate levels did not reach statistical significance. FA cases for PG1s decreased by 85%; TA cases for PG5s decreased by 78%. Finally, Damadi and colleagues16 examined operative log data for defined category cases from their institution for 2 years before and for 3 years after duty hour restrictions (which they enacted in July 2002). They reported a marked decrease of 19% for TS cases, with a decrease of 17% for SJ cases and 25% for SC cases. This study evaluated changes in the volume of total major cases reported in the roles of TS, SC, and SJ, spanning a period of time for 2 years before and 3 years after implementation of the ACGME duty hour restrictions. We also evaluated the change in the median number of FA and TA cases reported by graduating chief residents from 1992 to 1993 through the present, using the available national operative log data from the ACGME. The percentile data for TS cases were evaluated and examined relative to new rules being instituted by the ACGME and the American Board of Surgery for the minimum number of major cases re-
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quired for program accreditation and board eligibility, respectively.
METHODS The Accreditation Council for Graduate Medical Education Resident Statistics Summary reports B and C from the Residency Review Committee in Surgery from years 1992 to 1993 through 2005 to 2006 were evaluated. Preliminary data for year 2006 to 2007 were provided by the chief operations officer of the ACGME. Minor edits were still being performed before release of the final data report, but no major changes were anticipated (ACGME chief operations officer, personal communication). Permission to use the data was obtained from the ACGME. Evaluation of the Report B data revealed an apparent reversal of data for the percentile values for TA and FA for the years 1997 to 1998 through 2000 to 2001. This reversal was confirmed (ACGME chief operations officer, personal communication), and our subsequent data analysis proceeded with the data in the corrected format. Trends for the number of total major cases were evaluated in mean numbers for operations reported as TS, SC, and SJ for all graduating chief residents between the years 2001 to 2002 and 2005 to 2006. This time span was chosen to avoid the confounding effects that might arise from a correction of the Residency Review Committee in Surgery biostatistical database occurring before 2001 to 2002 and to avoid any inaccuracies that might arise from use of the 2006 to 2007 preliminary data. Data representing the 50th percentile (median) for operations reported as TS, FA, and TA for the years 1992 to 1993 through 2005 to 2006 were evaluated for total major operations. The 10th through 90th percentile data for TS operations were recorded as well. General linear model (GLM) procedures, with year as the main effect, were performed using SAS Release 9.1 software, including a macro provided by the SAS Institute. To adjust the analyses for missing standard deviations for years 2004 to 2005 and 2005 to 2006, we followed the conservative approach of imputing the highest nonmissing standard deviation in each series to the years in which the standard deviation was missing. Statistical significance was accepted at the p ⬍ 0.05 level. To evaluate the degree of correlation between the mean and median numbers of total major operations from 1992 to 1993 through 2005 to 2006, a Pearson product moment correlation coefficient was computed using Microsoft Excel 2003. RESULTS Total surgeon data
The mean total major operations, as is depicted in Figure 1,
Figure 1. Mean total major cases reported as total surgeon (SC ⫹ SJ) over a 5-year period. Trends were significant at p ⬍ 0.0001. *Accreditation Council for Graduate Medical Education preliminary data for academic year 2006 to 2007; not included in statistical analysis. SC, surgeon chief; SJ, surgeon junior.
reported by graduating surgical residents in the roles of SC or SJ declined substantially, from 930 in 2001 to 2002 to 909 in 2005 to 2006, representing a 2.3% decrease: F ⫽ 7.73 (df ⫽ 4,5028), p ⬍ 0.0001. For 2006 to 2007, the preliminary number of TS operations reported was 905. Surgeon chief data
The mean total major operations, as is depicted in Figure 2, reported by graduating surgical residents in the role of SC declined notably, from 252 in 2001 to 2002 to 231 in 2006 to 2007, representing a 8.3% decrease: F ⫽ 9.10 (df ⫽ 4,5028), p ⬍ 0.0001. For 2006 to 2007, the preliminary number of SC operations reported was 232. Surgeon junior data
The mean number of total major operations, as is depicted in Figure 3, reported by graduating surgical residents in the role of SJ began and ended this series at 677 and 678, respectively. There was no clear trend. For 2006 to 2007, the preliminary number of SJ operations reported was 671.
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Figure 2. Mean total major cases reported as surgeon chief (SC) over a 5-year period. Trends were significant at p ⬍ 0.0001. *Accreditation Council for Graduate Medical Education preliminary data for academic year 2006 to 2007; not included in statistical analysis.
Comparison of mean and median numbers of operations as total surgeon
Because the mean values were available only for TS, SC, and SJ cases, it was necessary to consider the median number of cases reported for the roles of FA and TA, to track changes in these values over time. The Pearson product moment correlation coefficient of the mean and median values of total major operations was 0.96, indicating a substantial degree of correlation (Table 1). First assistant and teaching assistant data
The reported FA median operative case volume, as is depicted in Figure 4, declined from 231 to 49 from years 1992 to 1993 through 2005 to 2006, representing a decrease of 79%. During the same time period, TA median operative case volume declined from 67 to 23, representing a decrease of 66%. Percentile data for total surgeon cases and possible effects for ACGME accreditation and American Board of Surgery certification
Review of the data from recent years indicate that, if current trends and distribution of cases continue, approxi-
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Figure 3. Mean total major cases reported as surgeon junior (SJ) over a 5-year period. No trend was noted. *Accreditation Council for Graduate Medical Education preliminary data for academic year 2006 to 2007; not included in statistical analysis.
mately 10% of residents are at risk for not having the 750 major operations needed to satisfy ACGME minimal case requirements or to be eligible for American Board of Surgery certification (Fig. 5). This is based on new requirements implemented by the ACGME for programs effective this academic year and, for the American Board of Surgery (ABS), for residents completing their training in 2009.
DISCUSSION These data demonstrated a marked decline in the number of operative cases reported in the roles of TS and SC for residents graduating from general surgery residencies during the past 5 years. Preliminary data for the current academic year suggest that the current trends are continuing. It may be tempting for some to conclude that this change is primarily from implementation of the 80-hour duty hour restrictions. But one cannot be certain of this because many other variables could contribute to this change. In any event, even if this recent decrease in mean operative cases could be attributed solely to the effect of the 80 duty hour restrictions, this report represents only an interim evaluation of that effect. Residents who completed surgical programs in 2007 have had no more than 3 years of their training under the full effect of the duty hour restric-
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Table 1. Correlation of Mean and Median Numbers of Major Cases Performed as Total Surgeon Year
Mean
Median
1992–1993 1993–1994 1994–1995 1995–1996 1996–1997 1997–1998 1998–1999 1999–2000 2000–2001 2001–2002 2002–2003 2003–2004 2004–2005 2005–2006 2006–2007*
922 924 943 950 961 933 954 967 962 930 938 932 900 908 905*
930 929 956 960 975 939 973 965 969 932 951 929 905 903 907*
Pearson correlation coefficient ⫽ 0.96. *Accreditation Council for Graduate Medical Education preliminary data for academic year 2006–2007; not included in statistical analysis.
tions. It will be at least another 2 years until the first residents who trained completely under these rules complete their residency, and several more years after that before all residents who spent time doing research fully pass through their programs. Only at that time will we have a complete understanding of the magnitude of the change in volume for cases reported as surgeon. The decreases in operative volume for TS and SC demonstrated here were statistically significant. In many ways, this finding was not particularly surprising. Before implementation of the duty hour restrictions in 2003, work hours for junior residents in general surgery averaged more than 100 hours per week.17 Many educational experiences
Figure 5. Percentile data for total surgeon volume reported for total major cases. The horizontal line indicates the new minimum number of cases required by graduating chief residents (750 cases). *Accreditation Council for Graduate Medical Education preliminary data for academic year 2006 to 2007.
Figure 4. Median number of total major cases reported for total surgeon, first assistant, and teaching assistant from academic years 1992 to 1993 to 2006 to 2007. *Accreditation Council for Graduate Medical Education preliminary data for academic year 2006 to 2007; not included in analysis.
for general surgery residents, including operative cases, as was pointed out by Chung and associates,18 had to be reduced to effect the 20% reduction in work hours needed to meet the ACGME restrictions. In a 2005 editorial entitled “Learning to operate in a restricted duty hours environment,” Richardson and Bland19 acknowledged that “. . .there almost certainly will be an impact in some programs that may diminish surgical experience.” Perhaps we should be somewhat encouraged that the extent of the decrease observed so far is quite small compared with the overall number of operations that are still recorded by general surgical residents completing their training. But this trend must be closely monitored, and we must continually adapt our programs to maximize the operative opportunities for our residents. Jarman and coauthors’4 initial report on the impact of the duty hour restrictions predicted a potential loss of more than 100 cases over the span of 5 years of training. To date, such a decrease has not been observed. The 8.3% decrease reported in SC cases is more concerning. If this decrease was indeed caused by the duty hour
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restrictions, it is reasonable that we would first see a change in the SC rather than in the SJ data. The SC data were collected in the final year of training (which, for the past 3 years, has been wholly under the effects of the duty hour restrictions); the SJ data were collected at least partly before enactment of the reforms. In this era of “night float” residents and “acute care surgery” services, chief residents may simply be coming in less frequently to operate at night and on weekends. It is very likely, however, that many factors could be responsible for the observed declines. Any interpretation of these data must be performed with an understanding of potential limitations of the dataset. These operative logs were entered either by residents or by staff in residency education offices. There were, as such, multiple opportunities for incomplete capture of operations performed, errors in procedure code assignment, or improper assignment of resident role. An interesting study by Veldenz and colleagues20 looked at a quality control tool known as “process capability analysis.” Their analysis found that chief residents on a vascular surgery service were not particularly careful in recording their case data. They concluded that more accurate reporting by residents could result in as many as 20% more cases being reported to the Residency Review Committee in Surgery. This implies that the case log numbers published by the ACGME could be inaccurately reported. In addition, during the last several years, the ACGME moved its data collection to a Webbased system, and that system is now mandatory for all data entry. Although one would hope that such a system would be easy for residents to use, this change might have had the unintended consequence of altering the capture rate of operative case reporting. It is possible that some residents or programs may be less diligent about entering cases for categories such as FA and TA (which do no count toward board eligibility or hospital credentialing), resulting in some of the decline seen for these categories. It is in our collective best interest, as educators, to encourage our residents to accurately log their cases so that we may all have an accurate assessment of current and future case volume. External factors also may have contributed to the declining number of SC cases reported by residents over the past 3 years. Historically, the ABS required chief residents to submit operative case logs at the completion of training. But in 2006, the Board changed its policy and required graduating chief residents to submit their (incomplete) case logs by the end of April, allowing for additional processing time and earlier scheduling of qualifying examinations. Residents are still expected to enter to their cases into the ACGME case log system up through the completion of their training. One potential unanticipated consequence of this change, however, might be that some residents may
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slow or even stop their entry of cases into the ACGME system after the April deadline. We have no way of assessing whether this could be happening from the available ACGME data, but we know, from subjective observations in our own program, that case entry by some chief residents declines markedly after the early ABS submission deadline. The loss of reported FA cases demonstrated in the median data is striking and represents a potentially enormous loss of early learning opportunities. The decline in the median value of FA cases during the past 14 years exceeded 180 cases. Such a decline, if noted in one of the surgeon categories, would certainly be cause for great consternation. We have heard faculty members at our own and at other institutions lament that present midlevel or even senior-level residents do not seem to have the same set of basic surgical skills and experience that residents demonstrated in the past. Perhaps the loss of early FA operative exposure and the experience that comes with it partly explains this change. But we must be careful to not elevate all previous experiences as FA as being outstanding learning experiences. Many residents and surgeons will undoubtedly recall FA experiences from their training, which consisted largely of holding a retractor and receiving no teaching whatsoever. It is best if that type of “learning” is no longer a part of modern surgical training. The loss of TA cases for senior residents represents a loss of a unique educational opportunity. For an upper level resident, taking a junior resident through an operative procedure as a TA, under the watchful guidance of the supervising attending, remains a profound learning and growth experience. One cannot superbly teach a procedure without first having a solid understanding of the indications and options for performing the procedure, familiarity with the relevant anatomy, full knowledge of all surgical complications and how to handle them, and the technical skills necessary to perform the procedure. It is also an opportunity for senior residents to hone their teaching skills. But in this era of greater accountability of the attending surgeon, billing rules, scrutiny of outcomes, and patient safety, it is perhaps unavoidable that this role has declined or at least become more carefully applied. A consideration of national events during the past 15 years may help to explain some of the external drivers for change over this period of time (Fig. 6). The passage of the “final rule” by the Health Care Financing Administration (HCFA) in 1996 created a higher standard of accountability for attending physicians and would be expected to cause a decrease in opportunities for senior residents to take a TA role. The Balanced Budget Act of 1997 “capped” the number of residency slots reimbursed at individual teaching hospitals. This made an increase in nondesignated prelim-
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Figure 6. Timeline of events from 1993 to 2007 that may have affected the number of operative procedures reported by general surgery residents. ABS, American Board of Surgery; ACGME, Accreditation Council for Graduate Medical Education.
inary resident positions difficult when the duty hour restrictions came into effect and when neurosurgery, orthopaedics, and otolaryngology demanded specific rotations for their interns. The latter changes pulled designated preliminary residents off of traditional general surgery rotations, leaving the categorical junior residents to assume patient care responsibilities, possibly at the expense of missing opportunities to operate. The release of the Institute of Medicine report in 1999 focused attention on the quality of care and potential medical errors, and may have also served to force a decline of TA opportunities for residents. It is notable that the percentile data (Fig. 5) indicates that roughly 10% of graduating residents may be at risk of not meeting the new requirements from the ACGME and ABS for a minimum of 750 operative cases as surgeon. Unless programs can rapidly increase their case volume, or decrease their resident complement, chief residents will be forced to take additional cases from junior residents to reach their minimums. It will then only become more difficult for those junior residents to reach their case requirements. The ABS has wisely chosen to not enact this requirement for Board eligibility until July 2009, giving graduating residents and programs more time to make necessary adjustments. What does the future hold for the residents who are currently in our training programs? How should we react to these data? Close monitoring of future case volumes, not only for the role of surgeon, but for the roles of FA and TA, is obviously essential. We must encourage and monitor our
residents to ensure that all operative case data are entered accurately. Surgical chairs and program directors must exercise great diligence and thoughtfulness in the manner in which we structure our training programs. We must maximize all educational experiences for our residents, both in the operating room and out. Careful redesign of our training programs, with the institution of new or blended models of education, may help to create situations in which we maintain the operative experience for our residents.21,22,14 The redesign experience detailed by Schneider and associates14 is particularly encouraging. Not only did they improve many aspects of their rotation schedule and improve resident satisfaction, but, under their new system, case volumes for PG1s increased from 114 to 188 (65%) and for PG2s, from 117 to 302 (158%). Can the emerging field of surgical simulation replace some of the time previously spent as FA or even some cases as surgeon? Although some technical skills can be taught and practiced in the laboratory environment, and judgment assessed in mock crisis situations, it is unlikely that those experiences will ever fully replace the variability in anatomy and pathology and the true tissue handling experience that surgeons gain only in the operating room. Nonetheless, it seems certain that simulation will play a valuable role in the future, as long as our programs devote the time and resources to make the experience worthwhile. Residents must deliberately practice basic operative skills in skills laboratories, at home, and in the hospital. Ericsson and others23-25 noted that the attainment of mas-
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tery in a particular area can take upward of 10,000 hours of deliberate practice in that domain. By comparison, it is interesting to note that Chung’s 26calculation of the time residents spend in the operating room and involved in immediate perioperative patient care totals just under 4,000 hours. Our residents, and their future patients, will benefit from the practice and experience that they acquire under our guidance to help them achieve mastery in this specialty. We, as surgeons, surgical educators, program directors, and surgical chairs, must understand and embrace these data. We must also continually strive to make our residents better surgeons, better technicians, and better decision makers, within the confines of our ever-changing educational environment.
11. 12. 13.
14. 15. 16.
Author Contributions Study conception and design: Kairys, Yeo Acquisition of data: Kairys, McGuire Analysis and interpretation of data: Kairys, Crawford, Yeo Drafting of manuscript: Kairys, Crawford Critical revision: McGuire, Crawford, Yeo
REFERENCES 1. Barden CB, Specht MC. Effects of limited work hours on surgical training. J Am Coll Surg 2002;195:531–538. 2. Hassett JM, Nawotniak R, Cummiskey D, et al. Maintaining outcomes in a surgical residency while complying with resident working hour regulations. Surgery 2002;132:635–639; discussion 639–641. 3. Whang EE, Mello MM, Ashley SW, Zinner MJ. Implementing resident work hour limitations: lessons from the New York State experience. Ann Surg 2003;237:449–455. 4. Jarman BT, Miller MR, Brown RS, et al. The 80-hour work week: will we have less-experienced graduating surgeons? Curr Surg 2004;61:612–615. 5. Mendoza KA, Britt LD. Resident operative experience during the transition to work-hour reform. Arch Surg 2005;140:137– 145. 6. Ferguson CM, Kellogg KC, Hutter MM, Warshaw AL. Effect of work-hour reforms on operative case volume of surgical residents. Curr Surg 2005;62:535–538. 7. Spencer AU, Teitelbaum DH. Impact of work-hour restrictions on residents’ operative volume on a subspecialty surgical service. J Am Coll Surg 2005;200:670–676. 8. Malangoni MA, Como JJ, Mancuso C, Yowler CJ. Life after 80 hours: the impact of resident work hours mandates on trauma and emergency experience and work effort for senior residents and faculty. J Trauma 2005;58:758–761; discussion 761–762. 9. Hutter MM, Kellogg KC, Ferguson CM, et al. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg 2006;243:864–871; discussion 871–875. 10. de Virgilio C, Yaghoubian A, Lewis RJ, et al. The 80-hour resident work week does not adversely affect patient outcomes or
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resident education. Curr Surg 2006;63:435–439; discussion 440. Tran J, Lewis R, de Virgilio C. The effect of the 80-hour work week on general surgery resident operative case volume. Am Surg 2006;72:924–928. Feanny MA, Scott BG, Mattox KL, Hirshberg A. Impact of the 80-hour work week on resident emergency operative experience. Am J Surg 2005;190:947–949. Bland KI, Stoll DA, Richardson JD, Britt LD. Members of the Residency Review Committee-Surgery. Brief communication of the Residency Review Committee-Surgery (RRC-S) on residents’ surgical volume in general surgery. Am J Surg 2005;190: 345–350. Schneider JR, Coyle JJ, Ryan ER, et al. Implementation and evaluation of a new surgical residency model. J Am Coll Surg 2007;205:393–404. Carlin AM, Gasevic E, Shepard AD. Effect of the 80-hour work week on resident operative experience in general surgery. Am J Surg 2007;193:326–329; discussion 329–330. Damadi A, Davis AT, Saxe A, Apelgren K. ACGME duty-hour restrictions decrease resident operative volume: a 5-year comparison at an ACGME-accredited university general surgery residency. J Surg Educ 2007;64:256–259. Baldwin DC Jr, Daugherty SR, Tsai R, Scotti MJ Jr. A national survey of residents’ self-reported work hours: thinking beyond specialty. Acad Med 2003;78:1154–1163. Chung R, Ahmed N, Chen P. Meeting the 80-hour work week requirement: what did we cut? Curr Surg 2004;61:609–611. Richardson JD, Bland KI. Learning to operate in a restricted duty hours environment. Am J Surg 2005;190:354–355. Veldenz HC, Dennis JW, Dovgan PS. Quality control of resident operative experience: compliance with RRC criteria. J Surg Res 2001;98:81–84. Mendoza KA, Mendoza B, Britt LD. A template for change and response to work hour restrictions. Am J Surg 2003;186:89–96. DaRosa DA, Bell RH Jr. Graduate surgical education redesign: reflections on curriculum theory and practice. Surgery 2004; 136:966–974. Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev 1993;100:363–406. Ericsson KA, Charness N. Expert performance: Its structure and acquisition. Am Psych 1994;49:725–747. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79:S70–81. Chung RS. How much time do surgical residents need to learn operative surgery? Am J Surg 2005;190:351–353.
Discussion DR ROBERT S RHODES (Philadelphia, PA): The authors are to be congratulated on an excellent study, and particularly on their appropriate and cautious interpretation of the results. Two particular strengths of the analysis are that they look at specific levels of resident experience and consider multiple factors responsible for the results. My first comment is related to the change in the ABS application dates, and they have already responded to that. Another related issue
Experience in the operating room is an essential component of the education and training of general surgical residents. Although a great deal of learning and professional development occurs in conferences, simulation laboratories, on hospital floors, and in the outpatient clinic, adequate exposure in the operating environment
remains critical to the development of the technical skills required to become a surgeon. It is also largely in the operating room that residents develop the surgical judgment that they require to ultimately practice competently and independently. There are many levels of involvement that a resident may have in the operating room. A resident, at the most basic level may serve as a “first assistant” (FA) to an attending or may “double scrub” with both an attending and a more senior resident. A resident, as a “surgeon junior” (SJ) or “surgeon chief ” (SC), not only assumes additional technical responsibilities, but also takes on a much greater responsibility for the overall care of the patient, both pre- and postoperatively, as mandated by the Accreditation Council for Graduate Medical Education (ACGME). At the senior-
Competing Interests Declared: None. Presented at the Southern Surgical Association 119th Annual Meeting, Hot Springs, VA, December 2007. Received December 13, 2007; Accepted December 28, 2007. From the Departments of Surgery (Kairys, McGuire, Yeo) and Health Policy (Crawford), Thomas Jefferson University, Philadelphia, PA. Correspondence address: John C Kairys, MD, Jefferson Medical College, Thomas Jefferson University, 1025 Walnut St, Room 100, Philadelphia, PA 19107.
© 2008 by the American College of Surgeons Published by Elsevier Inc.
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Abbreviations and Acronyms
ABS ⫽ American Board of Surgery ACGME ⫽ Accreditation Council for Graduate Medical Education FA ⫽ first assistant SC ⫽ surgeon chief SJ ⫽ surgeon junior TA ⫽ teaching assistant TS ⫽ total surgeon
level, a resident may also serve as a “teaching assistant” (TA), taking a junior resident through a procedure while under the watchful guidance of an experienced attending. Before implementation of the ACGME duty hour restrictions in 2003, surgical educators became concerned about the potential decrease in the number of operative cases performed by surgical trainees. Increasing numbers of studies appeared in the literature addressing the issue of surgeons’ attitudes and either perceived or actual changes in operative case volume for residents. Many early reports, which looked primarily at the early experience in New York State, reviewed single institution operative case volume reports.1,2 These data suggested that operative volume had remained unchanged. In a survey of residents, 50% of respondents subjectively thought that their case numbers had decreased.3 Jarman and colleagues4 reported on the number of cases that would potentially be lost after their program’s implementation of the duty hour restrictions. They calculated that without any changes made to their rotation and call schedule, up to 202 operations in the role as surgeon could be lost during a resident’s 5 years of training. But with implementation of a night float coverage scheme, the projected loss would be only 107 operations. A multiinstitutional survey of 80 programs performed by Mendoza and Britt,5 which included a review of operative log data before and after implementation of the duty hour restrictions, revealed no notable differences in the number of operative cases credited as total surgeon (TS), the sum of SC and SJ cases. Numerous other studies during this time examined single institution case volumes and similarly demonstrated no marked decrease in overall operative volume.6-11 Although some of these studies demonstrated trends or even some major variances up or down at individual postgraduate levels, no consistent patterns emerged. In addition to examining the number of cases credited as surgeon, a study by Feanny and associates12 examined the number of cases credited as FA or TA during this time and noted a considerable 34% decrease for both categories. Notably, there was a 50% drop in the number of FA cases credited by junior residents when working with a senior
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resident, and a 42% drop in the number of TA cases credited by senior residents. The drop in TA cases was even greater when only major abdominal trauma procedures were considered. In this situation, there was an 82% decrease in opportunities for a senior resident to act as a TA. The most definitive report on this issue originated from Bland and other members13 of the Residency Review Committee in Surgery (RRC-S). This study used the ACGME database to review data from the years 1997 to 2004. A perceived drop in the number of major cases reported as TS occurring in year 2001 to 2002 was attributed to changes made in procedural codes in the ACGME’s biostatistical database. A detailed statistical analysis of operations reported in years 2002 to 2003 and 2003 to 2004 both per resident and per program (including analysis of those programs with and without work hour exemptions) revealed no statistical variance in surgical case volumes. Recently published studies have demonstrated a variable picture. Schneider and colleagues14 detailed a redesign of their entire training program around the time of the enactment of the work hour restrictions to maximize the residents’ educational experience and optimize operative exposure. In part, their success was demonstrated by an increase in the overall number of cases for all residents in the program, with particularly dramatic increases at the junior levels. Carlin and coworkers15 used corporate operative reporting data from their institution over a 4-year period, spanning the introduction of the duty hour restrictions. They reported substantial decreases for the mean number of TS cases for PG 1, 2, and 4 residents of 37%, 75%, and 34%, respectively. But the change in mean numbers of TS cases for all postgraduate levels did not reach statistical significance. FA cases for PG1s decreased by 85%; TA cases for PG5s decreased by 78%. Finally, Damadi and colleagues16 examined operative log data for defined category cases from their institution for 2 years before and for 3 years after duty hour restrictions (which they enacted in July 2002). They reported a marked decrease of 19% for TS cases, with a decrease of 17% for SJ cases and 25% for SC cases. This study evaluated changes in the volume of total major cases reported in the roles of TS, SC, and SJ, spanning a period of time for 2 years before and 3 years after implementation of the ACGME duty hour restrictions. We also evaluated the change in the median number of FA and TA cases reported by graduating chief residents from 1992 to 1993 through the present, using the available national operative log data from the ACGME. The percentile data for TS cases were evaluated and examined relative to new rules being instituted by the ACGME and the American Board of Surgery for the minimum number of major cases re-
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quired for program accreditation and board eligibility, respectively.
METHODS The Accreditation Council for Graduate Medical Education Resident Statistics Summary reports B and C from the Residency Review Committee in Surgery from years 1992 to 1993 through 2005 to 2006 were evaluated. Preliminary data for year 2006 to 2007 were provided by the chief operations officer of the ACGME. Minor edits were still being performed before release of the final data report, but no major changes were anticipated (ACGME chief operations officer, personal communication). Permission to use the data was obtained from the ACGME. Evaluation of the Report B data revealed an apparent reversal of data for the percentile values for TA and FA for the years 1997 to 1998 through 2000 to 2001. This reversal was confirmed (ACGME chief operations officer, personal communication), and our subsequent data analysis proceeded with the data in the corrected format. Trends for the number of total major cases were evaluated in mean numbers for operations reported as TS, SC, and SJ for all graduating chief residents between the years 2001 to 2002 and 2005 to 2006. This time span was chosen to avoid the confounding effects that might arise from a correction of the Residency Review Committee in Surgery biostatistical database occurring before 2001 to 2002 and to avoid any inaccuracies that might arise from use of the 2006 to 2007 preliminary data. Data representing the 50th percentile (median) for operations reported as TS, FA, and TA for the years 1992 to 1993 through 2005 to 2006 were evaluated for total major operations. The 10th through 90th percentile data for TS operations were recorded as well. General linear model (GLM) procedures, with year as the main effect, were performed using SAS Release 9.1 software, including a macro provided by the SAS Institute. To adjust the analyses for missing standard deviations for years 2004 to 2005 and 2005 to 2006, we followed the conservative approach of imputing the highest nonmissing standard deviation in each series to the years in which the standard deviation was missing. Statistical significance was accepted at the p ⬍ 0.05 level. To evaluate the degree of correlation between the mean and median numbers of total major operations from 1992 to 1993 through 2005 to 2006, a Pearson product moment correlation coefficient was computed using Microsoft Excel 2003. RESULTS Total surgeon data
The mean total major operations, as is depicted in Figure 1,
Figure 1. Mean total major cases reported as total surgeon (SC ⫹ SJ) over a 5-year period. Trends were significant at p ⬍ 0.0001. *Accreditation Council for Graduate Medical Education preliminary data for academic year 2006 to 2007; not included in statistical analysis. SC, surgeon chief; SJ, surgeon junior.
reported by graduating surgical residents in the roles of SC or SJ declined substantially, from 930 in 2001 to 2002 to 909 in 2005 to 2006, representing a 2.3% decrease: F ⫽ 7.73 (df ⫽ 4,5028), p ⬍ 0.0001. For 2006 to 2007, the preliminary number of TS operations reported was 905. Surgeon chief data
The mean total major operations, as is depicted in Figure 2, reported by graduating surgical residents in the role of SC declined notably, from 252 in 2001 to 2002 to 231 in 2006 to 2007, representing a 8.3% decrease: F ⫽ 9.10 (df ⫽ 4,5028), p ⬍ 0.0001. For 2006 to 2007, the preliminary number of SC operations reported was 232. Surgeon junior data
The mean number of total major operations, as is depicted in Figure 3, reported by graduating surgical residents in the role of SJ began and ended this series at 677 and 678, respectively. There was no clear trend. For 2006 to 2007, the preliminary number of SJ operations reported was 671.
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Figure 2. Mean total major cases reported as surgeon chief (SC) over a 5-year period. Trends were significant at p ⬍ 0.0001. *Accreditation Council for Graduate Medical Education preliminary data for academic year 2006 to 2007; not included in statistical analysis.
Comparison of mean and median numbers of operations as total surgeon
Because the mean values were available only for TS, SC, and SJ cases, it was necessary to consider the median number of cases reported for the roles of FA and TA, to track changes in these values over time. The Pearson product moment correlation coefficient of the mean and median values of total major operations was 0.96, indicating a substantial degree of correlation (Table 1). First assistant and teaching assistant data
The reported FA median operative case volume, as is depicted in Figure 4, declined from 231 to 49 from years 1992 to 1993 through 2005 to 2006, representing a decrease of 79%. During the same time period, TA median operative case volume declined from 67 to 23, representing a decrease of 66%. Percentile data for total surgeon cases and possible effects for ACGME accreditation and American Board of Surgery certification
Review of the data from recent years indicate that, if current trends and distribution of cases continue, approxi-
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Figure 3. Mean total major cases reported as surgeon junior (SJ) over a 5-year period. No trend was noted. *Accreditation Council for Graduate Medical Education preliminary data for academic year 2006 to 2007; not included in statistical analysis.
mately 10% of residents are at risk for not having the 750 major operations needed to satisfy ACGME minimal case requirements or to be eligible for American Board of Surgery certification (Fig. 5). This is based on new requirements implemented by the ACGME for programs effective this academic year and, for the American Board of Surgery (ABS), for residents completing their training in 2009.
DISCUSSION These data demonstrated a marked decline in the number of operative cases reported in the roles of TS and SC for residents graduating from general surgery residencies during the past 5 years. Preliminary data for the current academic year suggest that the current trends are continuing. It may be tempting for some to conclude that this change is primarily from implementation of the 80-hour duty hour restrictions. But one cannot be certain of this because many other variables could contribute to this change. In any event, even if this recent decrease in mean operative cases could be attributed solely to the effect of the 80 duty hour restrictions, this report represents only an interim evaluation of that effect. Residents who completed surgical programs in 2007 have had no more than 3 years of their training under the full effect of the duty hour restric-
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Table 1. Correlation of Mean and Median Numbers of Major Cases Performed as Total Surgeon Year
Mean
Median
1992–1993 1993–1994 1994–1995 1995–1996 1996–1997 1997–1998 1998–1999 1999–2000 2000–2001 2001–2002 2002–2003 2003–2004 2004–2005 2005–2006 2006–2007*
922 924 943 950 961 933 954 967 962 930 938 932 900 908 905*
930 929 956 960 975 939 973 965 969 932 951 929 905 903 907*
Pearson correlation coefficient ⫽ 0.96. *Accreditation Council for Graduate Medical Education preliminary data for academic year 2006–2007; not included in statistical analysis.
tions. It will be at least another 2 years until the first residents who trained completely under these rules complete their residency, and several more years after that before all residents who spent time doing research fully pass through their programs. Only at that time will we have a complete understanding of the magnitude of the change in volume for cases reported as surgeon. The decreases in operative volume for TS and SC demonstrated here were statistically significant. In many ways, this finding was not particularly surprising. Before implementation of the duty hour restrictions in 2003, work hours for junior residents in general surgery averaged more than 100 hours per week.17 Many educational experiences
Figure 5. Percentile data for total surgeon volume reported for total major cases. The horizontal line indicates the new minimum number of cases required by graduating chief residents (750 cases). *Accreditation Council for Graduate Medical Education preliminary data for academic year 2006 to 2007.
Figure 4. Median number of total major cases reported for total surgeon, first assistant, and teaching assistant from academic years 1992 to 1993 to 2006 to 2007. *Accreditation Council for Graduate Medical Education preliminary data for academic year 2006 to 2007; not included in analysis.
for general surgery residents, including operative cases, as was pointed out by Chung and associates,18 had to be reduced to effect the 20% reduction in work hours needed to meet the ACGME restrictions. In a 2005 editorial entitled “Learning to operate in a restricted duty hours environment,” Richardson and Bland19 acknowledged that “. . .there almost certainly will be an impact in some programs that may diminish surgical experience.” Perhaps we should be somewhat encouraged that the extent of the decrease observed so far is quite small compared with the overall number of operations that are still recorded by general surgical residents completing their training. But this trend must be closely monitored, and we must continually adapt our programs to maximize the operative opportunities for our residents. Jarman and coauthors’4 initial report on the impact of the duty hour restrictions predicted a potential loss of more than 100 cases over the span of 5 years of training. To date, such a decrease has not been observed. The 8.3% decrease reported in SC cases is more concerning. If this decrease was indeed caused by the duty hour
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restrictions, it is reasonable that we would first see a change in the SC rather than in the SJ data. The SC data were collected in the final year of training (which, for the past 3 years, has been wholly under the effects of the duty hour restrictions); the SJ data were collected at least partly before enactment of the reforms. In this era of “night float” residents and “acute care surgery” services, chief residents may simply be coming in less frequently to operate at night and on weekends. It is very likely, however, that many factors could be responsible for the observed declines. Any interpretation of these data must be performed with an understanding of potential limitations of the dataset. These operative logs were entered either by residents or by staff in residency education offices. There were, as such, multiple opportunities for incomplete capture of operations performed, errors in procedure code assignment, or improper assignment of resident role. An interesting study by Veldenz and colleagues20 looked at a quality control tool known as “process capability analysis.” Their analysis found that chief residents on a vascular surgery service were not particularly careful in recording their case data. They concluded that more accurate reporting by residents could result in as many as 20% more cases being reported to the Residency Review Committee in Surgery. This implies that the case log numbers published by the ACGME could be inaccurately reported. In addition, during the last several years, the ACGME moved its data collection to a Webbased system, and that system is now mandatory for all data entry. Although one would hope that such a system would be easy for residents to use, this change might have had the unintended consequence of altering the capture rate of operative case reporting. It is possible that some residents or programs may be less diligent about entering cases for categories such as FA and TA (which do no count toward board eligibility or hospital credentialing), resulting in some of the decline seen for these categories. It is in our collective best interest, as educators, to encourage our residents to accurately log their cases so that we may all have an accurate assessment of current and future case volume. External factors also may have contributed to the declining number of SC cases reported by residents over the past 3 years. Historically, the ABS required chief residents to submit operative case logs at the completion of training. But in 2006, the Board changed its policy and required graduating chief residents to submit their (incomplete) case logs by the end of April, allowing for additional processing time and earlier scheduling of qualifying examinations. Residents are still expected to enter to their cases into the ACGME case log system up through the completion of their training. One potential unanticipated consequence of this change, however, might be that some residents may
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slow or even stop their entry of cases into the ACGME system after the April deadline. We have no way of assessing whether this could be happening from the available ACGME data, but we know, from subjective observations in our own program, that case entry by some chief residents declines markedly after the early ABS submission deadline. The loss of reported FA cases demonstrated in the median data is striking and represents a potentially enormous loss of early learning opportunities. The decline in the median value of FA cases during the past 14 years exceeded 180 cases. Such a decline, if noted in one of the surgeon categories, would certainly be cause for great consternation. We have heard faculty members at our own and at other institutions lament that present midlevel or even senior-level residents do not seem to have the same set of basic surgical skills and experience that residents demonstrated in the past. Perhaps the loss of early FA operative exposure and the experience that comes with it partly explains this change. But we must be careful to not elevate all previous experiences as FA as being outstanding learning experiences. Many residents and surgeons will undoubtedly recall FA experiences from their training, which consisted largely of holding a retractor and receiving no teaching whatsoever. It is best if that type of “learning” is no longer a part of modern surgical training. The loss of TA cases for senior residents represents a loss of a unique educational opportunity. For an upper level resident, taking a junior resident through an operative procedure as a TA, under the watchful guidance of the supervising attending, remains a profound learning and growth experience. One cannot superbly teach a procedure without first having a solid understanding of the indications and options for performing the procedure, familiarity with the relevant anatomy, full knowledge of all surgical complications and how to handle them, and the technical skills necessary to perform the procedure. It is also an opportunity for senior residents to hone their teaching skills. But in this era of greater accountability of the attending surgeon, billing rules, scrutiny of outcomes, and patient safety, it is perhaps unavoidable that this role has declined or at least become more carefully applied. A consideration of national events during the past 15 years may help to explain some of the external drivers for change over this period of time (Fig. 6). The passage of the “final rule” by the Health Care Financing Administration (HCFA) in 1996 created a higher standard of accountability for attending physicians and would be expected to cause a decrease in opportunities for senior residents to take a TA role. The Balanced Budget Act of 1997 “capped” the number of residency slots reimbursed at individual teaching hospitals. This made an increase in nondesignated prelim-
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Figure 6. Timeline of events from 1993 to 2007 that may have affected the number of operative procedures reported by general surgery residents. ABS, American Board of Surgery; ACGME, Accreditation Council for Graduate Medical Education.
inary resident positions difficult when the duty hour restrictions came into effect and when neurosurgery, orthopaedics, and otolaryngology demanded specific rotations for their interns. The latter changes pulled designated preliminary residents off of traditional general surgery rotations, leaving the categorical junior residents to assume patient care responsibilities, possibly at the expense of missing opportunities to operate. The release of the Institute of Medicine report in 1999 focused attention on the quality of care and potential medical errors, and may have also served to force a decline of TA opportunities for residents. It is notable that the percentile data (Fig. 5) indicates that roughly 10% of graduating residents may be at risk of not meeting the new requirements from the ACGME and ABS for a minimum of 750 operative cases as surgeon. Unless programs can rapidly increase their case volume, or decrease their resident complement, chief residents will be forced to take additional cases from junior residents to reach their minimums. It will then only become more difficult for those junior residents to reach their case requirements. The ABS has wisely chosen to not enact this requirement for Board eligibility until July 2009, giving graduating residents and programs more time to make necessary adjustments. What does the future hold for the residents who are currently in our training programs? How should we react to these data? Close monitoring of future case volumes, not only for the role of surgeon, but for the roles of FA and TA, is obviously essential. We must encourage and monitor our
residents to ensure that all operative case data are entered accurately. Surgical chairs and program directors must exercise great diligence and thoughtfulness in the manner in which we structure our training programs. We must maximize all educational experiences for our residents, both in the operating room and out. Careful redesign of our training programs, with the institution of new or blended models of education, may help to create situations in which we maintain the operative experience for our residents.21,22,14 The redesign experience detailed by Schneider and associates14 is particularly encouraging. Not only did they improve many aspects of their rotation schedule and improve resident satisfaction, but, under their new system, case volumes for PG1s increased from 114 to 188 (65%) and for PG2s, from 117 to 302 (158%). Can the emerging field of surgical simulation replace some of the time previously spent as FA or even some cases as surgeon? Although some technical skills can be taught and practiced in the laboratory environment, and judgment assessed in mock crisis situations, it is unlikely that those experiences will ever fully replace the variability in anatomy and pathology and the true tissue handling experience that surgeons gain only in the operating room. Nonetheless, it seems certain that simulation will play a valuable role in the future, as long as our programs devote the time and resources to make the experience worthwhile. Residents must deliberately practice basic operative skills in skills laboratories, at home, and in the hospital. Ericsson and others23-25 noted that the attainment of mas-
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tery in a particular area can take upward of 10,000 hours of deliberate practice in that domain. By comparison, it is interesting to note that Chung’s 26calculation of the time residents spend in the operating room and involved in immediate perioperative patient care totals just under 4,000 hours. Our residents, and their future patients, will benefit from the practice and experience that they acquire under our guidance to help them achieve mastery in this specialty. We, as surgeons, surgical educators, program directors, and surgical chairs, must understand and embrace these data. We must also continually strive to make our residents better surgeons, better technicians, and better decision makers, within the confines of our ever-changing educational environment.
11. 12. 13.
14. 15. 16.
Author Contributions Study conception and design: Kairys, Yeo Acquisition of data: Kairys, McGuire Analysis and interpretation of data: Kairys, Crawford, Yeo Drafting of manuscript: Kairys, Crawford Critical revision: McGuire, Crawford, Yeo
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resident education. Curr Surg 2006;63:435–439; discussion 440. Tran J, Lewis R, de Virgilio C. The effect of the 80-hour work week on general surgery resident operative case volume. Am Surg 2006;72:924–928. Feanny MA, Scott BG, Mattox KL, Hirshberg A. Impact of the 80-hour work week on resident emergency operative experience. Am J Surg 2005;190:947–949. Bland KI, Stoll DA, Richardson JD, Britt LD. Members of the Residency Review Committee-Surgery. Brief communication of the Residency Review Committee-Surgery (RRC-S) on residents’ surgical volume in general surgery. Am J Surg 2005;190: 345–350. Schneider JR, Coyle JJ, Ryan ER, et al. Implementation and evaluation of a new surgical residency model. J Am Coll Surg 2007;205:393–404. Carlin AM, Gasevic E, Shepard AD. Effect of the 80-hour work week on resident operative experience in general surgery. Am J Surg 2007;193:326–329; discussion 329–330. Damadi A, Davis AT, Saxe A, Apelgren K. ACGME duty-hour restrictions decrease resident operative volume: a 5-year comparison at an ACGME-accredited university general surgery residency. J Surg Educ 2007;64:256–259. Baldwin DC Jr, Daugherty SR, Tsai R, Scotti MJ Jr. A national survey of residents’ self-reported work hours: thinking beyond specialty. Acad Med 2003;78:1154–1163. Chung R, Ahmed N, Chen P. Meeting the 80-hour work week requirement: what did we cut? Curr Surg 2004;61:609–611. Richardson JD, Bland KI. Learning to operate in a restricted duty hours environment. Am J Surg 2005;190:354–355. Veldenz HC, Dennis JW, Dovgan PS. Quality control of resident operative experience: compliance with RRC criteria. J Surg Res 2001;98:81–84. Mendoza KA, Mendoza B, Britt LD. A template for change and response to work hour restrictions. Am J Surg 2003;186:89–96. DaRosa DA, Bell RH Jr. Graduate surgical education redesign: reflections on curriculum theory and practice. Surgery 2004; 136:966–974. Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev 1993;100:363–406. Ericsson KA, Charness N. Expert performance: Its structure and acquisition. Am Psych 1994;49:725–747. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79:S70–81. Chung RS. How much time do surgical residents need to learn operative surgery? Am J Surg 2005;190:351–353.
Discussion DR ROBERT S RHODES (Philadelphia, PA): The authors are to be congratulated on an excellent study, and particularly on their appropriate and cautious interpretation of the results. Two particular strengths of the analysis are that they look at specific levels of resident experience and consider multiple factors responsible for the results. My first comment is related to the change in the ABS application dates, and they have already responded to that. Another related issue